Haemorrhoids (Piles) is a condition in which the veins around the anus or lower rectum are swollen and inflamed. Haemorrhoids arise from congestion of internal or external venous plexuses around the anal canal. Haemorrhoids are both inside and above the anus (internal) or under the skin around the anus (external).

1) INTERNAL HAEMORRHOIDS
This form of hemorrhoid is inside the rectum. Internal haemorrhoids usually don’t causepain or protrude from the anus during bowel movements, but they may bleed. However, an internal hemorrhoid that prolapses or extends outside the anus can be quite painful.

2) EXTERNAL HAEMORRHOIDS
This form of hemorrhoid is located around the anus and when inflamed feels like a hardlump. They are covered by skin, are very sensitive to touch and can bleed, especiallywhile straining during a hard bowel movement.

STAGES OF HAEMORRHOIDS
Haemorrhoids are classified according to their size:

1st Degree	Remain in the rectum
2nd Degree	Prolapse through the anus on defecation but spontaneously reduce
3rd Degree	Prolapse through the anus on defecation but require digital reduction
4th Degree	Remain persistently prolapsed

CAUSES OF HAEMORRHOIDS

1. Constipation- Most common cause
2. Hard stools/straining during bowel movement
3. Faulty toilet habits (sitting on the toilet for a long time ex. Reading/using smartphone/texting)
4. Family history
5. Pregnancy and childbirth
6. Lifting heavy weights
7. Obesity

SYMPTOMS OF HAEMORRHOIDS

1. Painless bleeding while passing stools
2. Feeling a lump outside the anus
3. Unable to sit
4. Pruritus ani or itching around the anus
5. Faecal soiling of undergarments
6. If a blood clot forms in the haemorrhoid (Thrombosedhaemorrhoid) it leads to a    
7. severely painful swelling which worsens with bowel movement and sitting.

DIAGNOSIS OF PILES
A medical history followed by visual examination of the anus. Adigital examination and Proctoscopy (a scope is inserted to examine the anal canal) is done to confirm the diagnosis. At times a Barium study or Colonoscopy may be advised if your doctor suspects any other cause of bleeding that needs to be ruled out.

LASER HEMORRHOIDOPLASTY / LHP
It is a minimally invasive approach used for treatment of haemorrhoids. The energy of the laser is inserted centrally into the hemorrhoidal mass resulting in successive shrinkage of the piles.

The controlled laser energy obliterates the mass from inside and preserves themucosa and sphincter structure. The homogenous laser emission from the LHPfiber results in:

1. Closure of the arteries entering the haemorrhoidal cushion
2. Tissue reduction in the haemorrhoidal mass
3. Maximum preservation of muscle, anal lining and mucosa
4. Restoration of the natural anatomical structure

The controlled emission of laser energy which is applied submucosally with a specially designed laser fibre, causes the hemorrhoidal mass to shrink. In addition, fibrotic reconstruction generates new connective tissue, which ensures that the mucosa adheres to the underlying tissue. This prevents reoccurrence of a haemorrhoids. No foreign materials need to be inserted and unlike other procedures, LHP is not associated with any risk of stenosis.
Healing is excellent because, unlike conventional surgeries there are no incisions or stitches.

ADVANTAGES OF LHP

1. No cuts, no open wounds
2. Less post-operative pain as compared to other procedures
3. Healing is excellent as there are no cuts or stitches
4. No sense of urgency (need to rush to the toilet) after the procedure
5. No risk of rectal stenosis
6. Patient can return to normal activities within a shorter space of time

POTENTIAL DRAWBACKS OF LHP

1. Burning sensation
2. External skin tag thrombosis
3. May take few weeks for complete shrinkage

MIPH (Minimally Invasive Procedure for Haemorrhoids)
PPH (Procedure for Prolapse and Haemorrhoids)
Stapler Haemorrhoidopexy

It is a procedure that was originally conceived in 1994 by Dr Antonio Longo, and has since gained popularity as the treatment for large Grade 3 and Grade 4 prolapsed Piles.

Using the circular stapler, the mucosa which is responsible for the prolapsed of haemorrhoids is circumferentially excised and the prolapsed Haemorrhoids are pulled up back to their normal position.

ADVANTAGES OF MIPH / PPH
The Stapler procedure has definite advantages over other treatments available for Piles.

1. No external cuts / stitches
2. Minimal blood loss
3. Minimal pain
4. Sphincter function is not hampered hence voluntary control over motion is preserved
5. Faster recovery
6. Low recurrence rate (8%)

POTENTIAL DRAWBACKS
As with any surgical procedure there are possible drawbacks associated with MIPH.

1. Inflammation or Infection-Can be prevented with anti-inflammatory agents and antibiotics
2. Urgency (i.e. need to rush to the toilet) – May last for 4-8 weeks. This can be kept under control with Kegels exercises
3. Bleeding following the procedure (6-8%)
4. Staple line stricture (~5%)
5. Recurrence (8%)

Post operative care after Minimally invasive surgeries for haemorrhoids
Surgery for haemorrhoid is like taking a small nap! All you will feel is a small needleprick during your preparation for the procedure. The entire surgery takes about 30-45 minutes.
Patient can generally be able to start drinking water shortly after the procedure and can start eating subsequently after surgeons permission. Patient will be able to get outof bed a few hours after surgery.
You are likely to have some pain after the procedure that is easily controlled with painkillers. You can expect a small amount of bleeding and wearing a pad will protect your clothes from getting soiled.
Patient can be discharged by evening of the surgery if the effect of the anaesthesia has worn off, have passed urine and is feeling comfortable, eating and drinking. However, it is always advisable to stay overnight in the hospital for close observation. At the time of discharge patient will be advised about post-operative care and medication.
In post operativeperiod,  passage of stools may be uncomfortable at first and there could be a sense of 'urgency' (need to rush to the toilet). You may notice mild blood loss after bowel movement but this will gradually reduce over the next few days. Maintain hygiene, and wash and keep the operation site clean. It is important to maintain a regular bowel movement that should be well formed but soft. You may need to take prescribed laxatives for 2-4 weeks. Eating a high fiber diet and increasing water / fluid intake will help.
You can return to normal physical when you feel comfortable.
You can return to work usually by the 5th day after the surgery, although this also depends on the type of work you do.
Patient may need to come back for follow up after 1 week of discharge or as prescribed by surgeon. However, meet the surgeon early if you have

• Fever above 100 F
• Increasing pain, swelling, redness or discharge
• Severe bleeding
• Constipation >3 days