Local Anesthesia of Upper Anal Canal for Multiple Rubber Band Ligation: Description of Technique and Preliminary Results

Abstract

Symptoms caused by hemorrhoids are worse during defecation because of relaxation of the anal canal causing prolapse. We reviewed our experience of multiple rubber band ligations in a relaxed state of the anal canal using local anesthesia. Forty-five patients, the majority of whom had Grade 2 or 3 symptomatic hemorrhoids, who required treatment underwent four quadrant local anesthetic infiltration in the submucosa of the upper anal canal. We used 1.5 ml of 0.25 percent bupivacaine in 1:200,000 epinephrine, 5 mm above the dentate line. The exposure of the relaxed anal canal was excellent, allowing multiple introductions of the anoscope and application of multiple bands without discomfort. The average number of bands applied in a single session was 3.84 (range, 1-7). Forty-two percent of the patients had banding performed at four sites. Complications following the procedure were minimal. Forty-seven percent of patients reported pain, with an average pain score of 5.29 (range, 1-10). Forty-seven percent of patients did not experience any pain after the procedure. Seventy-three percent had relief of symptoms; 16 percent had symptomatic recurrences, one-half of them were successfully treated by repeat banding after local anesthetic; only one patient required surgical hemorrhoidectomy. Local anesthesia of the upper anal canal results in full relaxation and maximal mucosal redundancy of the anal canal simulating the anus in a natural condition during defecation. This gives an excellent exposure of the anal canal, enabling an accurate and multiple applications of rubber bands without pain during and shortly after the procedure.