Pre/Post Operative Instructions

Piles or hemorrhoids are vascular cushion in the anal canal, which are contributing with the anal muscles, called anal sphincters, to maintain continence to stool and gas. At times and for different reasons haemorrhoids can become swollen. When veins in the lining of the anus and rectum become enlarged, they are filled with excess blood, and cause the underlying tissues to also swell, forming abnormal lumps. It occurs at any age but most commonly in individuals over 50 years of age.

Hemorrhoids are classified into two types. They include:

  • Internal hemorrhoids: These are swellings that develop inside the anus. You may not be able to see or feel them. Sometimes, they may protrude through the anus to form external hemorrhoids.
  • External hemorrhoids: These are swellings that develop outside the anus while passing stools. You may be able to see and feel them. Formations of blood clots in external hemorrhoids are called thrombosedhemorrhoids and are extremely painful.

Piles are caused due to excessive abdominal pressure from standing or sitting for long periods, being obese, pregnancy and straining during constipation. Diet plays an important role in causing and preventing piles. People who consume more processed food, and less fibre and fluids may develop piles as a result of producing hard stools and straining during bowel movements.

Signs & Symptoms

Some of the commonly occurring signs and symptoms of piles (hemorrhoids) include:

  • Bleeding after a bowel movement (bright red blood)
  • Prolapse of a pile through the anus
  • Mucus discharge after a bowel movement
  • Sore, inflamed and itchy anus
  • Sensation that the bowels are not emptied completely
  • Sensitive or painful lump near the anus

The symptoms usually depend on the location of the piles in and around the anus. Piles that lie inside your rectum do not cause any discomfort, but bleeding may occur when they are irritated or while straining to pass stools. Sometimes, an internal hemorrhoid is pushed through the anus during straining, which may cause pain and irritation.

External piles may bleed and itch when they are irritated. These may also become severely inflamed, swollen and painful if a blood clot forms. The formation of blood clots in hemorrhoids is called perianal hematoma or thrombosed external hemorrhoid. External piles may form skin tags (painless soft tissue) at the edge of the anus, making it difficult to clean the anal region after a bowel movement. This increases the probability of skin infections.

Rectal bleeding may be a symptom of other conditions. Some of the symptoms such as passing black or maroon stools or blood clots may indicate bleeding at other locations in your digestive tract. In such cases, your doctor may order diagnostic tests to rule out other conditions.

Screening & diagnosis

On presenting with symptoms of piles, your doctor will conduct a thorough medical history and physical examination. Physical examination can help identify external piles that form on or around the anus. The following tests may be conducted to diagnose internal piles:

Digital rectal examination: Your doctor will insert a lubricated gloved finger into your rectum to detect abnormal growths. However, internal piles may be so small that they cannot be detected by digital rectal examination. Inform your doctor if you experience intense pain or discomfort during the procedure.

Anoscope, proctoscope, sigmoidoscope or colonoscope: These scopes are flexible lighted tubes that help your doctor to view your anus, rectum, and lower colon for abnormal lumps. Your doctor may recommend colonoscopy if you are at a high risk of developing colorectal neoplasms or are suspected to have some other disease of the digestive system.

Some other tests include:

  • Biopsy: If required, a sample of tissue can be removed for analysis.
  • Blood tests: If you experience heavy bleeding, your doctor may order blood tests to evaluate red blood cell count or haemoglobin (oxygen-transporting protein in blood) levels.

Treatment options

Piles usually do not require treatment as they often disappear after a few days. However, discomfort and itching may be treated with various options.

Dietary and lifestyle modifications

If the main cause for the formation of piles is constipation, the first line of treatment usually involves softening and regularizing stools. The symptoms of piles can be relieved with dietary changes and lifestyle modifications. A high fibre diet, including fruits, vegetables, whole grain cereals and breads can help to soften stools and avoid straining. Your doctor will also advise you to increase your water consumption and exercise regularly to avoid constipation. Soaking yourself in warm water for 10 minutes several times a day may also provide relief.


Your doctor may suggest short-term remedies such as over-the-counter creams, ointments, or suppositories to relieve pain, swelling, inflammation and itching. Avoid using them for a longer time as they may damage the skin around your anus. Your doctor may prescribe pain killers to treat painful piles, and laxatives to soften stools and empty your bowels.

Mnimally invasive procedures

When blood clots form in external hemorrhoids, your doctor will make a simple incision and remove the clot. Piles that are painful and bleed continuously may be treated with minimally invasive procedures. These include:

  • Rubber band ligation: This procedure involves placing tight elastic rubber bands at the base of an internal pile. The bands cut off blood supply causing the piles to fall off within a week. You may experience slight bleeding after the procedure. Rubber band ligation of piles should be limited to grade 1 and grade 2 haemorrhoids which are well above the dentate line as below that line the area is very painful
  • Transanal hemorrhoidal dearterialization or THD: This procedure does not deal directly with piles but instead is focused on identified the artery which is feeding the hemorrhoids and performed a precise ligation of it. The procedure is then completed with superficial continuous suturing of the lining above the hemorrhoidal tissue in order to lift the prolapsed hemorrhoidal tissue inside the anal canal. This procedure is completed under general anesthesia but is a fully day cases procedure and it does not required overnight stay. This type of procedure is also extremely well tolerated by the patient causing a minimal amount of pain that usually subsides in few days. The recovery and the time off work are also extremely limited usually within a week.

Transanal Hemorrhoidal Dearterialization THD

Pre/Post Operative Instructions

Transanal Hemorrhoidal Dearterialization - THD

The aim of this information sheet is to provide an answer the most frequently asked questions about THD procedure. Additional and detailed information on the technique of this procedure can be found in the Educational Video and Presentation in this website

Transanal Hemorrhoidal Dearterialization or THD is an innovative procedure which has completely transformed the way we can treat symptomatic hemorrhoid disease.

The principle of this procedure is to recognize and treat the cause which is responsible of transforming normal hemorrhoids into a swollen and inflamed tissue.

Hemorrhoid tissue removal through conventional surgical excision, laser treatment, photocoagulation or injection of sclerosing material, has been the standard for many years. THD is instead a procedure which respects the integrity of hemorrhoids as organ. As a vascular cushions sited at the end of the anal canal, hemorrhoids have an important role in maintaining the continence to feces, and their removal may be associated various degree of either transitory or permanent disturbance of the continence. THD aims to reduce the blood supply of the hemorrhoids with precise tying of their arterial blood supply associated with accurate suture or pexy of the internal lining or mucosa above the level of the hemorrhoid, which allows repositioning prolapsed tissue back into the anal. Such a procedure is performed as a day case surgery under general anesthesia without need to stay overnight. THD does not require preoperative bowel preparation of any type. Light diet is advised few days before the procedure. This procedure may be at times associated with Colonoscopy according to the patient circumstances and this case bowel preparation is required as per colonoscopy instruction. The procedure is completed with anesthetic block of inferior hemorrhoid nerve achieved with two injections close to the site of surgery.

What to expect after the procedure?

The vast majority of the patient during the first 24 to 48 hours after surgery complains a various degree of tenesmus, which is the urge pass stool even if the need is not really due to the presence of stool in the rectal ampulla. This is due to the presence of multiple ties in the anal canal that may trigger the reflex of passing stools. This symptom generally disappears within 48 hours after surgery but in certain individuals may drag a bit longer. Significant pain is very unusual. Patient may experience small traces of blood when they pass motion and a mild laxative will be prescribed on discharge in case the patient has history of constipation. Immediately after surgery patient may have shower or bath as there are no open wound and can also enjoy light physical activity. Diet can be resumed accordingly to the patient preferences but certainly avoiding heavy meals in the immediate postoperative days. Complete operation note, Discharge summary and sick note, when required will be provided before the patient leaves the hospital.

What activity would I be able to perform immediately after surgery?

Light physical activity can be sustained immediately after surgery and full physical activity can generally be resumed after one week. Full recovery happens usually within a week. Patients are generally able to resume work after few days although it is recommended to remain off work for one week. Sick leave will be granted accordingly.

What are the complications of this surgery?

THD is a very safe procedure as it is not associated to any open wound which requires healing time. Minor episodes of bleeding have been reported but they are generally very rare. Dr Cristaldi has been performing regularly this type of procedure since 2006, first in England where he introduced the procedure and then in the UAE where he performed the first THD done in the country in 2009. Since then he has performed more than 500 THD’s and he has been official trainer for this procedure in the Gulf region.

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  • The University of Milan
  • Oxford University Hospitals
  • The University of Milan
  • Oxford University Hospitals
  • The University of Milan