Hemorrhoid Ligation

Author: Pradeep Saxena, MBBS, MS; Chief Editor: Kurt E Roberts,

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Overview
Background
Hemorrhoid ligation is one of the most common outpatient
treatments available for patients with hemorrhoids. In this
procedure, a rubber band is applied to the base of the
hemorrhoid to hamper the blood supply to the hemorrhoidal
mass. The hemorrhoid will then shrink and fall off within 2-7
days. Rubber band ligation can be performed in an
ambulatory setting. The procedure causes less pain and has a
shorter recovery period than surgical hemorrhoidectomy. Its
success rate is between 60% and 80%.[1, 2, 3]
Outpatient treatment is feasible and sufficient for the majority
of patients with hemorrhoids. A number of prospective studies
have found rubber band ligation to be a simple, safe, and
effective method for treating symptomatic first-, second-, and
third-degree hemorrhoids as an outpatient procedure with
significant improvement in quality of life.[1, 2, 3, 4, 5] Hemorrhoid
ligation has a limited morbidity, good results, long-term
effectiveness, and good patient acceptance. It has been found
to be safe even for patients with cirrhosis and portal
hypertension and for patients on anticoagulation threrapy.[2, 3]

Indications
Hemorrhoid ligation is performed for first-degree, seconddegree, and some cases of third-degree hemorrhoids when
the patient complains of bleeding or prolapse of hemorrhoids.
Band ligation may also be considered for bleeding in severely
anemic patients with fourth-degree hemorrhoids who are unfit
for surgery.

Contraindications
Hemorrhoid ligation is contraindicated for the following:

Patients using anticoagulants

Any septic process in the anorectal region
In presence of large grade IV hemorrhoids
Hypertrophied anal papilla
Chronic anal fissure (surgical treatment is more appropriate)

Technical Considerations
Best Practices
Clinically, hemorrhoids usually present with bleeding, prolapse,
pain (with thrombosis or ulceration), perianal mucous
discharge, or pruritis. The complications of hemorrhoids are
thrombosis, infection with inflammation, ulceration, and
anemia.
Internal hemorrhoids are classified into four grades as follows:

First degree: Veins of anal canal increase in number and

size, and they bleed on defecation
Second degree: Hemorrhoids prolapsed outside anal canal
but reduce spontaneously

Third degree: Hemorrhoids protrude outside anal canal and

require manual reduction
Fourth degree: Irreducible hemorrhoids that remain
constantly prolapsed
A second-degree hemorrhoid is shown in the image below.

Second-degree hemorrhoids.

The initial treatment for symptomatic first- and second-degree

hemorrhoids with a short history of bleeding, prolapse, or
itching and pain is directed to control constipation with dietary
measures like a high-fiber diet, sitz bath, stool softeners,
laxatives, and various topical creams.[1, 2]
When medical treatment fails, ambulatory treatment is
advised. Ambulatory treatments for hemorrhoids include
injection sclerotherapy, rubber band ligation, cryosurgery,
infrared coagulation, and ultrasonic Doppler-guided transanal
hemorrhoidal ligation. Surgical treatment includes open or
closed hemorrhoidectomy and stapled hemorrhoidopexy.

Procedure Planning
A proctosigmoidoscopy or anoscopy is always performed
before considering any treatment for hemorrhoids. In patients
older than 40 years, polyps and other colonic pathology may
be present; therefore, colonoscopy is advised in these
patients before treating them for hemorrhoids. A colonoscopy
or barium enema should be always performed before any
treatment for hemorrhoids is considered in the following
cases[2] :
If there is suspicion of colonic disease based on patients
symptoms and clinical evaluation
When hemorrhoids do not appear to be the cause of
bleeding
When bleeding is continous even after hemorrhoid ligation
It has been now widely accepted that piles are nothing more
than a sliding downwards of part of the anal canal lining.[1] It is
therefore obvious that treatment measures have to address
the reduction of the prolapse as well as reduction of blood
flow to the hemorrhoid mass. The principle of outpatient
treatment is to fix the mucosa above the prolapsing
hemorrhoid. Preceding lateral internal sphincterotomy under
local anesthesia may be done simultaneously for patients with
high sphincter tone associated with first-degree hemorrhoids.

Complication Prevention
Because of the risk of hemorrhage, rubber band ligation is
absolutely contraindicated in patients on anticoagulant
therapy. Patients taking aspirin should stop the medication at
least 14 days before the procedure.[1]

The rubber rings must be applied on an insensitive area well

above the dentate line to avoid postprocedural pain.
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.

Periprocedural Care
Patient Education & Consent
A formal consent should always be taken before placement of
rubber bands to treat hemorrhoids because complications
have been reported in randomized controlled trials.[5]
Patients should be advised that there is a recurrence rate of
about 20-25% in 5 years.
Stool softeners and bulk agents should be prescribed and the
patient should avoid straining for bowel movements. The
patient should be warned about the possibility of bleeding
after the procedure and after 1-2 weeks when the rubber rings
are dislodged. If the patient thinks that bleeding is severe or
persistent, he or she should contact the surgeon.
In cases of pain or fever, the patient should come back for
consultation. A sitz bath may be advised to keep the anal area
clean and hygienic to prevent infections and reduce pain. The
patient should be advised to avoid heavy lifting or strenuous
activities for 34 days.

Equipment
Equipment for hemorrhoid ligation includes the following:

Barron hemorrhoidal ligator with rubber rings/bands (see the

image below)
Barron hemorrhoidal ligator with loading cone and grasping forceps.

Hemorrhoid-grasping forceps
Proctoscope/anoscope
Light source (torch)
Gauge piece
Artery forceps

Patient Preparation
Anesthesia
For lubrication and local anesthesia, 5% lignocaine jelly is
applied locally in the anal canal.
Positioning
The patient should be in the left lateral position with buttocks
projecting well over the operating table.

Monitoring & Follow-up

A single treatment can achieve satisfactory results. If the
symptoms of bleeding and prolapse due to hemorrhoids are
not relieved, further band ligation or other conservative
treatment may be tried. If the symptoms are not controlled
after three sessions, hemorrhoidectomy may be considered.

Complications
Most complications of hemorrhoid ligation are minor and selflimiting; they can be managed on an outpatient basis.
Complications of hemorrhoid ligation are pain
(32%),[2] vasovagal symptoms (dizziness and fainting),[3] ,
bleeding (1-5%), external hemorrhoid thrombosis (2-3%),
ulceration, and 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 later) may be significant and patient
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.
Thrombosis of the corresponding external hemorrhoid may
occur after internal hemorrhoid ligation in 2-3% of cases.
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 be
sometimes required.[1]

Technique
Preparation
A Barron hemorrhoidal ligator with 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 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 image below.

Loaded rubber rings on

drum of Barron hemorrhoidal ligator.

The hemorrhoid grasping forceps is then passed through the

drum of ligator and is now ready to grasp the hemorrhoid. See
the image below.

Loaded band ligator

ready for use.

Procedure
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 anoscope,
while the operator holds the preloaded Barron band ligator
with the grasping forceps. The internal hemorrhoid is grasped
by forceps about 1 cm proximal to the dentate line and
maneuvered into the drum of the ligator. See the image below.

Grasping forceps holding the

hemorrhoid.

If the patient complains of pain, a more proximal point should

be selected for band ligation.
The hemorrhoid is pulled taut through the drum of the ligator,
as shown in the image below.

Hemorrhoid held taut, with drum

of ligator pushed against base of hemorrhoid and trigger released.

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. The process is
repeated for other hemorrhoids. See the image below.

Rubber bands applied on

hemorrhoid.

Alternatively, a suction hemorrhoid ligator may be used. This

instrument draws the hemorrhoid mass into the drum through
suction; therefore, the grasping forceps are not required. After
adequately drawing the pile mass into the drum by 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.

http://emedicine.medscape.com/article/1892099