Top Tips for Endoscopic Banding of Hemorrhoids

TECHNIQUE ARTICLE

Keywords: hemorrhoid banding; rubber band ligation; internal hemorrhoids; endoscopic technique; retroflex banding; dentate line; rectal bleeding; water instillation; hemorrhoid localization

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Clinical History

A 75-year-old female patient with intermittent, painless rectal bleeding was referred for colonoscopy and therapy of internal hemorrhoids using rubber band ligation. During colonoscopy, internal hemorrhoids were found. Endoscopic rubber band ligation is a safe, effective, non-operative, and well-tolerated endoscopic procedure for treating symptomatic internal hemorrhoids.

Endoscopic Findings

1. Visualization of targeted hemorrhoids in retroflex position (Figure 1A, B).
2. Inflation is useful to confirm hemorrhoids to be treated, as those that remain bulging are targets, whereas the small hemorrhoids flatten out (Figure 1B).
3. Water instillation through the endoscope's water channel, with the patient in the left lateral decubitus position, indicates the location of hemorrhoids based on water accumulation (Figures 1C, D). The yellow arrow shows the water accumulation on the left side of the rectum. Thus, the bulgy hemorrhoid is located on the right side.

Endoscopic Technique

1. The endoscope is advanced to the rectal canal and positioned in retroflex. The targeted hemorrhoids are visualized (Figure 1A, B).
2. Inflation is performed to identify bulging hemorrhoids; those that disappear with inflation may not require treatment (Figure 1C, D).
3. To precisely localize hemorrhoids, water is instilled through the endoscope's water channel. With the patient in the left lateral decubitus position, water accumulation identifies the corresponding hemorrhoid on the right side. The yellow arrow highlights the area of water accumulation (Figure 1E).
4. Before banding, the location of the hemorrhoid in relation to the dentate line is determined. The dentate line is avoided during ligation to prevent pain.
5. The endoscope, loaded with the banding device, is advanced to the rectal canal. Hemorrhoids are banded in either an antegrade or retroflex position. The retroflex position is preferred for internal targeting and reduced risk of engaging the dentate line, providing excellent visualization of the anorectal area (Fig. 1F, G, H).
6. During suctioning of the hemorrhoid into the cap, excessive suctioning or filling more than two-thirds of the cap is avoided to prevent subsequent large ulcer formation. Also, if too much tissue is suctioned into the cap, the chances of including the dentate line are increased. Therefore, controlled and careful suctioning should be applied.
7. After deployment of the rubber band, the area is inspected to confirm appropriate distance from the dentate line (Figure 1H).

Discussion

Endoscopic rubber band ligation remains a cornerstone in the management of symptomatic internal hemorrhoids. This technique, when performed with careful attention to procedural details, offers a safe and effective treatment option.

Key considerations include precise localization of hemorrhoids, particularly in relation to the dentate line, to minimize patient discomfort and complications. The use of water instillation and retroflex viewing enhances accurate identification and targeting.

Optimal suctioning during band placement is critical to prevent over-ligation and potential ulceration. The described preference for retroflex banding highlights an approach aimed at maximizing precision and safety by allowing for direct visualization and internal targeting of the hemorrhoidal tissue, thereby reducing the risk of complications associated with inadvertent banding of the dentate line.