PILES (clinically known as Haemorrhoids) basically, is the swelling of blood vessels near the anal opening. The lumps are formed by increased pressure on blood vessels in the area, causing them to enlarge and swell. We understand that piles may not be a subject you feel comfortable talking about, but there is no need to suffer in silence.
Grades of Piles….
1) Symptoms are mild pain, itching sensation, heaviness where patient can be cured with medicine and diet and Healing Hands Innovative Ayurvedic Therapy.

2) Symptoms are painful defecation, recurrent bleeding, itching sensation, burning sensation, dragging sensation, and feeling of prolapse which reduces automatically after motion. This may require surgical intervention.

3) Symptoms are painful defecation, recurrent bleeding, itching sensation, burning sensation, dragging sensation, and feeling of prolapse which may require finger reduction after motion. This requires surgical intervention.

4) Symptoms worsen and the prolapse is irreducible. This requires surgical intervention.


NOTE : Only 30% of patients suffering from Piles will have bleeding, rest of the patients will have either burning, itching or constipation.

No Piles… Only Smiles..!

Innovative treatment for Piles : STAPLER Surgery

Procedure : It is a minimally invasive painless procedure that reduces the prolapsed HAEMORRHOIDAL (PILES) tissue. A unique stapling technique that is used to push the swollen blood vessels back into their normal position.

Preparation : Requires patient to take nothing by mouth about 4 hrs prior to the surgery.

Surgery : The surgery takes only about 20 to 30 minutes. It is usually done under spinal anesthesia. It is done
through a natural opening (anus), with the help of a use and throw device known as Stapler. In this surgery as there are no cuts and no stitches outside so there is no need of dressing.

Post Operative Care (after surgery care) : Patient can have full diet 4 hrs post surgery. He/she can
walk around just after 5–6 hrs of the surgery. Patient can be discharged within a span of 24 hrs. On discharge antibiotics and painkiller for7 to 10 days are advised.

Recovery : Patient normally gets discharged from the hospital within 24 hrs. The recovery period is relatively very short. Patient can resume daily routine after discharge and join work after 3 days.

NOTE : Stapler Surgery is done with any external cuts, so loss of control post surgery is a myth.

Piles is a embarrassing, problematic and a cause of major inconvenience. Hence, symptomatic care usually proves to be futile.It is important that the cure be absolute and the relief complete. This is possible via holistic and customized care involving a combination of dietary, medicinal and surgical management.

The chosen treatment modality is dictated by the severity and grading of the condition.

Grade I (marked by mild pain and itching sensation) and most cases of Grade II Piles (marked by symptoms of Grade I and recurrent bleeding) can be managed with dietary manipulation and medicines alone. Within Pune, the Healing Hands clinic and its clinical team under the leadership of Dr Ashwin Porwal has come to establish itself as the pioneer centre for care and cure of Piles and other ano-rectal diseases. HHC, Piles clinic in Pune offers one a choice to select from varied streams of medicine (Allopathy/ Homeopathy/ Aryurveda). Moreover, the in-house pharmacists prepare the management plan depending on one’s preference and individual history.

Our dedicated team of dieticians takes care of the daily dietary plans for patients to facilitate the medicinal management.

Surgical options are recommended only if Grade II piles have persisted for more than4 months or in cases of higher grades of piles where prolapse is irreducible.

HHC is also the only centre in Pune that provides piles treatment via the recommended Stapler Surgery which is a minimally invasive procedure that reduces the prolapsed Haemorrhoidal (piles) tissue.

Imagine major surgeries performed through the smallest of incisions.Imagine having the benefits of a definitive treatment but with the potential for significantly less pain, shorter hospital stay, faster return to normal daily activities as well as better clinical outcomes! The product is called "da Vinci " in part, because Leonardo da Vinci invented the first robot. He also used unparelleled anatomical accuracy and three dimensional details to bring his masterpieces to life. It provides surgeons with such enhanced detail and precision that the system can simulate an open surgical environment while allowing operation through tiny incisions. With the da Vinci Surgical system hospitals are rewriting accepted standards for surgical care and changing the experience of surgery. This breakthrough technology is an effective minimally invasive alternative to both open surgery and laparoscopy. Through the use of the da Vinci Surgical system, surgeons are now able to offer a minimally invasive option for complex surgical procedures. Some of the major benefits experienced by surgeons using the da vinci over traditional approaches have been greater surgical precision, increased range of motion,improved dexterity, enhanced visualization and improved access, Benefits experienced by patients include a shorter hospital stay, less pain, less risk of infection, less blood loss, fewer transfusion, less scarring, faster recovery and a quicker return to normal daily activities. None of these can be guaranteed, as surgery is necessarily both patient and procedure specific.
While clinical studies support the effectiveness of the Robotic surgeries, individual results may vary,There are no guarantees of outcome. All surgeries involve the risk of complications. Before you decide on surgery, discuss treatment options with your doctor. Understanding the risk of each treatment can help you make the best decision for your individual situation. It may not be appropriate for every individual, it may not be applicable to your condition. A very common question about robotic surgery is will it make the surgeon unnecessary? On the contrary, it enables surgeons to be more precise,advancing their technique and enhancing their capability in performing complex minimally invasive surgery. The system replicates the surgeons movements in real time. It cannot be programmed, nor can it make decisions on its own to move in any way to perform any type of surgical maneuver without the surgeons input. Does the surgeon have any sensations while performing the procedures ? The system relays some force feedback sensations from the operative field back to the surgeon throughout the procedure. This force feedback substitutes for the tactile sensation and is augmented by the enhanced vision provided by the high resolution 3D view. Although seated at a console few feet away from the patient, the surgeon views an actual image of the surgical field while operating in real time through tiny incisions,using miniaturized, wristed instruments. The system does not maneuver on its own outside of the surgeons direct, real time control.
Robotic surgery, a new tehnology in different parts of the world has its disadvantages also. Its uses and efficacy has not been fully determined. There are not many long term studies on this to confirm or deny its effectiveness. The prominent disadvantages to robotics include Time, Cost , Efficacy and its Compatibility with current and existing conditions. Robotic assisted heart surgeries can take nearly twice the amount of time and the patients are under anaesthesia for longer time . It definitely is more expensive.The cost may fall as surgeons gain more experience and start doing it more often but as the system gets upgraded and improved there are chances that the price may even go higher. Only when these systems gain more multidisciplinary use will the cost become more justified. Another disadvantage is the large system in an overcrowded operating room. The robotic arms are awkward and bulky and there are many instruments needed in the small space. For robotic assisted beating heart surgery the space is even smaller because stabilizers are needed. This cramped area can cause interference with the dexterity of the surgeon. The solution is to miniaturize the robotic arms or have larger operating areas. With either solution, robotics is an especially expensive technology. Current operating room instruments are not compatible with new robotic system. Without the correct equipment, tableside assistance is needed to perform part of the surgery. But with time and improvement in technology, these disadvantages will hopefully be remedied.

Fissure is often confused with piles, and people do not go to doctor for hesitation and shyness. Though the treatment of fissure is simple and does not require hefty spending, due to ignorance of patients and delaying of proper medical intervention, the condition at times becomes critical.

In India, there are many hospitals and clinics which provide treatment services for fissures, fistula and piles. These three diseases are often considered as piles only by patients due to mere ignorance.One can easily find clinics or hospitals who attend to these ailments in any city of the country. Pune, being a hub to fast growing cosmopolitan population, has many such healthcare providers who can provide effective and reliable treatment services. One can easily find healthcare facilities suiting to their budget, if they research about various hospitals and their services.

What is it – Fissure or Fistula or Pile

Before you decide to look for a clinic, you must know what you are looking for or suffering from. Though, it is always better to consult a Proctologist for any advice, the simple description of the three ailments will help you clear confusions,if any, and also come out of shyness and fears of suffering from piles.

Fissure:A small cut at anal margin with skin tags that lead to painful bleeding. The disease is categorized by: Moderate bleeding, severe pain, and low discharge.

Fistula:A smallopening is formed near to the anus from where discharge keeps flowing. The disease is categorized by: Low Bleeding, moderate pain, and heavy discharge.

Piles:Swelling of blood vessels in anal canal, which lead to excessive bleeding. The disease is categorized by: Intense bleeding, low or severe pain, and low or severe discharge.

The symptoms given above can vary depending upon severity of ailment too.Most of the clinics or hospitals commonly provide treatment for all the three ailments.

Fissure treatment in Pune

In Pune, there are many hospitals and clinics which provide treatment for fissures, fistula and piles. Common treatments provided for fissures are:

Conservative approach



Non constipating diet
Topical creams
Vasodilators (Nitric oxide donors) application

For complex fissures

Surgery is the best approach for treating complicated fissures. Various options available are:



Anal sphincter stretching
Anal fissure excision (Fissurectomy)
Sphincterotomy – Done in two ways: Surgery under anesthesia (laser surgery is the new development in the field)or pharmacological way as explained before

About Author:
Dr. Ashwin Porwal, founder of Healing Hands Clinic introduces you to a new world which assures relief from Constipation, Piles, Hernia, Fistula and other anorectal diseases. For more details visit : http://www.healinghandsclinic.co.in/

1. Name of Specialty: General Surgery



2. Name of System of Body: Gastrointestinal system




3. Title of Thesis
and year of submission of thesis: A Study of Surgical Management of Hemorrhoids using Minimally Invasive Procedure for Hemorrhoids (MIPH) -Recent Modality of Treatment . - June 2010



4. Name of the candidate: Dr. Sanap Narayan Arjunrao




5. Name of the Supervisor: Dr. N. Raghupathi RAO, M.S., MAMS, FICS, FICA




6. Name of Hospital: Apollo Hospitals Jubilee Hills Hyderabad.





7. Objectives of the study: to study the efficacy of stapled haemorrhoidectomy in terms of ease of use, time of surgery, intraoperative complications, associated morbidity & advantages and disadvantages.





8.1 Study area: Apollo Hospital Jubliee Hills Hyderabad is a well equipped 334 bedded tertiary care hospital with General Surgery Units serving the population of Hyderabad and surrounding regions. Being a tertiary care hospital, referrals are common for various grades of hemorrhoids for management with minimally invasive procedure. This Study was designed to understand the efficacy of the minimally invasive procedure for hemorrhoids done at our centre in dealing with various grades of hemorrhoids.



8.2 Study population: Data was collected from inpatients cases, mixed population of male and female patients from Hyderabad, and the refereed cases to the hospital from other centers.


8.3 Sample size & sample technique: Total 50 patients were selected randomly according to the inclusion and exclusion criterion.
-Inclusion criteria: 1. Grade II, III, IV Internal or external hemorrhoids in 20 to 70 years age group patients.

-Exclusion criteria: 1. associated with synchronous & metachronous malignant lesion found on
Colonoscopy
2. Exclusion of chrohns’ disease
3. Patient where the internal diameter of rectum will not accommodate the instrument and accessories
4. Patients with associated Grade I hemorrhoids



8.4 Data collection technique and tools: It was a prospective study and data was collected as an interview in the proforma mentioned with the desertation.

8.5 Data analysis: Information collected was categorized as per variables and demonstrated as bar charts.

9. Salient findings:
Age distribution of patients

Majority patients found to be in 41-50yrs age group followed by 51-60yrs group. The youngest was 26 years old and the oldest was 65 years old.

Sex distribution of patients

Incidence of males undergoing stapled hemorrhoidectomy was about 76% in males and about 24% in females.

Associated history

Constipation is seen as most associated history, followed by alcoholism.

Grades distribution

Most of presentation was with grade III, grade II contributes 56% & 30% respectively.

Indication for intervention

Bleeding & prolapse constitutes most common indication for surgery.

Emergency surgery

Total no of 50 cases which were studied over two years 42 cases were operated in routine operation theatre timings and 8 cases were operated on emergency basis

Intraoperative Time of surgery

Peri-operative time for application of stapler for hemorrhoid surgeries about 27.1 min which mostly depends on factors mentioned below

1) Patient position
2) Pursue string suture
3) Surgeons Experience

Mode of anesthesia

We recommend that general anesthesia, epidural or spinal anesthesia as per the requirement and patient fitness for it. It results in an increased relaxation of the anal sphincter muscles and therefore facilitates the insertion of the circular anal dilator without the manual stretch






Early complications

Out of 50 cases, 8 % cases had minimal bleeding, 6% suffered from retention of urine, 2% had haematoma. Most of patient had so minimal pain score of 1-2 in 90% cases. Out of 4 patients 3 had mild bleeding & 1 had moderate bleed, which was on anticoagulant agent.

Time of ambulation

Mostly patients ambulated in same day of surgery 66% in 6-12 hrs &
26% in 12-24 hrs.

Time of rejoin to work

Patients resume their work normally in 2- 3 days and without any discomfort for their daily activities to be performed normally
.
Late complications

During Postoperative follow-up found stricture at anal canal in 1 patient.
Study group was found to be recurrence free over six month follow-up

Follow-up

All the operated patients then were followed up to 6 months.
100% patient followed first visit at day 10, then follow up patient’s decreases to 72% in second visit at 3 month & further 38% at third visit at 6 months, may be due to not having any clinical symptoms.

Stay in hospital

Most of patient treated as day care admission & discharged at home same day advising proper analgesics if necessary with anti constipation agent. Some patients needed 1 day admission in view of insurances policy terms. Very few patients admitted for evaluation & other co morbidity.








10. Conclusions: we concluded that staplers is going to become the part and period considering its various advantages as increased speed, efficacy, less tissue trauma, access to difficult areas of the body, reliability and thus increases the quality of life of the patient by decreasing morbidity to some extent. It can eliminate hemorrhoidal bleeding, successfully eliminates pain in hemorrhoidal disease. It is a minimally invasive procedure which is simple when performed by an expert in it. Operative time for stapled hemorrhoidectomy was shorter compared with conventional techniques. Resumption to pain free defecation was significantly faster in stapled hemorrhoidectomy also was the shorter hospital stay and patients resumed there daily activities and work faster compared to others. No continence and defecation problem was noted neither recurrence seen in all theses studied patients. Staplers being precision devices, they are prone to mechanical faults in careless hands and hence proper training and technical expertise is a must before the application of staplers. Despite of its various advantages this technique is prohibitively costly. However like laparoscopy which was also costly to begin with, the cost of staplers may drop down with its frequent use. Indications for their adequately to other treatment grade two and three hemorrhoids also indicated in the uncomplicated grade four hemorrhoids also. Active sepsis, full thicknesses rectal prolapse is some of its contraindication for using this device. It has been concluded that the staplers are a novel way of doing hemorrhoidal surgeries and has increased the horizons of hemorrhoidal surgery to a great extent. However, technical skills, good on table judgment, intelligence and knowledge of all possible pitfalls and errors of stapling are required to achieve optimal results.





11. Recommendations:
1) Being a simple surgery, short operative time, early ambulation and minimal pain; this procedure can be widely accepted as day care surgery.

2) In the initial stages of learning procedure should be carried out under supervision of a senior surgeon as we technical difficulty and error may lead to inadequate or excess excision & sever post operative pain.

3) Despite of its various advantages this technique is prohibitively costly. However like laparoscopy which was also costly to begin with, the cost of staplers may drop down with its frequent use.

4) We recommend that minimally invasive procedure for hemorrhoids (MIPH) should be used as standard treatment for grade II, III, IV hemorrhoids, as good patient compliance is increasing.

5) Randomized trial and long-term follow-up warrant to determine
possible surgical and functional outcome.