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PharmEasy Blog

Rubber Band Ligation for Piles: Preparation, Recovery and Risks 

What is Rubber Band Ligation?

Rubber band ligation is a non-surgical procedure used in the treatment of piles that don’t respond to conservative management (dietary and lifestyle modifications). Piles or haemorrhoids are swollen and enlarged veins appearing like a pillow like cluster near the lowest part of anorectal region. Depending on their location, there are two kinds of haemorrhoids- internal (found inside the lower rectum) and external haemorrhoids (found beneath the skin around the anus). 

Internal haemorrhoids are of 4 types:

• Haemorrhoids which bleed but do not prolapse (fall outside the rectum)- Grade I 
• Haemorrhoids which prolapse but may reduce and gain the normal position quickly- Grade II
• Haemorrhoids which prolapse on exertion and require manual reduction (aligning the haemorrhoidal tissue in its normal position without cutting the skin)- Grade III
• Haemorrhoids which may prolapse and are irreducible – Grade IV

Depending upon the degree and severity of symptoms, there are different treatment modalities available for managing hemorrhoids ranging from dietary and lifestyle modifications to surgeries. One such treatment is the haemorrhoid rubber band ligation in which the haemorrhoid is tied off with a rubber band, which helps in cutting the blood flow to the haemorrhoid. This technique was performed for the first time by Blaisdel in 1950s.^1-3

Hemorrhoidectomy surgery is used for more advanced hemorrhoids, while rubber band litigation for hemorrhoids may be used for less severe hemorrhoids without the side effects of surgery.

Dr. M.G. Kartheeka, MBBS, MD

Diagnosis

Your doctor will take a detailed history and do a thorough physical examination to confirm hemorrhoids. External hemorrhoids are generally visible upon examination especially if a blood clot is present. For internal hemorrhoids, he may do a digital rectal examination. 

Depending upon the type of hemorrhoid and the severity, your doctor will decide the need for rubber band ligation.¹

Indications for rubber band ligation

Rubber band ligation for piles is indicated in the following situations:²

• First and second-grade haemorrhoids
• In third-grade haemorrhoids with bleeding or prolapse.

Surgery like laser surgery and stapled hemorrhoidectomy may be recommended for external piles if conservative treatments like sitz bath or topical ointments fail to provide relief or if the condition becomes severe. Rubber band ligation can quickly be done under local anesthesia for most patients.

Dr. Ashish Bajaj – M.B.B.S, M.D.

Treatment

Before going to the hospital for piles rubber band ligation, you should be aware of the following:

• It is always better to go for this procedure along with a friend or family member.²
• If you are on blood thinners, you should inform your proctologist before going for the procedure, your proctologist will ask you to do the necessary modifications.²

Rubber band ligation does not require any anaesthesia or any injections for bowel clearance. This procedure does not need hospitalisation and is usually carried out in a single session and hardly takes 10-30 minutes; although in cases of recurrent haemorrhoids, additional sessions may be needed.^3,4

Read More: What is the Cost of Piles Surgery in India?

Points to be kept in mind after rubber band ligation: ¹

Following are the common measures to do for symptomatic relief and avoiding the recurrence of the disease.

• Diet: Add high-fibre foods to your diet like fruits, vegetables, lentils, etc. Drinking plenty of non-sugary fluids will soften the stools and reduce straining. Fibre supplementation may also help in reducing inflammation and bleeding. If still you have complaints of constipation, you can consult your physician and he may prescribe you stool softeners for the same.
• Exercise: Moderate aerobic exercises like brisk walking for 20-30 minutes a day may help improve bowel function and keep your bowel smooth.
• Bowel habits and anal hygiene: A good anal hygiene includes washing after passing stools; avoid using soaps to wash the anal area as this can result in dry and itchy skin. Make a habit of emptying your bowel completely, whenever you feel the urge to pass motion you should go to the washroom immediately to help in reducing pressure due to straining.
• Sitz bath: After each bowel movement, a 20-minute warm water bath for the hips and buttocks may help relieve irritation and itching.  
• Topical relief: Placing an ice pack for a few minutes near the anal region may help reduce swelling and pain. Any medication should only be used after a doctor’s consultation.
• Sitting on a cushion instead of hard surfaces may avoid worsening of existing haemorrhoids and formation of new ones. 
• Your doctor may prescribe you antibiotics and painkillers. It should be ensured that the prescribed medication is taken properly.³
• You may return back to work and resume daily activities the very next day. In case of any complaints or discomfort, consult your doctor and take bed rest for 2-3 days.⁴

Read More: 8 Best Home Remedies For Piles

Risks^2,3

• Pain and swelling at the operated site
• Minor bleeding and ulceration in the anal region
• Urinary retention
• Formation of a clot in the haemorrhoid  
• Pelvic sepsis (severe bacterial infection)  
• Erection of penis³

Performing rubber band ligation is contraindicated in the following: ³

• Crohn’s disease
• HIV positive person

Conclusion

Rubber band ligation is a treatment modality to manage piles. In this, the haemorrhoid is tied off with a rubber band, preventing the blood flow to the haemorrhoid. This process does not need anaesthesia, bowel clearance or hospitalization but can result in anal discomfort and pain. Your doctor or proctologist will assess the need of the procedure and weigh its benefits against the risks involved and will counsel you in detail about rubber band ligation aftercare.

Frequently Asked Questions:

Disclaimer

The information provided at this site is for educational purposes only and is not intended to be a substitute for medical treatment by any healthcare professional. As per unique individual needs, the reader should consult his/her physician to determine the appropriateness of the information provided for his/her situation.

References:

1. Hemorrhoids and what to do about them (2021) Harvard Health. Available at: https://www.health.harvard.edu/diseases-and-conditions/hemorrhoids_and_what_to_do_about_them 
2. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World journal of gastroenterology: WJG. 2012 May 5; 18(17):2009. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/
3. Albuquerque A. Rubber band ligation of hemorrhoids: A guide for complications. World journal of gastrointestinal surgery. 2016 Sep 9; 8(9):614. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5037334/
4. Stavrou G, Tzikos G, Malliou P, Panidis S, Kotzampassi K. Rubber band ligation of hemorrhoids: is the procedure effective for the immunocompromised, hemophiliacs and pregnant women?. Annals of Gastroenterology. 2022 Aug 30:509. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9399576/
5. Kumar M, Roy V, Prasad S, Jaiswal P, Arun N, Gopal K. Outcomes of Rubber Band Ligation in Haemorrhoids Among Outdoor Patients. Cureus. 2022 Sep 29; 14(9). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9618009/

Haemorrhoidectomy: Types, Procedure, Recovery and Risks 

What is Haemorrhoidectomy?

Haemorrhoidectomy is the surgical removal of haemorrhoids, commonly called piles. Haemorrhoids are a condition characterised by swollen veins in the anal and rectal region. Depending upon the location of haemorrhoids, these can be internal (inside the rectum) or external (around the anal opening. Haemorrhoids are managed using both non-surgical and surgical treatment along with lifestyle modifications. Usually, haemorrhoids which are recurrent, prolapsed (falling outside the rectum) and the ones which require reduction (shrinkage of haemorrhoidal mass) are often surgically removed by haemorrhoidectomy.¹

Diagnosis

Medical History and Physical Examination

Your doctor will take a detailed history and do a thorough physical examination before diagnosing haemorrhoids. He may do a digital rectal examination and a few imaging tests. Depending upon the type of haemorrhoid and the severity, he/she will decide the need for surgical excision of the haemorrhoid.^1,2

Indications for Haemorrhoidectomy

Following are the indications for haemorrhoidectomy:¹

• If there is no improvement after non-operative management (medications and lifestyle modifications)
• Haemorrhoids that show bleeding
• Severe haemorrhoids like recurrent haemorrhoid, clot in a haemorrhoid unresponsive to medications
• Mixed haemorrhoids (both internal and external haemorrhoid) that bulge out
• Incarcerated haemorrhoids (prolapsed internal haemorrhoids)  

Thrombosed haemorrhoids in which a blood clot is formed inside the haemorrhoid.²

Read More: 8 Best Home Remedies For Piles

Treatment

In this section, we will look at the different types, procedures, available for haemorrhoidectomy:

Types of haemorrhoidectomy:

• Open haemorrhoidectomy or Milligan-Morgan haemorrhoidectomy wherein the haemorrhoid is surgically removed and the wound is left open to heal.¹ 
• Closed haemorrhoidectomy also called as Ferguson haemorrhoidectomy in which the wound is closed with a suture.¹
• Stapler haemorrhoidectomy (SH) also known as procedure for prolapsed haemorrhoids (PPH) which involves excision of the haemorrhoidal tissue and use of a stapling procedure to lift the haemorrhoid back to the normal position.³
• LigaSure haemorrhoidectomy ³
• Cryosurgical haemorrhoidectomy which uses nitrous oxide to freeze and remove haemorrhoidal tissue.⁴
• Laser haemorrhoidectomy uses laser to shrink the haemorrhoids.⁴
• Harmonic ultrasonic scalpel haemorrhoidectomy⁴
• Clamp and cautery haemorrhoidectomy⁴
• Submucosal haemorrhoidectomy⁴
• Whitehead’s circumferential haemorrhoidectomy⁴
• Bipolar diathermy haemorrhoidectomy⁴
• Starion haemorrhoidectomy⁴

Before performing haemorrhoidectomy, you will be given an enema for bowel clearance. It should not be painful but will make you little uneasy and uncomfortable. Haemorrhoidectomy procedures are carried out after anaesthetizing the patient with local anesthesia. The surgery procedure is usually carried out in prone jack-knife position, which requires you to lie on your stomach on a table which is flexed at 90 degrees. Your head and body will be lowered and your hips will be raised.¹ 

The duration of hospital stay for stapled haemorrhoidectomy is one day; whereas conventional haemorrhoidectomy may require hospitalization for 6-7 days and the duration of laser surgery is short and requires no hospitalisation. As haemorrhoidectomy may require immobilization temporarily, you should always go to the hospital along with a family member or caretaker.⁵

Post-operative medications:

1. Stool softeners may help reduce straining associated with constipation.
2. Topical treatment with ointments may help reduce pain and swelling.
3. Your doctor may prescribe suppositories, pills, creams and wipes for symptomatic relief.
4. Your doctor may prescribe you antibiotics post-surgery that should be taken sincerely.^3,4

Read More: What is the Cost of Piles Surgery in India? 

Points to be kept in mind after haemorrhoidectomy: ⁶

• Dietary and lifestyle modifications: increased intake of oral fluids (5-6 glasses of water or any other non-caffeinated beverage) and dietary fibers like fruits, vegetables, lentils, etc, mild- moderate intensity exercises and refraining from straining activities like weight lifting.
• A good anal hygiene should be practised that includes washing after defecation and avoid using soaps to wash the anal area as this can result in dry and itchy skin.
• You should avoid self-medicating as they can cause hard stools and constipation which may lead to tearing of tissues in the anus. 
• For the next few weeks, you may experience mild bleeding in stool. You can place new gauze over the wound if the older one becomes soiled. In case of heavy bleeding, you should contact your physician.
• Your physician may advise you to apply antibiotic ointments to the site daily for the first week after surgery. In case of surgical-site redness, swelling or foul-smelling drainage, contact your doctor.
• A twenty-minute sitz bath which involves soaking the affected area in a tub of warm water to aid healing. 
• After surgery, ensure your bowel remains soft. This can be done by increasing the intake of oral fluids and taking a high-fibre diet.

Read More: 8 Best Home Remedies For Piles

Risks

• Open haemorrhoidectomy may increase the risk of urinary retention, pain, thrombosed haemorrhoids and bleeding.¹
• Late onset complications may include the risk of recurrent haemorrhoids, skin tags, narrowing of the anal canal (anal stenosis).¹
• Although rare but haemorrhoidectomy may also increase the risk of abscess formation, sepsis, excessive bleeding and  inflammation of the abdominal wall.¹
• Stapler haemorrhoidectomy may increase the risk of fluid leakage from the surgical site, Fournier’s gangrene (bacterial infection of penis, scrotum) and pelvic sepsis.³
• Cryosurgical haemorrhoidectomy may increase the risk of discharge and edema.⁴

Haemorrhoidectomy is contraindicated in the following conditions: ¹

• Uncontrolled bleeding disorder
• Portal hypertension (high pressure in a vein which supplies blood to the liver)
• Inflammatory bowel disease  
• Faecal incontinence (not able to control bowel movements)
• Any medical condition which makes the patient unable to undergo anesthesia
• Rupture of the wall between rectum and vagina in women 

Read More: Patient Experiences Before & After Piles Surgery

Conclusion

Haemorrhoids or piles can be managed using different treatment modalities. The surgical excision of haemorrhoids is called as haemorrhoidectomy. Different types include conventional haemorrhoidectomy (open and close), laser, LigaSure, cryosurgical, stapled haemorrhoidectomy, etc. Each type has its own benefits and risks. Your doctor or proctologist will assess the need of the surgery and weigh the benefits against the risks involved.

Frequently Asked Questions (FAQs):

References:

1. Cristea C, Lewis CR. Haemorrhoidectomy. InStatPearls [Internet] 2022 Jul 4. StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK549864/
2. Holzheimer RG. Haemorrhoidectomy: indications and risks. European journal of medical research. 2004 Jan 26; 9(1):18-36. Available at: https://pubmed.ncbi.nlm.nih.gov/14766336/
3. Yeo D, Tan KY. Haemorrhoidectomy-making sense of the surgical options. World Journal of Gastroenterology: WJG. 2014 Dec 12; 20(45):16976. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258566/
4. Agbo SP. Surgical management of haemorrhoids. Journal of surgical technique and case report. 2011 Jul; 3(2):68. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3296437/
5. George R, Vivek S, Suprej K. How long to stay in hospital: Stapled versus open haemorrhoidectomy? Saudi Surgical Journal. 2016 Sep 1; 4(3):108. Available at: https://www.saudisurgj.org/text.asp?2016/4/3/108/193985
6. Lohsiriwat V. Treatment of haemorrhoids: A coloproctologist’s view. World Journal of Gastroenterology: WJG. 2015 Aug 8; 21(31):9245. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541377/

Disclaimer

The information provided at this site is for educational purposes only and is not intended to be a substitute for medical treatment by any healthcare professional. As per unique individual needs, the reader should consult his/her physician to determine the appropriateness of the information provided for his/her situation.