A. RUBBER BANDING OF HEMORRHOIDS
This is an office procedure generally reserved for grade 1 or 2 hemorrhoids with minimal symptoms. The anatomy of internal and external hemorrhoids is shown in figure 1.
Fleets enema. No anesthetic is necessary.
The patient is usually placed in a standard kneeling position on a Ritter table, although this may also be done in the left lateral position.
The hemorrhoidal bander is prepared with two rubber bands loaded. After digital examination, a Hirschman anoscope is inserted in the anal canal, the obturator removed, and the internal hemorrhoids are evaluated. After evaluation, which includes inspection of the internal hemorrhoids in their cardinal positions (right anterior, right posterior, and lateral), a decision is made as to which hemorrhoid is the most suitable for banding. This is usually the largest hemorrhoid. The Hirschman anoscope is positioned over the target hemorrhoid to allow prolapsed into the anoscope. Care must be taken to ensure that the site of the banding (all of the tissue encompassed by the band) is above the dentate line. An Allis clamp is first placed through the Hirschman anoscope to test the area (figure 2a). The hemorrhoid in question is grabbed with the Allis clamp. If the patient has significant discomfort, the clamp is too far distal and needs to be moved more proximal. Once the correct position of the clamp is determined, the bander is placed through the Hirschman anoscope, and the hemorrhoid is prolapsed with the Allis clamp into the bander (figure 2b). If there is no discomfort, the bander is fired, and the band is placed on the hemorrhoid. The instruments are then removed.
If the patient has significant, sharp pain immediately after placement of the band, it should be removed. This is done by incising the band with the tip of an 11-blade scalpel or with suture-removal scissors.
It is generally unsafe to place more than one or two bands at any one sitting. If more than two hemorrhoids are banded, they should be done at two or more office visits over the course of a couple of months. It is not unusual for the symptoms to improve after a single banding. Banding the largest hemorrhoid involved will sometimes resolve the patient’s symptoms for a significant period of time.
The patient will usually report some bleeding when the hemorrhoid sloughs in 4 to 7 days, which is entirely normal. However, the patient should be instructed to call immediately if he or she develops urinary retention or fever, as these may be early indications of pelvic sepsis. The procedure may be repeated in 6 weeks if symptoms have failed to completely resolve.