INTRODUCTION Hemorrhoids or piles are a common ailment among adults. More than half of men and women aged 50 years and older will develop hemorrhoid symptoms during their lifetime1. Hemorrhoids are rare in children but now days several reports state the occurrence of hemorrhoids in children2, and in elderly people3. In United States three-quarter of individuals have hemorrhoids at some point in their lives, and about half of them over age 50 required treatment4, and much smaller percentage approximately 4% seek medical treatment for the condition. Hospital based proctoscopy studies show prevalence rates of hemorrhoids with a symptomatic state in 86% of patient5. According to The Merck Manual definition hemorrhoids is “Varicosities of the veins of the hemorrhoidal plexus, often complicated by inflammation, thrombosis, and bleeding”6. But a recent definition of hemorrhoids is “Vascular cushions, consisting of thick submucosa containing both venous and arterial blood vessels”7 Chronological inspection of Hemorrhoids . It has been estimated that hemorrhoids can affect both men and women8. Hemorrhoids are mentioned in ancient medical writings of every culture9. The word “hemorrhoids” is derived from the Greek “haema”= blood, and “rhoos”= flowing, and was originally used by Hippocrates to describe the flow of blood from the veins of the anus10. Commonly in society it is known as piles, the word pile is derived from Latin, meaning a ball or a mass, as this condition may not always be accompanied by bleeding, the word piles is better used for this condition11. John Andrene remarks that common people call them piles and the aristocracy calls them hemorrhoids, the French call them figs, means to clot12 Histology of hemorrhoids . Hemorrhoidal tissue, cushions of tissue within the anal canal that contain blood vessels and supporting tissue made up of muscle and elastic tissue, are present in all individuals4. Universally hemorrhoids are classified according to anatomical origin as shown in fig 1. Internal hemorrhoids are consisting of redundant mucus membrane of the anal canal with the origin above the dentate (anorectal) line, and external hemorrhoids have an epithelial component and originate below the dental line13. Internal hemorrhoids or true hemorrhoids are further graded based on the extent to which the tissue descends in to the anal canal. First degree Hemorrhoids “The mucosa barely prolapse, but with severe straining may be trapped by the closing of the anal sphincter. Subsequently, venous congestion occurs occasionally, resulting in discomfort and/or
bleeding”. Second degree Hemorrhoids “With further protrusion of the mucosa, the patient complains of an obvious lump, but this disappears spontaneously and rapidly after defecation unless thrombosis occurs” Third degree Hemorrhoids “In chronic hemorrhoidal disease, the persistent prolapsing produces dilatation of the anal sphincter, and the hemorrhoids protrude with minimal provocation and usually require manual replacement”. Fourth degree Hemorrhoids “These are usually described as external hemorrhoids and are protruding all the time unless the patient replaces them, lies down, or elevates the foot of the bed. In these fourth degree hemorrhoids, the dentate line also distends, and there is a variable external component consisting of redundant, permanent perianal skin”13. On basis of lithotomy position there are usually three major hemorrhoidal