Rubber Band Ligation of Internal Hemorrhoids

Abstract

Hemorrhoids, although extremely common, require treatment only when they are symptomatic. Symptoms consist of bleeding, discomfort due to protrusion, and pain generally due to thrombosis. Although painful thrombosis most often occurs in external hemorrhoids, the source of symptoms in most patients is the internal hemorrhoid. Surgical treatment for most cases of symptomatic internal hemorrhoids can be carried out in the office without anesthesia by utilizing rubber band ligation, by injecting sclerosing solution, or by applying cryosurgery. This last method, however, produces an excessive amount of drainage during the postoperative period, and because it has no compensating advantages, it is uncommonly used at the present time. If the proper guidelines are followed in the technique of rubber band ligation, this technique achieves satisfactory results over the long term in more cases than does the injection of sclerosing solution. The modern method of rubber band ligation was introduced by Barron. It involves the application of a strangulating rubber band ligature to an internal hemorrhoid, with the rubber band being placed above the mucocutaneous junction to avoid grasping sensory nerve endings. Nivatvongs and Goldberg point out that a hemorrhoid is caused by downward displacement of the anal cushion. Therefore, they advocate applying the rubber band to the redundant rectal mucosa above the hemorrhoid rather than to the hemorrhoid itself. When the banded segment of mucosa shrivels up into fibrous tissue, the hemorrhoid is eliminated. This method has the advantage of avoiding the sensitive tissues at the dentate line and thus minimizing pain. Alexander-Williams and Crapp experienced excellent results with this technique. This method is suitable for most patients with second-degree, and for many with third-degree, hemorrhoids.