Stapled hemorrhoidopexy is a

surgical Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery ...

procedure that involves the cutting and removal of anal hemorrhoidal vascular cushion, whose function is to help to seal stools and create continence. Procedure also removes abnormally enlarged hemorrhoidal tissue, followed by the repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. Severe cases of hemorrhoidal prolapse will normally require surgery. Newer surgical procedures include

stapled transanal rectal resection Stapled trans-anal rectal resection (STARR) is a Minimally invasive procedure, minimally invasive surgical procedure for conditions such as obstructed defecation syndrome, internal rectal prolapse, and rectocele. Circular surgical staplers are use ...

(STARR) and procedure for prolapse and hemorrhoids (PPH). Both STARR and PPH are

contraindicated In medicine, a contraindication is a condition (a situation or factor) that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a rea ...

in persons with either

enterocele An enterocele is a herniation of a peritoneum-lined sac containing small intestine through the pelvic floor, between the rectum and the vagina (in females). Enterocele is significantly more common in females, especially after hysterectomy. It has ...

anismus Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women (although it is more common in women). It can be caused ...

. This procedure is for internal hemorrhoids only and not for external hemorrhoids or anal fissures. During the procedure the external anal sphincter muscle is pulled in when the anal cushion is cut followed tight stapling with 2 rows of 28 staples so if external hemorrhoids are present they also get pulled in and get hidden inside and get tucked inside the anal canal and reappear when the staples fall after a few months when the external anal sphincter comes to its normal position. Previously a lot of surgeons thought that this procedure is for external hemorrhoids also as they disappear but instead they are hidden inside and fool the eye and reappear after the staples fall off.

Background

Hemorrhoids Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term ''he ...

are amongst the most common anal disorders. Patients may complain of bleeding,

prolapse In medicine, prolapse is a condition in which organ (anatomy), organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is al ...

, personal discomfort and minor anal leakage. Where traditional non-surgical measures such as rest, suppositories and dietary advice fail to improve the condition, there is then a choice of further treatments. Opinion on the best management for patients varies considerably. While many treatments for hemorrhoids may be performed without

anesthetics An anesthetic (American English) or anaesthetic (British English; see spelling differences) is a drug used to induce anesthesia ⁠— ⁠in other words, to result in a temporary loss of sensation or awareness. They may be divided into tw ...

, the lasting effect of these conservative therapies has been questioned. Many patients treated with

rubber band ligation Rubber band ligation (RBL) is an outpatient treatment procedure for internal hemorrhoids of any grade. There are several different devices a physician may use to perform the procedure, including the traditional metal devices, endoscopic banding ...

or injection

sclerotherapy Sclerotherapy (the word reflects the Greek ''skleros'', meaning ''hard'') is a procedure used to treat blood vessel malformations ( vascular malformations) and also malformations of the lymphatic system. A medication is injected into the vessels ...

require multiple treatments and there is high recurrence rate following these procedures. Conventional hemorrhoidectomy provides permanent symptomatic relief for most patients, and effectively treats any external component of the hemorrhoids. However, the wounds created by the surgery are usually associated with considerable post-operative pain which necessitates a prolonged recovery period. This can put a stress on a

general practitioner A general practitioner (GP) is a doctor who is a Consultant (medicine), consultant in general practice. GPs have distinct expertise and experience in providing whole person medical care, whilst managing the complexity, uncertainty and risk ass ...

’s resources, may alienate the patient and delays the patient's return to a full, normal lifestyle and the workplace. Because of this, surgeons will generally reserve formal excision for the most severe cases of prolapse, or for patients who have failed to respond to conventional treatments.

Stapled transanal rectal resection (STARR)

Stapled trans-anal rectal resection (STARR) is a

minimally invasive surgical procedure Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definition ...

for conditions such as

obstructed defecation syndrome Obstructed defecation syndrome (abbreviated as ODS, with many synonymous terms) is a major cause of functional constipation (primary constipation), of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying o ...

internal rectal prolapse Internal rectal prolapse (IRP) is medical condition involving a telescopic, funnel-shaped infolding of the wall of the rectum that occurs during defecation. The term IRP is used when the prolapsed section of rectal wall remains inside the body and ...

, and

rectocele In gynecology, a rectocele ( ) or posterior vaginal wall prolapse results when the rectum bulges ( herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of ...

. Circular surgical staplers are used to resect (remove) sections of the wall of the

rectum The rectum (: rectums or recta) is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. Before expulsion through the anus or cloaca, the rectum stores the feces temporarily. The adult ...

via the

anus In mammals, invertebrates and most fish, the anus (: anuses or ani; from Latin, 'ring' or 'circle') is the external body orifice at the ''exit'' end of the digestive tract (bowel), i.e. the opposite end from the mouth. Its function is to facil ...

. The defects are then closed with

surgical staple Surgical staples are specialized Staple (fastener), staples used in surgery in place of surgical suture, sutures to close skin wounds or to resection (surgery), resect and/or anastomosis, connect parts of an Organ (biology), organ (e.g. bowels, ...

s. The procedure is controversial. The results of many thousands of STARR procedures have been published in research. Proponents state that the procedure is simple, minimally invasive, safe, and effective. Skeptics argue that the complications may be significant (

fecal urgency Fecal urgency (also termed bowel urgency, rectal urgency or defecation urgency) is a medical symptom where there is a sudden, strong need to defecate that is difficult to defer. The difference between fecal urgency and urge fecal incontinence is ...

, urge

fecal incontinence Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents—including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom ...

) or rarely even life-threatening. There is a general trend away from STARR towards

ventral rectopexy Ventral rectopexy is a surgical procedure for external rectal prolapse, internal rectal prolapse (rectal intussusception), and sometimes other conditions such as rectocele, obstructed defecation syndrome, or solitary rectal ulcer syndrome. The re ...

for surgical treatment of obstructed defecation syndrome.

Procedure for Prolapse and Hemorrhoids (PPH)

PPH uses a circular stapler to reduce the degree of prolapse. The procedure avoids the need for wounds in the sensitive perianal area thus reducing post-operative pain considerably, and facilitates a speedier return to normal activities. This procedure is for internal hemorrhoids only and not for external hemorrhoids or anal fissures. Racalbuto, A. et al. Hemorrhoidal stapled prolapsectomy vs. Milligan-Morgan hemorrhoidectomy: a long-term randomized trial. International Journal of Colorectal Disease, 2004; 19: 239-244Rowsell, M., Bello, M., Hemmingway, D.M. Circumfrential mucosectomy (stapled hemorrhoidectomy) vs. conventional haemorrhoidectomy: randomised controlled trial. The Lancet, 4 March 2004; 355: 779-781Boccasanta, P. et al. RCT between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy on advanced hemorrhoids with external mucosal prolapse. American Journal of Surgery, 2001; 182(1): 64-68

Development

This procedure was first described by an Italian surgeon – Dr. Antonio Longo, Department of Surgery, University of Palermo – in 1993 and since then has been widely adopted through Europe. This procedure avoids the need for wounds in the sensitive perianal area and, as a result, has the advantage of significantly reducing the patient's post operative pain. Follow-up on relief of symptoms indicate a similar success rate to that achieved by conventional haemorrhoidectomy.Ganio, E., Altomare, D.F., Gabrielli F., et al. Prospective randomised multicentre trial comparing stapled with open haemorrhoidectomy. British Journal of Surgery, 2001; 88: 669-674 Since PPH was first introduced it has been the subject of numerous clinical trials and in 2003 the National Institute of Clinical Evidence (NICE) in the UK issued full guidance on the procedure stating it wa
safe and efficacious

Indications

PPH is generally indicated for the more severe cases of internal hemorrhoidal prolapse (3rd and 4th degree) where surgery would normally be indicated. It may also be indicated for patients with minor degree haemorrhoids who have failed to respond to conservative treatments. The procedure may be contra-indicated when only one cushion is prolapsed or in severe cases of fibrotic piles which cannot be physically repositioned. In addition to correcting the symptoms associated with the prolapse, problems with bleeding from the piles are also resolved by this excision. Although the cushions may be totally or partially preserved, the blood supply is interrupted or venous drainage is improved by the repositioning. Any external component which remains will usually regress over a period of 3–6 months. Prominent skin tags may, on occasion, be removed during the operation but this may increase the postoperative pain so is not routinely performed.

Procedure

PPH employs a unique circular stapler which reduces the degree of prolapse by excising a circumferential strip of mucosa from the proximal anal canal. This has the effect of pulling the hemorrhoidal cushions back up into their normal anatomical position. Usually, the patient will be under general anesthetic, but only for 20–30 minutes. Many cases have been successfully performed under local or regional anesthesia and the procedure is suited to day case treatment.

Post operative course

Due to the low level of post-operative pain and reduced analgesic use, patients will usually be discharged either the same day or on the day following surgery. Most patients can resume normal activities after a few days when they should be fit for work. The first bowel motion is usually on day two and should not cause any great discomfort. Staples may be passed from time to time during defecation. This is normal and should not be a cause for concern.

Post-operative complications

Since 2002 more than 100 articles have been published reporting complications during and after stapled hemorrhoidectomy.

Short-term complications

Bleeding is the most common postoperative complication. Severe postoperative pain could be caused by dehiscence of the anastomosis or due to the fact that the anastomosis is too near to the linea dentata. A rare complication stemming from PPH is intra-

abdominal The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...

bleeding.

Long-term complications

Many long-term complications have been described. Most of them are related to either an incorrect indication for surgery or technical errors. Several authors stated that although it seems to be an easy operation to perform, it should only be done by experienced surgeons. Severe complications leading to death have been described but are rare. Irreversible urge incontinence due to lesions of the sphincter muscle or a diminished rectal capacity due to resection of too much mucosa, are quite common complications if the procedure is not performed properly. Rectovaginal fistulas and anastomotic diverticula are very rare but possible.

References

{{DEFAULTSORT:Stapled Hemorrhoidectomy Digestive system surgery Colorectal surgery