Background Information:

What are the other Names for the Procedure?

• Rubber-Band Ligation

What is Hemorrhoid Banding surgical procedure?

• Hemorrhoid Banding or Rubber-Band Ligation is by far the most frequently practiced technique in office-based procedures for hemorrhoids (swollen veins in the rectum). It may also be performed in an endoscopy room or operating room, under sedation
• The technique uses an instrument that delivers 1 or 2 circular rubber rings around an internal hemorrhoid at the base, to constrict the blood supply
• Due to a lack of blood supply, the hemorrhoid tissue will die and subsequently slough off

What part of the Body does the Procedure involve?

A Hemorrhoid Banding procedure involves the anal canal and lower rectum.

Why is the Hemorrhoid Banding surgical procedure Performed?

A Hemorrhoid Banding procedure is performed for symptomatic internal hemorrhoids.

• Hemorrhoids are swollen and inflamed blood vessels located inside the rectum, or around the anus
• Hemorrhoids are classified into 2 types - internal hemorrhoids and external hemorrhoids
• These are differentiated by their position with respect to the dentate line (a line which divides the upper two-thirds and lower one-third of the anal canal)
• Internal hemorrhoids are those that originate above the dentate line and external hemorrhoids are those that originate below the dentate line
• Internal hemorrhoids usually present with painless, bright red, rectal bleeding during or following a bowel movement. The blood is on the toilet paper or drips into the toilet bowl. Usually, the stool itself appears normally-colored
• Other symptoms may include mucous discharge, a perianal mass, if they prolapse through the anus, itchiness, and fecal incontinence. They are usually only painful, if they become thrombosed or necrotic
• External hemorrhoids are generally painful when thrombosed - blood inside the hemorrhoid clots

Internal hemorrhoids are classified into 4 grades, based on the degree of prolapse:

• Grade I: No prolapse
• Grade II: Prolapse upon bearing down, but spontaneously reduces
• Grade III: Prolapse upon bearing down and requires manual reduction
• Grade IV: Prolapsed and cannot be manually reduced

What are some Alternative Choices for the Procedure?

• Other procedures may include sclerotherapy, infrared coagulation, bipolar coagulation, and direct current electrotherapy, all of which are performed through the anoscope
• All of these techniques attempt to decrease the vascularity of the internal hemorrhoid, thereby making it to slough-off

What are the Recent Advances in the Procedure?

Stapled hemorrhoidopexy is a recent advancement to the procedure:

• Stapled hemorrhoidopexy is performed under general anesthesia
• The surgeon uses a stapling device to anchor the hemorrhoids in their normal position
• The patient goes home the same day, after the procedure
• Research is now under way comparing stapled hemorrhoidopexy with Rubber Band Ligation and hemorrhoidectomy as a first-line treatment for internal hemorrhoids.

What is the Cost of performing the Hemorrhoid Banding surgical procedure?

The cost of Hemorrhoid Banding procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Hemorrhoid Banding procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://hospitals.unm.edu/gastro/procedures/hemorrhoid-banding.html (accessed on May 18, 2014)

http://www.health.harvard.edu/newsweek/Hemorrhoids_and_what_to_do_about_them.htm (accessed on May 18, 2014)

http://www.mayoclinic.org/hemorrhoids/ (accessed on May 18, 2014)

Prior to Hemorrhoid Banding surgical procedure:

How is the Hemorrhoid Banding surgical procedure Performed?

A Hemorrhoid Banding procedure is most frequently performed in the office.

• Typically, sedation or anesthesia is not administered for this procedure
• The patient is asked to lie on the left side. The physician slowly advances an anoscope (a cone-shaped rigid instrument with a light source) into the rectum and examines the anal canal and lower rectum
• Then, the rubber-band deploying device is used and the rings are placed, at the base of the hemorrhoid
• In some devices, the hemorrhoid tissue can be suctioned into a plastic cap and then the rubber band is deployed, at the base of the suctioned tissue.
• There are no pain nerve endings in the lining of the rectum, and therefore one should not feel pain during the procedure
• The procedure itself usually takes approximately 10 minutes and the rubber band usually lasts between 2-10 days

Where is the Procedure Performed?

• A Hemorrhoid Banding is usually performed in the physician’s clinic or office
• It may also be performed in an out-patient surgery center facility or a hospital. Normally, the individual can go home, once the procedure is completed

Who Performs the Procedure?

The Hemorrhoid Banding procedure is performed by a trained physician or a general surgeon.

How long will the Procedure take?

It usually takes 10-15 minutes to complete the Hemorrhoid Banding procedure.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Hemorrhoid Banding procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Hemorrhoid Banding surgical procedure?

Examination of anus and lower rectum is performed by the physician, with the help of an anoscope. The healthcare provider may perform other tests, as required.

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Hemorrhoid Banding procedure?
• Why is this procedure necessary? How will it help?
• What does the procedure involve?
• How soon should I get it done? Is there an emergency?
• Who are the medical personnel involved in this procedure?
• What are the risks while performing the procedure?
• What are the possible complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any lifestyle restrictions or modifications required, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• What are the costs involved?

During the Hemorrhoid Banding surgical procedure:

What kind of Anesthesia is given, during the Procedure?

Typically, no sedation or anesthesia is administered for the Hemorrhoid Banding procedure.

How much Blood will you lose, during the Procedure?

There is very little to no blood loss involved in this Hemorrhoid Banding procedure.

What are the possible Risks and Complications during the Hemorrhoid Banding surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the surgery are:

• Bleeding
• Pain
• Discomfort
• Infection
• Local abscess
• Pelvic sepsis syndrome: This condition can be fatal, though the exact reasons are unknown

Typically, patient experiences a triad of symptoms that include severe pain, urinary retention, and fever. Patients developing any of these symptoms after band ligation must be evaluated for pelvic sepsis syndrome and should be warned at the time of the procedure. Fortunately, this is a rare complication.

What Post-Operative Care is needed at the Healthcare Facility after the Hemorrhoid Banding surgical procedure?

At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise.

After the Hemorrhoid Banding surgical procedure:

What are the possible Risks and Complications after the Hemorrhoid Banding surgical procedure?

Post Hemorrhoid Banding procedure, the following complications may arise:

• Bleeding
• Pain and discomfort
• Infection

What is the Prognosis after the Surgery?

• Rubber-Band Ligation is a durable procedure
• The control of symptoms is typically good
• Recurrent symptoms can occur over time, but years of successful control of symptoms is likely
• Less than 10% of patients have persistent symptoms that require surgery

When do you need to call your Physician?

Do contact your physician, if you notice any of the following symptoms:

• Persistent anal pain
• Urinary retention
• Swelling and redness
• Bleeding
• Fever
• Dizziness
• Signs of infection

What Post-Operative Care is needed at Home after the Hemorrhoid Banding surgical procedure?

At home, the following post-operative care is recommended, after a Hemorrhoid Banding procedure:

• Avoid any possibilities of constipation, take medications, if required to do so (per advise of physician)
• Increase fiber content in the diet
• Take plenty of fluids
• Avoid pain killers, unless prescribed

How long does it normally take to fully recover, from the Procedure?

• Discomfort can last for days (but is generally 24-48 hours)
• Band retention usually lasts for 2-10 days
• A single hemorrhoid or multiple hemorrhoids may be treated per session
• Discomfort increases with the number of hemorrhoids treated in a session, and most surgeons do not advocate banding 3 columns in one setting
• If only one hemorrhoid is banded at the first encounter, it can give the patient an introduction to the treatment. At a repeat visit, more columns can be treated at one time, because the patient is experienced
• Repeat banding is best performed after a 4-week interval, to allow the inflammatory response to subside

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The procedure does not involve the surgical removal of any tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Hemorrhoid Banding surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility, physician’s office or hospital
• A family physician or a general surgeon

Individuals are advised to inquire and confirm the type of billing, before the Hemorrhoid Banding procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA