Rubber-Band Ligation of Hemorrhoids Technique

Updated: Sep 05, 2017
  • Author: Pradeep Saxena, MBBS, MS; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Rubber-Band Ligation

Usually, one or two hemorrhoids are ligated at a time. Any remaining hemorrhoids may be ligated after a period of 4-6 weeks.

A Barron hemorrhoidal ligator with a hemorrhoid-grasping forceps is used. The ligator has a drum at one end over which rubber bands are loaded. It is connected with a 30-cm shaft to the handle, which has a trigger to release the bands.

A loading cone is screwed over the drum of the Barron hemorrhoidal ligator. Two rubber rings/bands are slipped to load the ligator (see the first image below). The hemorrhoid-grasping forceps is then passed through the drum of the ligator and is now ready to grasp the hemorrhoid (see the second image below).

Loaded rubber rings on drum of Barron hemorrhoidal Loaded rubber rings on drum of Barron hemorrhoidal ligator.
Loaded band ligator ready for use. Loaded band ligator ready for use.

A proctoscope/anoscope is inserted into the anal opening. The hemorrhoids are visualized, and the most prominent hemorrhoid is addressed first. The assistant holds and maintains the position of the anoscope, while the operator holds the preloaded Barron band ligator with the grasping forceps. The internal hemorrhoid is grasped with the forceps about 1 cm proximal to the dentate line and maneuvered into the drum of the ligator (see the image below). If the patient complains of pain, a more proximal point should be selected for band ligation.

Grasping forceps holding the hemorrhoid. Grasping forceps holding the hemorrhoid.

The hemorrhoid is pulled taut through the drum of the ligator (see the first image below). The ligator is then pushed up against the base of the hemorrhoid, and the trigger is released to apply two rubber rings/bands to the base of the hemorrhoid (see the second image below). The process is repeated for other hemorrhoids.

Hemorrhoid held taut, with drum of ligator pushed Hemorrhoid held taut, with drum of ligator pushed against base of hemorrhoid and trigger released.
Rubber bands applied on hemorrhoid. Rubber bands applied on hemorrhoid.

Alternatively, a suction hemorrhoid ligator may be used. This instrument draws the hemorrhoidal mass into the drum through suction; therefore, the grasping forceps is not required. After the pile mass has been adequately drawn into the drum by means of suction, the trigger is released to apply the rings to the base of the hemorrhoid.

Multiple pile masses may be ligated, but more than one banding session spaced over 3-4 weeks may be required.

The procedure is shown in the video below.

Barron band ligation for hemorrhoids.
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Complications

Most complications of the procedure are minor and self-limiting; they can be managed on an outpatient basis. Complications of rubber-band hemorrhoid ligation include the following:

  • Pain (32%) [3]
  • Vasovagal symptoms (dizziness and fainting) [4]
  • Bleeding (1-5%)
  • External hemorrhoid thrombosis (2-3%)
  • Ulceration [13]
  • Fulminant sepsis

Some discomfort in the anal region may be felt for a few days and is usually relieved by sitz baths and analgesics. In case of severe pain, removal of the rings is necessary. The rubber ring may be removed by conventional stitch-cutting scissors.

Late bleeding (1-2 weeks after the procedure) may be significant, and patients should be advised to keep a watch on the amount of blood loss. If bleeding is reported, anoscopic examination should be done under adequate visualization and anesthesia. If the bleeding site is identified, suture ligation should be done. If the patient is pale, hypotensive, and tachycardic, hospitalization and blood transfusion may be required.

If thrombosis of the corresponding external hemorrhoid occurs after internal hemorrhoid ligation, excision of the thrombosed external hemorrhoid may be required.

Sepsis has been reported in a few cases after band ligation. Young males are at increased risk. The septic patient presents with fever, anorectal pain, perineal pain, scrotal swelling, difficulty in micturition, cellulitis, and sometimes frank gangrene. The clinician should carefully examine the patient for anorectal complains before embarking on rubber-band ligation. Failure to recognize a septic process in this region may lead to fatal sepsis with extensive cellulitis and gangrene after the procedure. Treatment is with extensive debridement, wound toilet, and parenteral antibiotics. Colostomy may sometimes be required. [2]

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