Haemorrhoid

Dr.WendeLL Ken, Sp.B

Department of Surgery
Indonesian Christian University Medical
SchooL
UKI Hospital Jakarta
2013
 Terminologi
Haemorrhoides (Yunani)
Haem = darah,
rhoos = mengalir
Darah yang mengalir keluar
Pile berasal dari kata pila
(Latin)
Benjolan, bola
 Anatomi Anorectum
Anorektum termasuk didalamnya
rongga anus, kulit perianal, sfingter ani
dan rectum bagian distal.
Anus +/- 3cm
Rectum +/- 12 cm
Batasnya : garis anorectal, garis
mucocutan disebut linea dentata
Ada perbedaan arteri, vena,
persyarafan,epithel dan sistem limfatik
 Anatomi Hemorroid
Bantalan hemorroid adalah jaringan
normal dalam saluran anus dan
rectum distal.
Untuk fungsi kehidupan bersosial
yang normal
Fungsi kontinens menahan pasase
abnormal gas, feses cair dan feses
padat
 Anatomi Hemorrhoid
Bantalan vaskuler arterio-venous,
matriks jaringan ikat dan otot polos
Bantalan hemorroid normal terfiksasi
pada jaringan fibro elastik dan otot
polos dibawahnya
Hemorroid interna dan eksterna
saling berhubungan terpisah linea
dentata
 HEMORRHOIDS
Normal anatomical structures

1. Treitz muscle 8. Int.

1 Hemorrhoidal
2. M levator ani plexus
3
2 9. Columns
3. Circular muscle
4 of Morgagni
4. Longitudinal 8
10. Ext.
muscle Sphincter
9
5 (deep band)
5. Internal
10
sphincter 11 11. Anal crypt
7 12
6. Conjoint 6 12. Dentate line
longitudinal
13. Ext. Sphincter
layer
13 (subcutaneous
14 band)
7. Parks ligament
14. Ext.
Hemorrhoidal
plexus
Anatomy and Physiology
of The anal Cushion (1)
External and internal
haemorrhoid cushions
are normal anatomical
formations presents
from embriological life

Good continence for

passage of air, fluid
and solid material
Anal cushions
 Defekasi
Def : Proses defekasi adalah proses
pengosongan isi rectum, kontraksi
sfingter, relaksasi sfingter yang
merupakan proses yang kompleks
Feses masuk ke rectum refleks
relaksasi dari sfingter tekanan intra
abdominal meningkat sudut
anorectal mengecil kontraksi usus
mengosongkan colon kiri ke rectum
feses keluar melalui anus
Normal Defacation Process
Effect of Fecal Material
to The Anal Cushion
 Klasifikasi
1. Hemorrhoid eksterna
2. Hemorrhoid interna
- Grade I
- Grade II
- Grade III
- Grade IV
 HEMORRHOIDAL DISEASE
Staging

Grade I
Anchoring tissue (AT)
Internal sphincter (IS)
Internal hemorrhoids (IH)
Parks ligament (PL)
Anal canal (AC)
External hemorrhoids (EH)

Grade II Grade III Grade IV

Haemorrhoid stadium I II - III
 Patofisiologi (1)
Kerusakan atau degenerasi jaringan
fibroelastik yang memfiksasi
bantalan hemorrhoid
Terjadi prolaps dan pembesaran
jaringan vaskuler
 HEMORRHOIDAL DISEASE
1. Mechanical factor

Degeneration of supportive ligament: Parks ligament

Mobile hemorrhoids Prolapsed hemorrhoids

Rupture of
Mobilization anchoring tissue
of plexus
Permanent int.
Stretching of
hemorrhoidal
anchoring tissue prolapse

Internal Stretching or
hemorrhoidal rupture of
plexus prolapsing Parks ligament
on straining
Lateralization
Parks ligament of ext. hemorrhoidal
functional plexus
Haemorrhoidal prolaps
Prolaps with vein dilatation
 Patofisiologi (2)
Kebiasaan mengedan lama dan
berlangsung kronik
Peninggian tekanan saluran anus
sewaktu beristirahat Venous return
menurun Vena membesar dan
merusak jaringan ikat penunjang
Faktor endokrin dan usia
HEMORRHOIDAL DISEASE
2. Hemodynamic factor

Increased
arterial flow

Disfunction of
arteriovenous shunt
Extended
venous back flow
Microvascular stastis

Venous
stasis

Capillary fragility
Hyperpermeability

Local inflammatory
process
 Patofisiologi (3)
Tidak jelas hubungannya dengan :
- Konstipasi
- Feses keras, solid atau encer
- Multipara
- Hipertensi portal
- Dilatasi vena pada varises,
hiperplasia vaskuler
 Diagnosa hemorrhoid
Anamnesa
Inspeksi
Palpasi Rectal toucher
Anoskopi protoskopi
Sigmoidoskopi
Proctoscopic View of Haemorrhoids
 Komplikasi hemorrhoid
Komplikasi kronik
Hemorrhoid eksterna

- anal tag
- Sentinel pile
Hemorrhoid interna

- Anemia
- Basah
- Pruritus
Skin tag fibrous polyp sentinel pile
 Komplikasi Hemorrhoid
Komplikasi akut
Hemorrhoid eksterna trombosis
nyeri
Hemorroid interna

umumnya tidak nyeri

- Perdarahan
- Prolaps
- Strangulasi ( nyeri )
- Nekrosis ( nyeri )
 Diagnosis banding ( 1 )
Perdarahan
Fisura ani
Eksoriasi kulit
Kondilomata
Tumor anus maligna
Prolaps recti
Dll

Bila gejala ini ditemukan diperlukan

pemeriksaan lengkap untuk menentukan
penyebab perdarahan, khususnya resiko
adanya tumor
 Diagnosis banding ( 2)
Nyeri
Fisura

Abses dan fistula

Karsinoma

Dll

Penting untuk mengetahui kapan nyeri timbul

saat defekasi dan pengosongan rectum.
Hemorrhoid interna dapat terasa sangat nyeri
bila berhubungan dengan trombosis atau
fisura ani
 Diagnosis banding ( 3 )
Pembengkakan dan prolaps
- abses
- kondilomata
- Karsinoma
- Prolaps recti
- dll
Pada hemorrhoid, prolaps biasanya mengalami
retraksi spontan kecuali pada derajat IV jika
tidak kemungkinan terdapat proses
neoplastik.
 Penatalaksanaan
Hemorrhoid eksterna
eksisi dengan local anestesi

Hemorrhoid Interna
Non invasive treatment : Nasihat, obat-
obatan vasotropik, obat-obat topikal
Ambulary treatment : Sklerotheraphy,
Infrared coagulation, Cryoteraphy, Rubber
band ligation
Tindakkan bedah : Dilatasi,
hemorrhoidectomy
 Kesimpulan
Bantalan hemorrhoid adalah jaringan
normal, berfungsi sebagai katup
Menjamin fungsi bersosial yang
normal
Komplikasi hemorrhoid berupa
penyakit yang umum
Harus disingkirkan kemungkinan
penyakit lainnya yang berbahaya
Terima kasih
 LONGO PROCEDURE
Firstly done by Antonio Longo,
University of Palermo Italy
Operated on 144 patients
Followed by others :
G.C. Beattie, Edinburgh UK (2000)
M.Rowsell, Leicester UK (2000)
B.J. Mehigan, Cottingham UK (2000)

The results was satisfied

 LONGO PROCEDURE
(1993)
Based on the theory of
cushion
Circumferential resection
above the dentate line
using a stapler device
Obliterate inf. haemorrhl a.
and restore the mucosal
prolapse
Thus, decreasing arterial
blood flow and improving
venous drainage
 Main Adventage
of The Operation
Cure or significant improvement of pre-
operative symptoms
Average operating time of 8 minutes
One day of hospitalization only
Little or no post - operative discomfort
Infrequent or minor post - operative
complications
Rapid post operative recovery
No stenosis, no relapses
Good aesthetic results
 STEPS of LONGO
PROCEDURE
INDICATIONS
II, III, and IV
degree
haemorrhoidal
prolapse

CONTRAINDICATION
Previous perianal
surgery (fibrosis)
PPH PROCEDURAL SET

Haemorrhoidal
Circular Stapler
33mm (HCS33)
Circular Anal
Dilator (CAD33)
Purse-string
Suture Anoscope
(PSA33)
 Anal Verge is held
by 3 Duval forceps
Anal dilatation
using CAD33
Remove Obturator,
leaving the
transparent device
Device may be
fixed with 2
stitches
 Introduce Purse String
Anuscope
Make purse string at
least 5 cm distal from
dentate line
Bites only includes the
mucous membrane
In the case of
asymetric prolapse,
make two half purse
strings
 Open the stapler to its
maximum position
Introduce
Hemorrhoidal Stapler
Using the suture
threader, pull the ends
of threads through the
lateral holes of
transparent dilator
 The end of threads
are knotted
externally
Partially tighten
the stapler
STEP
STEP 77
Moderate traction of the purse
string
This manoeuvre will draw the
prolapsed mucous membrane into
the casting
Stapler is tightened completely, and
fire
Allow instrument to be in closing
position 20 seconds before and after
firing to enhance hemostasis
Open the instrument partly, retract
the stapler and dilator
simultaneously to avoid damage
Check the stapled line, add stitches
if necessary
 Final result
Retain part of
cushion
Maintain air and
fluid continence
BEFORE AFTER