History

The principle behind rubber band ligation technique is actually an ancient one – in 460 BC, Hippocrates wrote about a surgical procedure of ligating or tying a thread around the hemorrhoids to cause them to shrivel.

In the nineteenth century, rubber band ligation experienced increased popularity. However, at the time, this technique involved painfully tying off the hemorrhoids with the surrounding sensitive tissue and skin, and soon it fell into disuse.

In 1958, Blaisdell suggested that only the hemorrhoidal tissue be ligated, resulting in a less painful procedure. Today’s modern technique of rubber band ligation was pioneered by Barron in 1963, who used a special instrument to apply the bands with great precision. In his honor, this technique and instrument are called Barron’s Ligature method and the Barron ligator, respectively.

How It Works

Rubber band ligation works by using a constricting band to stop the blood flow into the hemorrhoids, thus causing them to shrivel and fall off along with the band. This usually happens within 7 to 10 days.

Who Is It Used For?

This technique is effective for treating second-degree hemorrhoids.

Who Shouldn’t Get This Procedure?

Rubber band ligation is not appropriate for treating third-degree piles or even bulky second-degree cases. Hemorrhoids that are previously treated with sclerotherapy are difficult to band, and therefore should not be treated with this procedure.

The Equipment

The original design of the Barron ligator consists of two concentric barrel connected by a long shaft and a handle that move the barrels over each other. By squeezing the handle, a doctor can move the outer barrel over the inner one, and thereby pushes a rubber band forward onto the base of the hemorrhoids.

The band is a small rubber O-ring about 1 mm in diameter and 2.5 mm in thickness.

This simple design has been improved over the past years: for example, the McGiveny ligator also has a short cylinder at the end of the shaft. The hemorrhoidal mass can be maneuvered into this cylinder (manually or by use a vacuum), thus improving the accuracy of the application of the band.

Rubber Band Ligation Procedure

1. Pre-operative Medications
   
   Prior to the procedure, the patient is advised not to take any medications that can cause bleeding, such as aspirin and coumadin.
   
   Pre-operative antibiotics are usually prescribed if the patient is taking steroid medications, has immune system deficiency, or has implanted prosthetic devices such as artificial joints or heart valves.
   
   Pain killers can also be prescribed if the patient has unusually high level of anxiety.
   
   
2. Enema
   
   The patient is usually given an enema to clear the rectum of any stool.
   
   
3. Position
   
   The most common position is the left lateral position, where the patient is laid down on the left side with knees drawn up and buttocks projecting over the edge of the surgical table.
   
   
4. Application of Band
   
   A warmed and lubricated proctoscope is inserted into the anal canal. The hemorrhoid is grasped by a forcep and pulled through the barrel of the ligator. The cylinder is then pushed upward until it reaches the end of the hemorrhoidal tissue. The doctor will then squeeze the handle of the ligator and apply the rubber band on the base of the piles.
   
   Sometimes, two bands are applied at each location to guard against breakage and to ensure that blood supply to the hemorrhoid is properly cut off.
   
   Local anesthetic can be used to reduce post-banding pain. Any sharp pain, however, is most likely due to improper technique (either the band is applied too low below the dentate line in the sensitive anal region or too much sensitive tissue and skin are accidentally banded). In this case, the band should be cut and removed promptly, and then re-applied.

Success Rate

Studies have suggested that rubber band ligation is comparable to other methods of treating hemorrhoids of similar grade. Typically, between 60 to 80% of patients who have undergone this procedure are satisfied with the result.

Controversies

Patients should be aware that although rubber band ligation procedure is popular, there are two main controversies regarding specific techniques:

1. Single vs. Multiple Locations
   
   Barron originally proposed that only a single hemorrhoidal mass be treated at a time for fear of developing anal stenosis (or narrowing of the anal canal, thus causing constipation). If other hemorrhoids are present, they should be treated at 3-week intervals.
   
   Other doctors have subsequently reported that bandings of multiple sites do not cause increased level of discomfort or other side-effects.
   
   
2. Injection of Local Anesthetic
   
   To decrease pain, doctor may inject local anesthetic into the banded location. However, others point out that this does nothing to decrease the normal mild pain after application. Instead, this can mask sharp pain associated with improper application of bands.
   
   Injection of too much anesthetic into general circulation can also cause other health complications, such as complete heart block or arrhythmia where the rhythm of the heartbeat is altered.

Complications

Some possible complications of this procedure are:

1. Pain
   
   The most common complication is severe or sharp pain immediately after band application. This is almost always caused by improper placement of the band either too low in the anal canal. In this case, the band should be removed immediately, and re-applied at locations further above the dentate line.
   
   Mild pain or a feeling of pressure is normal and should go away within one to two hours. Local pain killer can be injected into the site of the application to help alleviate mild pain.
   
   
2. Bleeding
   
   Some bleeding normally occur at the first bowel movement after the procedure. However, severe bleeding which requires hospitalization and blood transfusion is very rare and occurs at a rate of less than 1%.
   
   When the hemorrhoid shrivels and falls off about a week after the procedure, some bleeding is to be expected. If the bleeding does not stop by itself, however, local pressure, local application of adrenaline or stitching may be necessary.
   
   
3. Band slippage
   
   Slippage of the band can occur if there is not enough pile mass to band in the first place. Some doctors may use two bands at each site to avoid failure due to slippage or breakage.
   
   In cases of band slippage, re-application is all that is required.
   
   
4. Infection and Pelvic Sepsis
   
   Although rare, complications involving post-treatment infection and sepsis are very serious and can be life-threatening. In a sepsis, infection from the hemorrhoidal banding site enters the bloodstream to cause a widespread infection. Both infection and sepsis should be immediately treated
   
   Infection is typically preceded with symptoms of pain, fever, and inability to urinate. The doctor should advise the patient to watch for these symptoms, and to seek immediate medical attention if they occur.
   
   
5. Blood clot
   
   In about 5% of patients, a very painful blood clot develops in a condition called thrombosed hemorrhoids. Surgery may be necessary to excise this type of hemorrhoids.
   
   
6. Anal fissure
   
   Fissure develops in about 1% of the patients as a result of sloughing of the hemorrhoid. Although most cases of fissure can be treated by prescribing pain killer medications, some may require surgery.