Haemorrhoid Banding

Introduction

Rubber band ligation is a procedure involving the placement of rubber bands on internal haemorrhoids which are not responsive to home and topical based remedies. The procedure is not performed on external haemorrhoids, alongside those with coagulation disorders due to the risk of bleeding. The placement of the rubber band constricts blood supply to the haemorrhoid and causes it to fall off over time.   

Due to the relatively quick and simple nature of the procedure, no anesthesia is used unless several haemorrhoids need to be banded in one session. Recovery usually involves pain management using standard pain medication such as paracetamol, and bed rest for 2-3 days after the procedure. Particular emphasis is placed on dietary modifications and increased fluid intake to avoid straining when defecating in order to prevent recurrence of haemorrhoids.   

Complications of the procedure range from pain which is relatively common, to more severe complications such as infection and delayed haemorrhage resulting from misplacement of the rubber band.   

What is it?

Haemorrhoid band ligation is the most commonly used treatment for treating symptomatic internal haemorrhoids due to its simplicity, low cost, and low risk for complications. The procedure involves tying off the base of the haemorrhoid with rubber bands, effectively cutting off blood supply to it and causing it to necrose and fall off over time (1).   

Why is it done?

The procedure is only performed on internal haemorrhoids, and hence external haemorrhoids are not treated in this way. Haemorrhoids are typically benign and can usually be left alone. Treatment is only indicated if you feel as if your symptoms are severe enough. Haemorrhoids are usually treated using home remedies and topical creams. If the internal haemorrhoids do not respond to this treatment, they can become increasingly itchy and painful and hence rubber band ligation may be recommended (2).    

Will I need to do any preparation?

Before the procedure, the doctor will evaluate the medications you are currently taking to see if rubber band ligation is a suitable procedure for you. If you are taking anticoagulant medication such as warfarin and clopidogrel, or if you have certain coagulopathies (blood clotting disorders), then rubber band ligation may be contraindicated for you and hence the doctor will discuss alternative approaches. This is due to the risk of delayed bleeding (4).    

Technique

Anaesthesia

Standard haemorrhoid band ligation does not require any local or general anesthesia, however sedation may be given to reduce discomfort and help you relax during the procedure. Please speak to the nurse or doctor before the procedure takes place if you would like to request a sedative, as they will have to go through some safety procedures with you to ensure you are not allergic to the sedative.   

In more severe cases of internal haemorrhoids where there are several haemorrhoids that need to be banded, general anesthetic can be used to mitigate the pain and discomfort. However this is relatively rare and if several haemorrhoids need to be banded, it is more common for the doctor to schedule multiple rubber band ligation appointments with sufficient time in between to ensure the area has healed. 

What does it involve?

 

On arrival at the department, a member of the nursing team will conduct an initial assessment and you will be provided with a consent form and a gown to change into. 

The procedure is as follows: 

1) You will be placed in either the semi-inverted jackknife or left lateral position. You will be given pillows to help you feel more comfortable. 

2) An anoscope (a viewing instrument) is inserted into the anus, allowing the doctor to visualise the haemorrhoids. 

3) The doctors will identify the largest haemorrhoid first and hold it with forceps. 

4) The trigger on the end of the rubber ring ligating drum will cause rubber bands to be released onto the haemorrhoid. 

5) At this point, you will be asked about any pain to assess whether the rubber band has been placed in the correct position. 

6) Once the rubber bands have been assessed to be correctly fitted, the equipment will be removed and the area cleaned. 

In the next 3-5 days after discharge, the rubber band will cause the haemorrhoid to thrombose and become ischemic. Eventually, the haemorrhoid shrinks and falls off, resulting in damaged tissue which takes several weeks to fully recover (5).   

How long does it take?

The whole procedure is short and is usually completed within 20 minutes. If there are 2-3 haemorrhoids present, then they can all be banded in one session as long as you are comfortable and can tolerate it. 

Post procedure course (follow up)

Since rubber band ligation is an outpatient procedure, you will be allowed to go back home once the procedure is done. Usually, between 1-2 haemorrhoids can be banded in any given session provided that general anesthetic is not used. Hence if you have haemorrhoids remaining that have not been banded, you will need to have the procedure repeated and will be given a follow up appointment after 6-8 weeks to ensure that tissue from the original procedure has healed properly.  

It is recommended to try not open your bowels until the day after your banding, however this may not always be possible. 

How long will I stay in hospital?

The procedure is usually conducted as an outpatient procedure and hence you will not need to stay overnight in hospital as long as there are no complications.   

What care will I need at home?

Most people may require 2-3 days of bed rest to allow for the pain to fully subside. Standard pain relief such as Paracetamol can be used to reduce the pain, alongside warm baths with sitz salts. If you take aspirin and any NSAIDs, the doctor will advise you to avoid taking these in the few days before and after your operation to reduce the risks of any delayed bleeding. The haemorrhoid is likely to fall off between 7-10 days after surgery, and hence a small amount of bleeding may occur at this stage; although this is minor and likely to stop by itself.    

Will I need someone to stay with me?

This is not necessary.

What follow up care is needed?

The doctor will advise you on any dietary and behavioural changes required to be taken to reduce the risk of haemorrhoid recurrence. These include taking stool softeners and ensuring plenty of fibre and fluid intake to prevent straining when defecating, which increases the likelihood of haemorrhoid formation (6). 

While rubber band ligation is generally a safe procedure with few complications, if you experience a severe amount of bleeding at home or develop a high fever with pain, please seek urgent medical attention at the nearest Accident and Emergency Department.   

When can I start my normal activities (e.g. driving, sports, or work?)

After discharge, the doctor will recommend you to return to normal activities as you see fit.