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1 Year Author Technique 1869 John Morgan Sclerotherapy (IS) - Mitchell technique (Illinois, USA) 1882 Whitehead Amputative Technique 1935 Milligan, Morgan Open Dissection and ligature - GOLD STANDARD 1955 A.G. Parks Submucosal technique 1960 J.A. Fergusion, US Closed Method 1963 J. Barron Rubber Band Ligation Most Common 1968 P.H. Lord Anal dilatation 1969 Lewis Cryo therapy - Cryosurgery 1970 New Methods for Physical destruction 1970 Sokol Semi-closed technique 1978 Faraq Pile “suture” 1987 Griffith Bipolar diathermy BD (BICAP) 1989 Norman Direct current electrotherapy (Ultroid) 1995 Dr Antonio Longo SH, PPH - Mechanical anopexy with circular clamp 1995 Morinaga, Japan THD or DG HAL Doppler - guided hemorrhoidal artery ligation 1998 Gupta Radiofrequency ablation (RFA) Emborrhoid Superior rectal arteries are occluded with 2015 Vidal embolization coils 2018 Dr. P. B. Patel 4 PF 2 Ideological classification Improving Historic Trial and Error Parks Pre classic Applying Logic Fergison Classic Effective Logic - MMH Sokol Post Classic In Search of Better Option Post classic New Era Intention to Cure Improving Searching new Options Searching New Options Technology New Era Mixed or Hybrid RBL Intention to Cure Sclerotherapy (?) Technology Cryosurgery Preserving Anatomy, New Methods Physiology and Function Lord’s Energy Devices HAL (?)

Personlized, Energy Devices Purposeful, Predictable and New Methods IRC Harmonic Precise Fibrosis (4PF) SH/PPH Laser Starion THD/DG HAL Ligasure Bipolar - BICAP c Emborrhoids 3 Copyright RFA Direct Current - ULTROID Control or Cure

High Recurrence High Complications

Minimal Pain Pain Fast Recovery Slow Recovery

All Haemorrhoidectomy

Other https://requestreduce.org/image/left-and-arrow- clipart/126565.html#gal post 4981 left-and-right-arrow-clipart-15.jpg 4 Comparison of Outcomes Table-2 Comparison of Outcomes Between Different Surgical Procedures for Treatment of Reduction of Procedure Resolution of Prolapsing Likelihood of Amount of Post- Longer Recovery Symptoms tissue (Mucopexy) Recurrence Surgical Pain Time Banding (I.E., Rubber band ligation) ++ ++ ++ ++ ++ +

Infrared Photocoagulation + Not Applicable +++ + +

Open Hemorrhoidectomy +++ ++ + +++ +++

Closed Hemorrhoidectomy +++ ++ + +++ +++

Stapled Hemorrhoidectomy ++ +++ ++ ++ ++ Hemorrhoidal Artery Ligation ++ Not Applicable ++ + + (Without Mucopexy)

Hemorrhoidal Artery Ligation ++ ++ ++ ++ + (With Mucopexy)

+ = Outcome Less Likely. ++ = Outcome Relatively Neutral in comparison with other Surgical Procedures. +++ = Outcome more Likely. Information from references 7,21 and 23 Through 28. Hemorrhoids : Diagnosis and Treatment Options https://www.aafp.org/afp/2018/0201/p172.html 5 Hemorrhoids - Ideological Classification of End Result of Treatment Principle Method Sub Method MuEx ExHe Examples Excision Complete Complete Yes EH - Open, Closed, Semi, Sub More Than Ligation Incomplete No RBL, Ayurvedic - KSHARA SUTRA Remove Laser, Bipolar - BICAP, Direct Destruction Energy Devices Complete ? Current - ULTROID, Ligasure TM , Harmonic R, StarionTM , RFA, Vaporization Atomizer TM Complete Atomizer TM Fixation Pull Up Above No Stapled Hemorrhoidectomy Blood Supply Arterial Ligation No No DG-HAL, RAR may be needed Repair Blood Supply Embolization No No DG - HAL,E RmAbRo rrmhaoyid be Needed Blood Supply Thermal Occlu. No No EDmGb-Lorrahseorid Tone Reduction No No Lord 4PF Only if Yes 4PF Replace Fibrosis Precise No No IRC Diffuse Damage No Sclerotherapy, Cryosurgery, Laser MiX c Copyright MuEX = Mucosal Excision, ExHe = External Hemorrhoids Addressed, EH Excisional Hemorrhoidsectomy EH = Excisional Hemorrhoidectomy, 4PF = Personalized, Purposeful, Predictable and Precise Fibrosis 6 Hemorrhoids - Greading of Frequency and Amount of Bleeding Grade Frequency of Bleeding Amount of Bleeding Grade 0 No No 0 1 Once in Year or Less Countable Drops Or Strip 1 2 Once in a Month or Less Uncountable Drops 2 3 Once in a week or Less Spurt Without Anemia 3 4 With each act / Daily c Copyright Spurt With Anemia 4

Grading External Hemorrhoids Grade External Hemorrhoid 0 No 1 Nonvascular 2 Vascular 3 Increase on Straining

4 Active Bleeding c Copyright 7 CLINICAL GUIDELINES STAPPLE HAEMORRHOIDECTOMY DANISH MEDICAL JOURNAL Table 1 Statements and Level of Evidence Level of Statement Evidence SH is an Effective Treatment for Hemorrhoids la Grade II-III SH has a Higher rate of additional operations, la but less pain than MMH SH Patients return more rapidly to normal la activity compared with MMH SH can be repeated if recurrence occur lla SH have Higher Relapse Rate of prolapse than MMH during long-term la

8 Cochrane Library 2006 Author’s Conclusions Stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and the symptom of prolapse. It is also associated with a higher likelihood of long-term symptom recurrence and the need for additional operations compared to conventional excisional hemorrhoid . Patients should be informed of these risks when being offered the stapled hemorrhoidopexy as surgical therapy if hemorrhoid recurrence and prolapse are the most important clinical outcomes, then conventional excisional srugery remains the “gold standard” in the surgical treatment of internal hemorrhoids. Stapled versus conventional for hemorrhoids (Reveiw)

Lumb KJ, Colquhaun PH, Ma Post Classic – Technology 9 Standard Treatment. The Excision can be performed with a cold scalpel, Diathermy, Scissors, Laser, Ultrasonically activated scalpel of a bipolar electrothermal sealing device. The use of scissors or Laser compared to Diathermy provided no significant benefits (Madoff 2004; Pandini 2006). Conflicting reuslts have been reported concerning the use of an ultrasonically activatede scalpel (Ultracission TM) making impossible to draw definitive conclusions in this respect (Madoff 2004). A bipolar electrothermal sealing device LASER NO DEFINATE ADVANTAGE

Conventional versus Ligasure hemorrhoidectomy for patients with symptomatic Post Classic - Energy Devices 10 Table-3 Int. Surg. 2015 jan; 100(1) 44-57, doi 10.9738/INTSURG-D-13-00173.1 PMCID: PMC4301293 PMID:25594639 Case Reports Documented Complications of Staple Hemorrhoidopexy : A Systematic Review Study Liesel J. Porret,jemma k. Porrett and Yik-hong Ho Treatment Death

Aumann et al37 Intra-abdominal hemorrhage Blouhos et al33 Hemoperitoneum for anterior resection Buyukasik et at33 Rectal obliteration Removal of anal staples Use of manual sutures to repair Ciprani et at40 Tenesmus Mucus soiling Stricture release Rectal bleeding Rectal obstruction Rectal stricture Cirroco11 Hartmann’s Procedure 1 Intestinal obstruction and perforation Sepsis Air retroperitoneum Multi-rgan failure Abdominal exploration Rectal obstruction and perforation Loop Del Castillo et al 36 Repair and colostomy Surgical exploration Filingeri (2005) 85 Rectal performation Sutured perforation closed via transanal route Gao et al85 Passage of fluid per None 1 Staple line dehiscence Rectal perforation Perforation repair Rectal perforation Terminal ileostomy Fever Peritonitis Perforation repair Rectal perforation Transverse colostomy Abdominal pain and distension Perforation repair Peritonitis Colostomy Pain, fever Pelvic drainage Rectal perforation Perforation repair Pain, distension Transverse colostomy Fever, distension Perforation repair Fever Sigmoid colostomy Pain, distension Giaordano et al 41 Fever Rectal obliteration Flexible Gastrografin enema Herold (2000) 86 Rectal Perforation Dilatation Rectal Perforation Temporary stoma Temporary stoma 11 Complex Vascular Anatomy

12 Keloids: Current concepts of pathogenesis (Review) GREGOR M. BRAN, ULRICH R. GOESSLER, KARL HORMANN, FRANK RIEDEL and HANEEN SADICK

Figure 1. Any Disturbance of the delicate balance of normal wound repair leads to a

Distruption of Anatomical Structure of Function 13 Grade III Significant Highly and IV External Vascular

4PF : Pt Selection Challenging

Secondary Circumferentially Prolapsing

-

14 COMPLEX ANATOMY PHYSIOLOGY AND FUNCTION Highly sensitive Anal sphincter - nerve ending extremely dynamic

Influenced by a variety of reflexes Mucosa and Skin Vital specialized sensory end organs

Gastroenterology-2019

C Copyright 15 Precise Damage Precise Fibrosis

Personalized Purposeful Predictable

https://www.sciencedirect.com/science/article /pii/S0945053X1730375X C Copyright Gastroenterology-2019 16 Guiding Principles

• Too Much - Too less • Appropriate - Inappropriate • Lifetime cost • Anatomy Physiology and Function • Sensory Inputs • Fibrosis

17 New Post op Symptoms RBL : Rubber Bend Ligation Unique Complications SH/PPH : Stapled Haemorrhoidectomy Hal : Haemorrhoidal Artery Ligation I Scle : Sclerotherapy n Multiple procedures Not effective for large external or Thrombosed Hemorrhoids a Long term medication p Recurrence p Dr. Visits r o 4PF p RBL r SH HAL No Recurrence I No Follow ups a Scle No Long Term Medications t e

Appropriate C Copyright 18 Re ccurence No recurrence Re Operation No Follow ups Dr. Visits No longterm Medications Long term medication External Haemorrhoids not addressed 4PF T O RBL O SH HAL L E Long Term Medication RBL : Rubber bend ligation Dr. Visits S SH/PPH : Stapled Haemorrhoidectomy Re Operation S HAL : Haemorrhoidal artery ligation Incontinence Scle : Sclero Therapy Stricture EH : Excisional Haemorrhoidectomy EH, ED ED : Energy Devices

TOO MUCH C Copyright 19 C Copyright 20 Ideological classification Historic Trial and Error Pre classic Applying Logic Classic Effective Logic - MMH Post Classic In Search of Better Option New Era Intention to Cure New Era Intention to Cure

Preserving Anatomy, Physiology and Function

Personalized, Purposeful, Predictable and Precise Fibrosis (4PF)

c Copyright 21 C Copyright 2200 Advance Haemorrhoids : Last Line Personalized, Purposeful, Predictable and Precise fibrosis (4PF)

Discharge Pruritus Pain Limitations First Research Single Institutional Study @Nidhi Bias Conclusions and Implications Potential to Replace

All Available Surgical Methods C Copyright 23 30+ years of experience

Key Life Time Cost Fibrosis New Way of Thinking

Dr. P.B. Patel MS, ADIT Shiv Shraddha Nursing Home Request For Opp. Rajasthan Hospitals, Keynote Address Free Book / PDF Shahibaug, Ahmedabad-4. (Guj.) INDIA Lecture Be Part of Research Mob. : 98 98 98 98 96 26 Full Text [email protected] 24