Landmarks in the History of Haemorrhoids Charles V. Mann Date Comments c.2250 BC 1700 BC 1552 BC 460-375 BC Old Testament, Samuel 5:9 Old Testament Samuel 5:12 25 BC-AD 50 AD 130-200 Sometime between the fourth & sixth century AD 10 th century AD 10 th _5 th century AD Code of Hammurabi, King of Babylon. Description of anal symptoms (haemorrhoids). Edwin Smith papyrus. Use of astringent lotions for anal symptoms (haemorrhoids?) described. Eber papyrus. The most complete record of Egyptian medicine. Haemorrhoid remedies described. Writings of Hippocrates. Treatment of haemorrhoids by cautery and excision described. Philistines punished with "emerods". After the Ark moved to Ekron, perpetrators smitten by "emerods". Celsus describes ligature of piles with flax. Galen recommended conservative management of piles (laxatives, ointments, leeches) and regarded bleeding as therapeutic. Also described, however, use of a tight thread to induce sloughing of haemorrhoids. Susruta Samhita described use of treatment by clamp and cautery method. EI-Zahrawy described treatment by application of cautery irons. Treatment in Byzantine medical practise by twisting pile, application of ligature to its base, followed by amputation. A "modern" approach that lapsed for many centuries. 173
174 Surgical Treatment of Haemorrhoids Date Comments 1307-1370 1660-1734 1835 1849 1935 1955 1960 1963 1970 1975 1990 John of Arderne published his treatise on the treatment of fistula and haemorrhoids, and the use of clysters (enemas). Georg Ernst Stahl published a classic work on the treatment of haemorrhoids. Foundation of St. Marks Hospital, London by Frederick Salmon for the treatment of anal diseases, especially fistula in ano and haemorrhoids. J.G. Maisonneuve described treatment by forceful anal dilation. Subsequently, this treatment was revived by P.H. Lord. Development of the classical method of open dissection and ligature at St. Marks Hospital by E.T.C. Milligan and C. Naughton Morgan. Development of a closed method of haemorrhoidectomy by A.G. Parks, London. The closed surgical method of treatment established by J.A. Ferguson and colleagues at Grand Rapids, Missouri. Invention of the method of rubber band ligation of haemorrhoids as an office procedure by J. Barron (USA). Method widely adopted thereafter. New methods for physical destruction of haemorrhoids developed (cryotherapy infrared thermocoagulation, diathermy, laser). Some still used. Use of anal dilatation advocated by P.H. Lord. Was not widely adopted but of historical importance. Classical studies by W.H.F. Thomson into the nature of haemorrhoids, and their development from anal cushions, which are normal structures. Day-case surgery initiated in special centres.
Index A Abdominal examination 27-28 Acute haemorrhoids 124 Age of patients 25,75, 109, 159 as contraindication to surgery 139 Ageing anatomical changes 11 changes in anal cushions 8 AIDS 142-157 Alcohol abuse, as contraindication to surgery 140-141 Ampullary pump 10 Anaemia 26-27,42 Anaesthesia 110 day case 166-170 analgesia 169-170 positioning 168-169 preoperative selection and preparation 166-167 technique 167-168 Anal cushions changes with ageing 8 function of 7-8 role in anal sphincter control 17 Anal dilatation 51-56,115,150-151 complications 55 contraindications 53 indications 51 post-dilatation care 54-55 results 55-56 technique 53-54 Anal fissure 31,35,68,151-152,158 postoperative 86, 137 Anal fistula 31,35, 137, 156 postoperative 86-87 Anal hypertonia 10 Anal intercourse 25,142 Anal stenosis 87 Anal stricture 136-137 Anal tags 136 Anal tone 13 Anal ulcer 137 Anatomy 5-7,8-9 Anopexy ("stapling") see Circular stapler anopexy Anoscopy 34-36 Antibiotics, prophylactic 112-113 Anxiety management 113 Autoimmune deficiency 76 B Banding see Rubber band ligation Barber surgeons 2 Bleeding see Haemorrhage Bowel habit 27 Bowel regulation postoperative 116 preoperative 112 Bulking agents 45 ( Carcinoma, as contraindication to surgery 143 Cardiovascular problems 109 Cathartic colon 45 Circular stapler anopexy 97-104 complications 101-102 indications 97-98 postoperative course 99-101 results 102-103 technique 98-99, 100 Classification of haemorrhoids 13-15 external 15 primary internal 13-15 secondary internal 15 Closed haemorrhoidectomy 89-92 complications 91 diathermy 120-121 indications 89 position and anaesthesia 89 postoperative management 91 preoperative preparation 89 procedure 89-91 results 91 175
176 Index Co-morbidity 155-161 anal abnormalities 158-159 inflammatory bowel disease 155-156 old age 159 perianal/perineal sepsis 156 sexual habits 159 systemic 156-158 Coagulopathy 156 Colitis 24, 25 Complications of haemorrhoidectomy 133-138 anal fistula 137 anal stricture 136-137 anal tags 136 constipation 134-135 ectropion 136 epidermal cyst 137 faecal incontinence 137-138 fissure/ulcer 137 haemorrhage 135 infection 135-136 mucosal prolapse 136 pain 133-134 pruritus ani 137 pseudopolyps 137 rectal stricture 137 recurrence 138 retroperitoneal air 138 urinary retention 134 urinary tract infection 134 Complications of haemorrhoids 145-153 anal fissure 151-152 recurrent haemorrhoids 152 thrombosis 145-147 internal haemorrhoids 147-151 Condylomata 35 Conservative management of haemorrhoids 4 Constipation 43,47,158-159 postoperative 134-135 Continence disorders 20 Contraindications to haemorrhoidectomy 139-144 age 139 anal intercourse 142 carcinoma 143 chronic illness 139-141 deformed anal canal 142-143 drug and alcohol abuse 141-142 gastrointestinal disease 141 immune deficiency disorders 142 lymphogranuloma venereum 143 mucosal inflammation 143 pregnancy and parturition 141 tuberculosis 143 venereal disease 143 weak anal sphincter 142 Crohn's disease 24,25,30,36,155-156 Cryotherapy 129-131 immediate after effects 129 long-term effects 130 D Day case haemorrhoidectomy 163-171 anaesthesia 166-170 consent 164 payment 163 postoperative care 165-166 preoperative preparation 164 selection of patients 163-164 social considerations 163 technical aspects 164-165 Deep-vein thrombosis prevention 113 Defaecatory position 10 Deformed anal canal 142-143 Dermatitis 30 Diabetes mellitus 110 Diagnosis 23-36 concomitant conditions 24 haemorrhoid size 23 history 24-27 age 25 childbirth 25 family history 25 gender 25 marital status 25 previous treatment 25-26 principal complaints 26 secondary complaints 26-27 social/occupational background 27 Diathermy haemorrhoidectomy 119-125 acute haemorrhoids 124 circumferential prolapsed piles 121-124 closed 120-121 open 120 results 124-125 Diet 10,43-44 Digital examination 32 Drug abuse, as contraindication to surgery 140-141 E Ectropion 136 Egyptians, references to haemorrhoids Enemas 46-47 Epidermal cyst 137 Examination 27-36 abdominal 27-28 anoscopy 34-36 digital 32
Index 177 flexible recto-colonoscopy 34 general appraisal 27 position 28-30 preparation 28 proctoscopy 34-36 rectoscopy 32-34 sigmoidoscopy 32-34 visual inspection 30-32 External haemorrhoids 15,19 thrombosis of 145-147 F Faecal incontinence 40-41,55,87,137-138 Faecal retention 86 Family history 25 Far East, references to haemorrhoids 2 Fissure see Anal fissure Fissure-in-ano see Anal fissure Fisting 142 Fistula see Anal fistula Fistula-in-ano see Anal fistula Flexible recto-colonoscopy 34 Funnel anus 142-143,152 (i Gastrointestinal disease, as contraindication to surgery 140 Gay bowel syndrome 159 Greeks, references to haemorrhoids Gutter deformity 143 H Haemorrhage 26, 38-39, 68 postoperative 135 risk of 114 Haemorrhoidectomy closed see Closed haemorrhoidectomy complications see Complications of haemorrhoidectomy contraindications see Contraindications to haemorrhoidectomy day case 163-171 diathermy 119-125 laser 127-128 open see Open haemorrhoidectomy submucosal see Submucosal haemorrhoidectomy total see Total haemorrhoidectomy Historical aspects 1-4,173-174 barber surgeons 2 Egypt 1 Far East 2 Greece 1 Master Surgeons 2 nineteenth century 3 Renaissance 2-3 Rome 2 twentieth century 3-4 HIV 157 Immune deficiency disorder 142 Immunosuppression 156-157 Indications for intervention 37-42 anaemia 42 bleeding 38-39 faecal soiling and incontinence 40-41 mucus seepage and pruritus 40 pain thrombosis 41-42 prolapse 39-40 Infection 10, 68 perineal 156 postoperative 135-136 urinary tract 110,134 Infrared thermocoagulation 71-74 technique 73-74 tissue effects 72 Internal haemorrhoids 13-15,19 thrombosis of 147-151 L Landmarks (historical) 173-174 Laser haemorrhoidectomy 127-128 Laxatives 45 Lymphogranuloma venereum, as contraindication to surgery 143 M McGiveny ligator 65, 66 Master Surgeons 2 Metronidazole 165,169 Mucosal inflammation 143 Mucosal prolapse 136 Mucus discharge 26, 40, 42 N Non-invasive therapy 43-49 bulking agents 45 diet 43-44 enemas 46-47 laxatives 45 purgatives 45-46 suppositories 47-48 Non-steroidal anti-inflammatory drugs 169
178 o Obesity 29,34,110,140 Obstetric history 25 Occupation of patient 27 Open haemorrhoidectomy (St Marks Milligan-Morgan technique) 75-88 aftercare restoration of defaecation 85 to anal wounds 84-85 case selection 75-76 complications 85-87 acute urinary retention 86 anal stenosis 87 faecal retention 86 fissue-in-ano 86 fistula-in-ano 86-87 incontinence 87 postoperative haemorrhage 86 recurrent haemorrhoids 87 secondary haemorrhage 86 diathermy 120 difficult haemostasis 84 position 77 preoperative preparation 76-77 prolapsing skin bridges 83 residual circumferential haemorrhoids 82-83 residual skin tags 83-84 results 87 technique 77-82 p Pain 26,40-41,68,133-134 Parks method see Submucosal haemorrhoidectomy Pathophysiology of haemorrhoids 17-21 Pecten band 51,53 Pelvic sepsis 68 Perianal abscess 156 Perineal infection 156 Perineal problems 111-112 Perioperative precautions 114-115 Porphyria 110 Portal hypertension 9,156 Postoperative haemorrhage 86 Postoperative management 115-118 closed haemorrhoidectomy 91 submucosal haemorrhoidectomy 95 total haemorrhoidectomy 107-108 Pregnancy 24,76,157-158 as contraindication to surgery 140 Preoperative preparation 109-114 antibiotics 112-113 anxiety management 113 assessment 109-112 bowel regulation 112 closed haemorrhoidectomy 89 haemorrhage risks 114 open haemorrhoidectomy 76-77 perineavanal skin problems 111-112 prevention of deep-vein thrombosis 113 regulation of food and drink 113 submucosal haemorrhoidectomy 93 total haemorrhoidectomy 106 Prevalence of haemorrhoids 9 Proctalgia 40-41 Proctoscopy 34-36 Prolapse 13,26,39-40,55 circular stapler anopexy for 97-104 diathermy for 121-124 Prostate enlargement 110 Pruritus ani 26,40,47, 137 Pseudopolyps 137 Pulmonary disease 109-110 Purgatives 45-46 R Rectal stricture 137 Rectocele 158 Rectoscopy 32-34 Recurrent haemorrhoids 138, 152 Renaissance, references to haemorrhoids 2-3 Renal disease 110 Retroperitoneal air 138 Romans, references to haemorrhoids 2 Rubber band ligation 65-70 complications 68 equipment 65-66 injection of local anaesthetic 69 operative technique 66-67 patient positioning and preparation 66 principle 65 results 67 single versus multiple band application 68-69 S St Marks Milligan-Morgan technique see Open haemorrhoidectomy Sclerotherapy 26,57-64 aftercare 63 case selection 58 complications 61-63 bleeding at injection site 61-62 intravenous injection 62 pain 62 prostatic injection 62-63 results 63 technique injection 58-61 position 58 preparation 58 Index
Index 179 Sigmoidoscopy 32-34 Sinuses 31 Size of haemorrhoids 23 Skin abnormalities 30-31 Skin tags 19,31,83-84 fibrotic 36 Stapling see Circular stapler anopexy Stool consistency 10 Strangulated piles 147-151 see also Prolapse Submucosal haemorrhoidectomy (Parks method) 93-96 follow-up regimen 95 indications 93 postoperative management 95 preoperative preparation 93 results 95-96 technique 94-95 Suppositories 47-48 Surgery see Haemorrhoidectomy Syphilis 30 T Therapy see Cryotherapy; Haemorrhoidectomy; Noninvasive therapy Thrombosis of haemorrhoids 40-41,68,145-151 external 145-147 aetiology 145 complications 147 presentation 145 treatment 146-147 internal 147-151 aetiology 149 presentation 149 treatment 149-151 Total haemorrhoidectomy 105-108 complications 108 indications 106 postoperative care 107-108 preoperative preparation 106 technique 106-107 Thberculosis, as contraindication to surgery 143 U Ulcerative colitis 155 Urinary retention 62, 86, 134 Urinary tract infection 110,134 V Varicose veins 9 Venereal disease, as contraindication to surgery 143 Visual inspection 30-32 W Weak anal sphincter 142 Whitehead deformity 20 Whitehead operation see Total haemorrhoidectomy