Today Mbah Dukun Bagong the Original Indonesian Shaman has guest. She complaints about her anal. She feel comfort while sit and hurt when get pup. she telss that her faeces is bleeding. Whats wrong? Mbah Dukun will explain1. Definition
2. Etiology
3 Classification
4 Therapy and Treatment
Definition
Haemorrhoid is enlarged veins or swelling and inflammation of the plexus hemorroidale veins, of rectum or anus region. Haemorrhoid is a submucosal swelling in the anal canal that contains a venous plexus, the small arteries, and the widened areolae tissue. Increased venous pressure caused by straining ( low-fiber diet ) or hemodynamic changes ( during pregnancy ) causes chronic dilatation of the submucosal venous plexus. Found at 3 o'clock position, 7, and 11 in the anal canal.
Haemorrhoid is enlarged veins or swelling and inflammation of the plexus hemorroidale veins, of rectum or anus region. Haemorrhoid is a submucosal swelling in the anal canal that contains a venous plexus, the small arteries, and the widened areolae tissue. Increased venous pressure caused by straining ( low-fiber diet ) or hemodynamic changes ( during pregnancy ) causes chronic dilatation of the submucosal venous plexus. Found at 3 o'clock position, 7, and 11 in the anal canal.
Etiology
In addition Haemorrhoid also caused by:
1. Heredity
2. Pregnancy due to hormonal changes
3. chronic Obstipation ( constipation).
4. Disease which makes sufferers often push
5. The emphasis of venous blood return flow,
6. More sit position.
7. Chronic diarrhea.
8. stretching
1. Heredity
2. Pregnancy due to hormonal changes
3. chronic Obstipation ( constipation).
4. Disease which makes sufferers often push
5. The emphasis of venous blood return flow,
6. More sit position.
7. Chronic diarrhea.
8. stretching
Classification
Generally, divided into two haemorrhoids, Haemorrhoid Internal and external:
1. Internal Haemorrhoids, swelling occurs in the rectum that can not be seen or touched, usually pink.
2. External Haemorrhoids, anal attacked, causing pain, soreness, and itching. If pushed out by the stool, constipation can lead to clotting ( thrombosis ), which makes the pile of blue - purple.
• Grade 1 are small swellings on the inside lining of the back passage. They cannot be seen or felt from outside the anus. Grade 1 haemorrhoids are common. In some people they enlarge further to grade 2 or more.
• Grade 2 are larger. They may be partly pushed out (prolapse) from the anus when you go to the toilet, but quickly spring back inside again.
• Grade 3 hang out (prolapse) from the anus. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger.
Grade 4 permanently hang down from within the anus, and you cannot push them back inside. They sometimes become quite large.
Haemorrhoid Treatment
1. Non-surgical therapy
a. Drug therapy (medical) / diet
Most people with Haemorrhoids grade I and grade II can be treated by simple local actions and diet advice. Diet (food) should consist of high-fiber foods such as vegetables and fruits. These foods make the blob contents of the colon, but soft, making it easier defecation and excessive straining reduces the necessity. Rectal suppositories and ointments are known to have no significant effect except for the effects of anesthetic and astringent.
Prolapsed Internal Haemorrhoids with edema can usually be put back slowly followed by bed rest and local compress to reduce swelling. Soak sitting with a warm liquid can also relieve pain
b. Sclerotherapy
Sclerotherapy is the injection of chemical solutions that stimulate, for example 5% phenol from vegetable oil. The injection is given into the submucosa in the loose areolar tissue beneath the internal Haemorrhoids with the intention of causing a sterile inflammation that later become fibrotic and scar. Inoculation is done on the upper side of mucocutaneous line with a long needle through anoscope. If the injection done at the right place, there is no pain. Injection complications include infection, acute prostatitis if included prostate, and hypersensitivity reactions to drugs injection.Injection of sclerotic material with advice about food is an effective therapy for Haemorrhoids internal grades I and II, are not appropriate for more severe Haemorrhoids or prolapse.
c. With rubber band ligation
Rubber band ligation is the most popular acts in America to treat Haemorrhoids, because without anesthesia, without sedation, and without hospitalization with a relatively low cost compared to surgery Haemorrhoidectomy techniques. However, these measures are only effective at grade II and III. This technique can actually be very meaningful solution for Haemorrhoid patients who do not want surgery but want therapy effectively. In Indonesia, this tool has not been widely circulated, so the technique is still limited.
This technique is the simplicity only pair at the base of the Haemorrhoid rubber band which serves to clamp the blood vessels of Haemorrhoid. In a few days and despite the Haemorrhoid will cured automatically and ruptured with faeces when defecation. Usually after three to four days. "there will be a scar which useful to prevent Haemorrhoids to recur.
Procedural in using this technique: First, patient with left lateral position, then, anoscope with obturator inserted into the anal canal and then pull the obturator to be able to see. Anoscope used to look at the three locations Haemorrhoids. Put two rubber bands on the ligator with filler cone. Place the forceps into the ligator and insert them into the anoscope. Clamp Haemorrhoid by forceps and then pull into the drum ligator. Press the handle to release the second ligator rubber band to the bottom of Haemorrhoids. Note the appearance of Haemorrhoids after the release of the instrument. Haemorrhoid Ligator has length work seven inches. At one time treatment only tied one Haemorrhoidal complex, whereas next ligation performed within the next 2-4 weeks.
The main complications of this ligation is the onset of pain caused mucocutaneous line exposeda. To avoid this the bracelet is placed far enough from the mucocutaneous line. Severe pain can be caused by infection. Bleeding Haemorrhoids can occur when experiencing necrosis, usually after 70-10 days.
d. Cryotherapy / surgical frozen
Haemorrhoids can also be frozen by low temperatures once using CO2 or NO2, resulting in necrosis and finally fibrosis. If used carefully, and only given to the top of the Haemorrhoids in the rectum anus connection, then cryotherapy achieve results similar to those seen in ligation with rubber bands and no pain. Cold induced through the sonde from the small engine
designed for this process. This action is fast and easy to do in an office or clinic. This therapy is not widely used because of the necrotic mucosa difficult specified extent. Cryotherapy is more suitable for palliative therapy in rectal carcinoma ireponibel
e. Haemorroidal artery ligation (HAL)
Use Doppler ultrasound method Haemorrhoidal Transproctoscopie Artery ligation (TDUHAL). Implementation of this method is quite simple; patients underwent only the binding action of the arteries that leads to the swelling of Haemorrhoids. Characteristic TDUHAL method is employed the tool of Doppler ultrasound and
supporting equipment. In the sophisticated and expensive equipment have doppler transducer, such sensors are equipped loudspeakers. With the help of this tool, doctors may hear the sound pulse so that it can know where the troubled artery. In front of the doppler transducer, there is a small window and lights. From this hole in the artery the doctor performs the binding problem earlier. Approximate fastening point 10 cm from the anus. With the introduction of therapy in the form of sedation in order not anxious, this action only takes 15 minutes plus to recovery from sedation for about 30 minutes, handling the piles in this way is painless means. Post-action is not required special care. Patients do not need to be hospitalized. Only be given antibiotics and analgesic, Haemorrhoids medicine (anusol), and laxatives to make soft of dirt. By doing the binding of arteries, Haemorrhoidal blood supply is no longer received. "In theory, two weeks after the binding, the blood vessels going to die," therefore, over time the lump will shrink, not lost. The success rate of this method is about 80%. TDUHAL best method to handle up to third-degree Haemorrhoids. The more severe Haemorrhoid suffered by patients, the more binding performed.
f. Infra Red coagulation (IRC) / Infra Red Coagulation
With the infrared rays generated by a tool called a photocuagulation, cauterized Haemorrhoids bulge resulting in tissue necrosis and ultimately fibrosis. This method is best used on bleeding Haemorrhoids.
g. Generator galvanized
Haemorrhoidal tissue damaged by direct electrical current from the battery chemistry. This method is most effectively used on internal Haemorrhoids.
h. Bipolar coagulation / bipolar diathermy
The principle remains the same with the other above the Haemorrhoid therapy that is causing tissue necrosis and finally fibrosis. But used as a destroyer of the tissue of high-frequency electromagnetic radiation. In therapy with bipolar diathermy, mucous membranes around the Haemorrhoidal heated by electromagnetic radiation frequency
height until eventually arise tissue damage. This method is effective for internal bleeding Haemorrhoids.
2. Surgical Therapy
a. Haemorrhoidectomy
A surgery and the appointment hemoroidalis plexus and mucosal or without mucosa that is only done on the tissue which really excessive. Indications: Patients with chronic complaints and grade III and IV Haemorrhoids, recurrent bleeding and anemia that doesn’t heal with other simple therapies, Haemorrhoids degrees IV with thrombus and severe pain. Surgical therapy was chosen for patients who experience chronic complaints and in patients with degree III and IV hemorrhoids. Surgical therapy can also be done with recurrent bleeding and anemia that can not be cured by other therapies are more modest. Fourth-degree Haemorrhoidsufferers with thrombosis and severe pain can be helped immediately by haemoroidectomy.
The principle that must be considered in hemoroidektomi is excision which is only done on the tissue that actually redundant. Excision anoderm economically performed on normal skin and does not interfere with the anal sphincter. Excision of this tissue should be combined with the reconstruction of the tunica mucosa because of a deformity of the anal canal due to mucosal prolapse. There are three surgical treatments available today that is conventional surgery (using a knife and scissors), laser surgery (laser beam as a cutting tool) and surgical staplers (using a tool with the working principle of a stapler).
Currently there are three commonly used surgical techniques are:
a. Conventional Surgery
1. Engineering Milligan - Morgan
This technique is used for Haemorrhoidbulge in three main places. This technique was developed in England by Milligan and Morgan in 1973. Hemorrhoidal mass base just above the linea mucocutaneous, hold with hemostats and retracted from the rectum. Then mounted transfiction catgut sutures proximal to the plexus hemoroidalis. It is important to prevent the installation of suture through the internal sphincter muscle. The second hemostat is placed distal to the external hemorrhoids. An elliptical incision is made with a scalpel through the skin and the tunica mucosa around plexus hemoroidalis internus and externus, released from the underlying tissue. Haemorrhoids excised totally. When the dissection reached transfiction cat gut sutures then excised haemorrhoidal ekstrenal under the skin.
After securing hemostasis, the anal mucosa and skin was closed longitudinally with a simple tack. Usually no more than three groups of Haemorrhoidare removed at one time. Rectal stricture can be a complication of excision of the tunica mucosa of the rectum that is too much. So it is better to take too little rather than taking too much tissue.
2. Whitehead Engineering
Surgical technique used for Haemorrhoidthat this circular is to peel the entire Haemorrhoidby exempting from the submucosal and mucosal resection held a circular to the mucosal area. Then try again mucosal continuity.
3. Langenbeck technique
In Langenbeck technique, the internal Haemorrhoidradier clamped with clamps. Perform tack under the clamp with cat gut chromic No. 2 / 0. Then the excision of tissue above the clamps. After the clamps removed and baste under the clamp jaws tied up. This technique is used more often because of how easy and does not contain the risk of formation scar tissue causing stenosis secondary usual.
b. Laser Surgery
In principle, this surgery same with conventional surgery, but only the tool uses a laser cutter. When the laser cut, burned tissue vessels so not much bleeding, not a lot of injuries and with minimal pain.
In the laser surgery, pain decreased because of nerve pain seared participate. In the anus, there are a lot of nerve. In conventional surgery, when postoperative pain will be felt at all when cutting the tissue, nerve fibers nerve fibers did not open due to shrinking while the sheath to contract. While the laser surgery, nerve fibers and nerve sheath attached together, such as engraved so that nerve fibers do not open.
For haemoroidectomy, required laser power 12-14 watts. Once the tissue is removed, the incision soaked antiseptic solution. Within 4-6 weeks, the wound will dry up. This procedure can be performed only by an outpatient basis.
c. Surgical Stapler
This technique is also known by the name of the Procedure for Prolapse Haemorrhoid(PPH) or Haemorrhoids Circular Stapler. This technique was introduced in 1993 by Italian physician named Longo so the technique is also often called the Longo technique. In Indonesia, this tool was introduced in 1999. Tools used in accordance with the principles of working stapler. This tool forms like flashlights, consisting of a circle in front of and driving force behind it. Basically hemorrhoidal tissue is naturally contained in the anal canal. Its function is as a cushion during defecation. Cooperation hemorrhoidal tissue and m. sfinter ani to dilate and constrict ensure control of discharge and feces from the rectum. PPH technique reduces the prolapse of hemorrhoidal tissue by pushing it upward
mucocutaneous line of hemorrhoidal tissue and restore it to its original anatomic position because hemorrhoidal tissue is still needed as a cushion during defecation, so it does not need to be removed all.
At first the prolapsed hemorrhoidal tissue is pushed upwards with a tool called a dilator, and then sewn to the tunica mucosa of the anal wall. Then the stapler device is inserted into the dilator. From stapler issued a bracelet of titanium inserted in the suture and implanted in the upper anal canal to strengthen the position of hemorrhoidal tissue. Part of excess hemorrhoidal tissue into the stapler. By turning the screw located at the tip of the tool, the tool will cut the excess tissue automatically.
Truncated hemorrhoidal tissue with the blood supply to tissues is interrupted so that the hemorrhoidal tissue to deflate by itself. The advantage of this technique is to return to anatomical position, do not interfere with the function of the anus, no anal discharge, pain minimal because of the actions carried out sensitive parts, the action be quick about 20-45 minutes, patients recover more quickly so that the inpatients in the hospital getting shorter.
Although rare, the action has the risk of PPH:
1. If too much tissue that go wasted, will result in damage to rectal wall.
2. If m. sfinter ani internus strechted, can cause dysfunction in both the short and long term.
3. As with other techniques in surgery, pelvic infections have been reported.
4. PPH may fail to Haemorrhoid which too large because it is difficult to gain entrance into the anal canal and even if they could get in, the tissue may be too thick to get into the stapler.
1. Non-surgical therapy
a. Drug therapy (medical) / diet
Most people with Haemorrhoids grade I and grade II can be treated by simple local actions and diet advice. Diet (food) should consist of high-fiber foods such as vegetables and fruits. These foods make the blob contents of the colon, but soft, making it easier defecation and excessive straining reduces the necessity. Rectal suppositories and ointments are known to have no significant effect except for the effects of anesthetic and astringent.
Prolapsed Internal Haemorrhoids with edema can usually be put back slowly followed by bed rest and local compress to reduce swelling. Soak sitting with a warm liquid can also relieve pain
b. Sclerotherapy
Sclerotherapy is the injection of chemical solutions that stimulate, for example 5% phenol from vegetable oil. The injection is given into the submucosa in the loose areolar tissue beneath the internal Haemorrhoids with the intention of causing a sterile inflammation that later become fibrotic and scar. Inoculation is done on the upper side of mucocutaneous line with a long needle through anoscope. If the injection done at the right place, there is no pain. Injection complications include infection, acute prostatitis if included prostate, and hypersensitivity reactions to drugs injection.Injection of sclerotic material with advice about food is an effective therapy for Haemorrhoids internal grades I and II, are not appropriate for more severe Haemorrhoids or prolapse.
c. With rubber band ligation
Rubber band ligation is the most popular acts in America to treat Haemorrhoids, because without anesthesia, without sedation, and without hospitalization with a relatively low cost compared to surgery Haemorrhoidectomy techniques. However, these measures are only effective at grade II and III. This technique can actually be very meaningful solution for Haemorrhoid patients who do not want surgery but want therapy effectively. In Indonesia, this tool has not been widely circulated, so the technique is still limited.
This technique is the simplicity only pair at the base of the Haemorrhoid rubber band which serves to clamp the blood vessels of Haemorrhoid. In a few days and despite the Haemorrhoid will cured automatically and ruptured with faeces when defecation. Usually after three to four days. "there will be a scar which useful to prevent Haemorrhoids to recur.
Procedural in using this technique: First, patient with left lateral position, then, anoscope with obturator inserted into the anal canal and then pull the obturator to be able to see. Anoscope used to look at the three locations Haemorrhoids. Put two rubber bands on the ligator with filler cone. Place the forceps into the ligator and insert them into the anoscope. Clamp Haemorrhoid by forceps and then pull into the drum ligator. Press the handle to release the second ligator rubber band to the bottom of Haemorrhoids. Note the appearance of Haemorrhoids after the release of the instrument. Haemorrhoid Ligator has length work seven inches. At one time treatment only tied one Haemorrhoidal complex, whereas next ligation performed within the next 2-4 weeks.
The main complications of this ligation is the onset of pain caused mucocutaneous line exposeda. To avoid this the bracelet is placed far enough from the mucocutaneous line. Severe pain can be caused by infection. Bleeding Haemorrhoids can occur when experiencing necrosis, usually after 70-10 days.
d. Cryotherapy / surgical frozen
Haemorrhoids can also be frozen by low temperatures once using CO2 or NO2, resulting in necrosis and finally fibrosis. If used carefully, and only given to the top of the Haemorrhoids in the rectum anus connection, then cryotherapy achieve results similar to those seen in ligation with rubber bands and no pain. Cold induced through the sonde from the small engine
designed for this process. This action is fast and easy to do in an office or clinic. This therapy is not widely used because of the necrotic mucosa difficult specified extent. Cryotherapy is more suitable for palliative therapy in rectal carcinoma ireponibel
e. Haemorroidal artery ligation (HAL)
Use Doppler ultrasound method Haemorrhoidal Transproctoscopie Artery ligation (TDUHAL). Implementation of this method is quite simple; patients underwent only the binding action of the arteries that leads to the swelling of Haemorrhoids. Characteristic TDUHAL method is employed the tool of Doppler ultrasound and
supporting equipment. In the sophisticated and expensive equipment have doppler transducer, such sensors are equipped loudspeakers. With the help of this tool, doctors may hear the sound pulse so that it can know where the troubled artery. In front of the doppler transducer, there is a small window and lights. From this hole in the artery the doctor performs the binding problem earlier. Approximate fastening point 10 cm from the anus. With the introduction of therapy in the form of sedation in order not anxious, this action only takes 15 minutes plus to recovery from sedation for about 30 minutes, handling the piles in this way is painless means. Post-action is not required special care. Patients do not need to be hospitalized. Only be given antibiotics and analgesic, Haemorrhoids medicine (anusol), and laxatives to make soft of dirt. By doing the binding of arteries, Haemorrhoidal blood supply is no longer received. "In theory, two weeks after the binding, the blood vessels going to die," therefore, over time the lump will shrink, not lost. The success rate of this method is about 80%. TDUHAL best method to handle up to third-degree Haemorrhoids. The more severe Haemorrhoid suffered by patients, the more binding performed.
f. Infra Red coagulation (IRC) / Infra Red Coagulation
With the infrared rays generated by a tool called a photocuagulation, cauterized Haemorrhoids bulge resulting in tissue necrosis and ultimately fibrosis. This method is best used on bleeding Haemorrhoids.
g. Generator galvanized
Haemorrhoidal tissue damaged by direct electrical current from the battery chemistry. This method is most effectively used on internal Haemorrhoids.
h. Bipolar coagulation / bipolar diathermy
The principle remains the same with the other above the Haemorrhoid therapy that is causing tissue necrosis and finally fibrosis. But used as a destroyer of the tissue of high-frequency electromagnetic radiation. In therapy with bipolar diathermy, mucous membranes around the Haemorrhoidal heated by electromagnetic radiation frequency
height until eventually arise tissue damage. This method is effective for internal bleeding Haemorrhoids.
2. Surgical Therapy
a. Haemorrhoidectomy
A surgery and the appointment hemoroidalis plexus and mucosal or without mucosa that is only done on the tissue which really excessive. Indications: Patients with chronic complaints and grade III and IV Haemorrhoids, recurrent bleeding and anemia that doesn’t heal with other simple therapies, Haemorrhoids degrees IV with thrombus and severe pain. Surgical therapy was chosen for patients who experience chronic complaints and in patients with degree III and IV hemorrhoids. Surgical therapy can also be done with recurrent bleeding and anemia that can not be cured by other therapies are more modest. Fourth-degree Haemorrhoidsufferers with thrombosis and severe pain can be helped immediately by haemoroidectomy.
The principle that must be considered in hemoroidektomi is excision which is only done on the tissue that actually redundant. Excision anoderm economically performed on normal skin and does not interfere with the anal sphincter. Excision of this tissue should be combined with the reconstruction of the tunica mucosa because of a deformity of the anal canal due to mucosal prolapse. There are three surgical treatments available today that is conventional surgery (using a knife and scissors), laser surgery (laser beam as a cutting tool) and surgical staplers (using a tool with the working principle of a stapler).
Currently there are three commonly used surgical techniques are:
a. Conventional Surgery
1. Engineering Milligan - Morgan
This technique is used for Haemorrhoidbulge in three main places. This technique was developed in England by Milligan and Morgan in 1973. Hemorrhoidal mass base just above the linea mucocutaneous, hold with hemostats and retracted from the rectum. Then mounted transfiction catgut sutures proximal to the plexus hemoroidalis. It is important to prevent the installation of suture through the internal sphincter muscle. The second hemostat is placed distal to the external hemorrhoids. An elliptical incision is made with a scalpel through the skin and the tunica mucosa around plexus hemoroidalis internus and externus, released from the underlying tissue. Haemorrhoids excised totally. When the dissection reached transfiction cat gut sutures then excised haemorrhoidal ekstrenal under the skin.
After securing hemostasis, the anal mucosa and skin was closed longitudinally with a simple tack. Usually no more than three groups of Haemorrhoidare removed at one time. Rectal stricture can be a complication of excision of the tunica mucosa of the rectum that is too much. So it is better to take too little rather than taking too much tissue.
2. Whitehead Engineering
Surgical technique used for Haemorrhoidthat this circular is to peel the entire Haemorrhoidby exempting from the submucosal and mucosal resection held a circular to the mucosal area. Then try again mucosal continuity.
3. Langenbeck technique
In Langenbeck technique, the internal Haemorrhoidradier clamped with clamps. Perform tack under the clamp with cat gut chromic No. 2 / 0. Then the excision of tissue above the clamps. After the clamps removed and baste under the clamp jaws tied up. This technique is used more often because of how easy and does not contain the risk of formation scar tissue causing stenosis secondary usual.
b. Laser Surgery
In principle, this surgery same with conventional surgery, but only the tool uses a laser cutter. When the laser cut, burned tissue vessels so not much bleeding, not a lot of injuries and with minimal pain.
In the laser surgery, pain decreased because of nerve pain seared participate. In the anus, there are a lot of nerve. In conventional surgery, when postoperative pain will be felt at all when cutting the tissue, nerve fibers nerve fibers did not open due to shrinking while the sheath to contract. While the laser surgery, nerve fibers and nerve sheath attached together, such as engraved so that nerve fibers do not open.
For haemoroidectomy, required laser power 12-14 watts. Once the tissue is removed, the incision soaked antiseptic solution. Within 4-6 weeks, the wound will dry up. This procedure can be performed only by an outpatient basis.
c. Surgical Stapler
This technique is also known by the name of the Procedure for Prolapse Haemorrhoid(PPH) or Haemorrhoids Circular Stapler. This technique was introduced in 1993 by Italian physician named Longo so the technique is also often called the Longo technique. In Indonesia, this tool was introduced in 1999. Tools used in accordance with the principles of working stapler. This tool forms like flashlights, consisting of a circle in front of and driving force behind it. Basically hemorrhoidal tissue is naturally contained in the anal canal. Its function is as a cushion during defecation. Cooperation hemorrhoidal tissue and m. sfinter ani to dilate and constrict ensure control of discharge and feces from the rectum. PPH technique reduces the prolapse of hemorrhoidal tissue by pushing it upward
mucocutaneous line of hemorrhoidal tissue and restore it to its original anatomic position because hemorrhoidal tissue is still needed as a cushion during defecation, so it does not need to be removed all.
At first the prolapsed hemorrhoidal tissue is pushed upwards with a tool called a dilator, and then sewn to the tunica mucosa of the anal wall. Then the stapler device is inserted into the dilator. From stapler issued a bracelet of titanium inserted in the suture and implanted in the upper anal canal to strengthen the position of hemorrhoidal tissue. Part of excess hemorrhoidal tissue into the stapler. By turning the screw located at the tip of the tool, the tool will cut the excess tissue automatically.
Truncated hemorrhoidal tissue with the blood supply to tissues is interrupted so that the hemorrhoidal tissue to deflate by itself. The advantage of this technique is to return to anatomical position, do not interfere with the function of the anus, no anal discharge, pain minimal because of the actions carried out sensitive parts, the action be quick about 20-45 minutes, patients recover more quickly so that the inpatients in the hospital getting shorter.
Although rare, the action has the risk of PPH:
1. If too much tissue that go wasted, will result in damage to rectal wall.
2. If m. sfinter ani internus strechted, can cause dysfunction in both the short and long term.
3. As with other techniques in surgery, pelvic infections have been reported.
4. PPH may fail to Haemorrhoid which too large because it is difficult to gain entrance into the anal canal and even if they could get in, the tissue may be too thick to get into the stapler.
