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More on ligation and sclerosis of hemorrhoids

As I have written in other posts, ligation and sclerosis of hemorrhoids are the two techniques that I associate in my outpatient treatment protocol for internal hemorrhoids.
Therefore, I thought I would post two short videos of mine (short but actually absolutely adhering to the actual time of performance of the two procedures) that make clear how sclerosis and ligation are accomplished.
First a brief summary of the indications and how the technique is performed:

  • instrumental treatment is indicated in grade 2 internal hemorrhoids; in experienced hands, even in theLigation and sclerosis of hemorrhoids, internal hemorrhoids Grade 3 hemorrhoids in mucosal prolapses
  • Hemorrhoid ligation involves "shooting" a rubber band around each hemorrhoid packet; in this way, the packet strangles, goes into necrosis, and after a few days comes off and is eliminated with feces
  • sclerosis is accomplished by injecting the hemorrhoid packets and underlying mucosa with a sclerosing substance, kinurea, which causes fibrosis of the packets.

These practices are simple, very effective, cause no pain, and are performed on an outpatient basis without the need for any type of anesthesia or sedation.

Let's start with elastic ligation: our protocol includes six sessions, one for each hemorrhoid group:

At the end of the ligation sessions, two sclerosis sessions are performed to strengthen the adhesion of the mucosa to the underlying muscle wall:

Treatment with ligation and sclerosis of hemorrhoids is followed by annual outpatient checkups.


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Dr. Salvatore Cuccomarino
Ligation and sclerosis of hemorrhoids, BOTOX treatment of anal fissures, coloproctology, laparoscopic surgery, treatment of diverticulitis, minimally invasive surgery of hernias and diastasis of the rectus
61 Amerigo Vespucci Street
Phone 0110438161


what is a hernia
I have a hernia-but what is a hernia!!!?

Often, when we talk to our patients, we forget that medical language is a kind of "initiatory" language, little understood by those outside the environment. Therefore, the patient knows he has something but does not always know what.

This is especially true for conditions that are considered "minor" (which they are not): if the person in front of me has a tumor, I spend a lot of time explaining his situation well; but if he has an inguinal hernia, or hemorrhoids, I take it for granted that he already knows what it is, and I don't waste too much time in explanations.
But is it really a matter of wasting time? How many people really know what a hernia is-and, consequently, are able to understand whether and how dangerous it is?

Let's try to get some clarity.

What is a hernia

"A hernia is defined as the exit of a viscera from the cavity that normally contains it, through an orifice, an anatomical channel, or otherwise a continuous solution."

This is the classic definition of hernia, of any hernia, from inguinal hernia to herniated disc; but it is not so readily understood unless one has at least some basic knowledge of anatomy.

So let's try to reason by similarity. If you are of my generation, the generation of kids who when they punctured a bicycle tire did not change it but patched the inner tube, it will come easy to you.

Think precisely of a tire; and imagine that the tire tears, and out of the tear comes the inner tube, as in the photograph below: that's what a hernia is: the tear represents "the orifice, anatomical channel or otherwise continuous solution" of the definition from before; what we surgeons call "the herniated defect."

what is a hernia, abdominal hernia, inguinal hernia

The air chamber that comes out of the tear is the "hernial sac": in the case of the inguinal hernia, it is the peritoneum that used to line the "torn" inguinal wall on the inside and now peeps through the tear itself.

If then the sac contains a "viscera" that has pushed through the "tear"-and which in the case of an abdominal hernia (abdominal hernias are, depending on where in the abdominal wall they occur, inguinal hernia, crural hernia, umbilical hernia, epigastric hernia, Spigelius hernia...) is usually fat (the omentum) or a piece of intestine-these are the "herniary contents." Easy, right?

Now that (I hope) it is clear what a hernia is, let's come to the other question: why can a hernia be dangerous and must be operated on? Well, in abdominal hernias--of which the most common are inguino-crural and umbilical--and particularly, paradoxically, in those in which the defect is small, it is possible, as already mentioned, for the herniated content to be an intestinal loop. Sometimes, it happens that the leaked loop cannot be "reduced," that is, relocated to its natural position inside the abdomen. This is referred to in this case as an incarcerated hernia. The incarcerated loop, because of the compression it undergoes, becomes soaked with fluid and "swells," and this can cause compression of the arteries and veins that supply it. This is strangulated hernia, an extremely life-threatening condition because it is at very high risk of necrosis (i.e., death) of the intestinal loop and its perforation (as in the case of the photo opposite).

That is why all hernias should be referred to a surgeon experienced in abdominal wall surgery, the only specialist who can determine whether to operate, when, and with what technique.

inguinal hernia
Stitches no, stitches yes-Mr. Rossi and the inguinal hernia

I do not have accurate and up-to-date statistical data, but off the top of my head I would say that the most widely used technique in Italy foringuinal hernia surgery is the Trabucco technique.

Ermanno Trabucco, a Neapolitan surgeon who moved to New York early in his career, was one of the pillars of abdominal wall surgery in the 20th century; and his technique, developed in the 1980s, represents one of the milestones in the history of inguinal hernia repair.

The principle on which it is based is simple and - like all simple things - ingenious: if you have to use a net to repair the hernia, and if you put this net in an enclosed, virtual space, then it is impossible for it to move: therefore, it is useless to put stitches to fix it - which solves at least some of the problems related to the infamous "post hernioplasty inguinodynia," a terrible term for the postoperative inguinal pain that, not so rarely, remains in patients. In fact, this pain is due, at least in part, to the phenomenon of "nerve entrapment": sometimes, some of the often almost invisible sensory nerve sprigs located in the inguinal region are "trapped" by the stitches that are affixed to fix the mesh; this causes the onset of pain, varying in intensity and duration but not infrequently chronic and excruciating.

Trabucco called this space the "inguinal box," described it accurately in his papers and proved the validity of his idea with the results of his daily clinical work.

And, indeed, Trabucco's technique is simple, standardized, easily reproducible and easy to teach. It is, in fact, the classic "ideal" surgical technique, which admits of no argument, no interpretation, no error. It is almost a profession of faith (scientific faith, of course).

A great many Italian surgeons claim to use Trabucco's technique in their surgeries. But-will this really be the case?

In fact, if you talk to them, someone says, "Mah... I put a stitch on the tubercle... you know, just in case..." - "Mah... I leave the cord under the band, it looks more natural to me...." I don't want to go into technical details, boring for most, however... nice, beautiful, typical of much Italian surgery: we do things because "it seems to us," "just in case," not because there is the slightest scientific basis.

AND, MOST IMPORTANTLY, IT'S NOT TREBUCHET'S TECHNIQUE. Call it "Mr. Rossi's technique," folks, and let the Great Surgeons rest in peace.

colon cancer, screening
A new test for colon cancer screening

A group of Canadian researchers recently reported that they have developed a test by which "molecular traces" of the presence of precancerous colon polyps can be found in the blood. If the results of the study are confirmed, a sensitive, specific, inexpensive and absolutely noninvasive screening test for colon cancer will be available to complement the more traditional and invasive colonoscopy.

It is thanks to the latter that today we are able to diagnose and treat colon cancer early, or even prevent it, by removing during the examination those precancerous lesions-the polyps-from whose evolution the cancer itself may originate.

However, colonoscopy is an expensive and unpleasant test for patients; preparation of the colon with powerful laxatives is required in the days before the examination, and the patient must undergo sedation or anesthesia in order to tolerate it. Current screening programs call for colonoscopy to be performed starting at age 50, or earlier if you have a family history of colon cancer; however, since it is a less than "pleasant" exam, there are many people who decide not to have it. That's why numerous research groups around the world are scrambling to develop less invasive screening tests.

Working along these lines, researchers from the BC Cancer Agency and the University of British Columbia have found that there are differences between the blood of patients with precancerous polyps and that of healthy patients; and the blood chemistry test they developed is based on these findings.

Specifically, the results of a previous study were taken up, whereby differences in the Raman spectrum of blood from healthy patients compared with blood from colon cancer patients were demonstrated. The new research showed that spectroscopic differences also exist between the blood of patients with precancerous polyps compared with that of healthy patients, and that this can be applied in the clinic in screening programs.

It must be clear: no blood test will ever come to replace colonoscopy, which will still have to be carried out at the slightest suspicion of the presence of polyps; but it will certainly be easier to expand the pool of people undergoing screening programs. Today, colon cancer is a disease from which one can be cured: one only needs to identify and treat it in time.