Dr Deepak Varma Gastro Surgeon Cochin

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Surgeries for fistulas and haemorrhoids (piles)


When the anchoring of the anal cushion is disrupted, it causes mucosal and interstitial tissue inflammation in the veins surrounding the anorectum. It is commonly associated with excessive straining during defecation which engorges the anal cushions and inconsistent bowel habits. Surgery is opted for depending on the severity of the condition. Medical management is not adequate especially for grade III and grade IV haemorrhoids and a surgery is imperative for such cases.


Rubber band ligation

An anoscope along with a rubber band ligator (the Lurz-Goltner suction ligator) is used. Acute bleeding of the primary haemorrhoid is first controlled. The haemorrhoid mass is then sucked into a cup and the band is applied to the base of the hemorrhoidal mass. The band will fall away along with the hemorrhoidal mass after a few days. This is an office procedure and does not require hospital admission.


The procedure aims at full-thickness removal of the submucosa and mucosa. Care is taken to avoid any injury to the underlying sphincter muscle. When the mucosa is closed at the end of the surgery, it is called a closed haemorrhoidectomy. When the mucosa is left open, it is called an open haemorrhoidectomy.

Stapler Hemorrhoidectomy

This is a newer, very effective technique in which the haemorrhoids are removed using a sophisticated instrument called stapler. In this, there is no external wound and post-operative pain is negligible, making the recovery of the patient faster and he or she can go back to work early.

Transanal haemorrhoidal arterial ligation

Haemorrhoidal arteries are identified by the Doppler transducer. The opening is then ligated with the help of a special proctoscope.


A tiny channel develops between the skin near the anus (external opening of fistula) and the interior of the anal canal (internal opening). The abnormality is caused due to an improperly healed perianal abscess. A flexible sigmoidoscopy and colonoscopy aid in the diagnosis of fistula.


Seton techniques

A small piece of thread is left in the tract of the fistula due to the high risk of incontinence, which is normally the case when the fistula traverses the sphincter muscles. Multiple operations may be necessary.


Fistulotomy is a procedure that is popularly opted for in 95% of the cases. The entire fistula is laid open and the contents are flushed out. The healing period lasts approximately for about 1 2 months. It may be necessary to leave a thread (seton) after laying open part of the fistulous tract if the fistula is high (tract traverses the sphincter). The thread will be removed after 6 or 8 weeks through a small surgery.

Advancement flap procedures

The procedure is performed when the fistulas are at a high risk of incontinence and are complex in nature. A piece of skin and subcutaneous tissue near the anal opening is advanced to cover the defect of the fistula.


Human tissue is used to prepare a cone-shaped plug, known as a bioprosthetic plug that blocks the internal opening of the fistula. This is stitched on to the fistula to keep it in place. The fibrin glue plug is made of plasma protein and can also be used to seal the fistula.

Our team is an expert in the surgical and non-surgical anal treatments of hemorrhoids and also in dealing with complex fistulas.

Authored by Dr. Deepak Varma, MBBS, MS (General Surgery)

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