Overview
Definition:
Stapled hemorrhoidopexy, also known as Procedure for Prolapse and Hemorrhoids (PPH), is a surgical technique used to treat symptomatic internal hemorrhoids and anal prolapse
It involves excising a cuff of rectal mucosa and submucosa superior to the dentate line using a circular stapling device, thereby repositioning the prolapsed hemorrhoidal tissue and interrupting the vascular pedicles supplying them
This method aims to reduce the pain associated with traditional hemorrhoidectomy.
Epidemiology:
Hemorrhoids affect approximately 4-5% of the adult population, with internal hemorrhoids being common
Prolapse significant enough to warrant surgical intervention is less frequent but still impacts a considerable number of individuals
PPH is widely adopted in various countries due to its purported benefits in pain reduction and faster recovery compared to excisional hemorrhoidectomy.
Clinical Significance:
This procedure is crucial for surgical residents preparing for DNB and NEET SS examinations as it represents a common and effective treatment for a prevalent anorectal condition
Understanding its principles, indications, techniques, and potential complications is vital for managing patients presenting with symptomatic hemorrhoids and rectal prolapse, ensuring optimal patient outcomes and adherence to evidence-based practices.
Indications
Primary Indications:
Significant symptomatic internal hemorrhoids (Grades III and IV)
Anal prolapse with internal hemorrhoidal components
Bleeding, prolapse, and discomfort not responding to conservative management
Patient preference for reduced postoperative pain.
Contraindications:
Significant rectal prolapse without significant internal hemorrhoids
Anal sepsis or active perianal infection
Inflammatory bowel disease involving the rectum (e.g., active proctitis, Crohn's disease)
Significant coagulopathy
Previous anorectal surgery causing extensive scarring that might compromise stapling.
Relative Contraindications:
Large external hemorrhoids which will not be addressed by PPH
Pregnancy
Very elderly or frail patients.
Patient Selection:
Careful assessment of hemorrhoid grade and degree of prolapse is paramount
Patients should be well-informed about the procedure, potential risks, and expected outcomes, including the possibility of recurrence or residual symptoms.
Preoperative Preparation
History And Examination:
Detailed history focusing on symptoms (bleeding, prolapse, pain, itching), bowel habits, and previous treatments
Digital rectal examination to assess hemorrhoid grade, prolapse, anal tone, and presence of masses
Anoscopy or rigid sigmoidoscopy may be performed to confirm the extent of internal hemorrhoids and assess the mucosa above the dentate line.
Bowel Preparation:
Standard bowel preparation including clear liquid diet the day before surgery and oral laxatives or enemas on the morning of surgery to ensure a clean rectal vault
Antibiotic prophylaxis is generally recommended, typically a single dose of a broad-spectrum agent like metronidazole and a fluoroquinolone or cephalosporin, depending on local protocols.
Anesthesia:
PPH can be performed under general, spinal, or regional anesthesia
The choice depends on patient factors, surgeon preference, and institutional protocols
Postoperative pain management planning is essential.
Informed Consent:
Thorough discussion of the procedure, benefits, risks (including bleeding, pain, infection, fistula, stricture, recurrence, and urinary retention), and alternatives
Documentation of informed consent is critical.
Procedure Steps
Instrumentation:
A specialized circular stapling device (e.g., PPH 030, PPH 031) with a 33-35 mm diameter stapler is typically used
It consists of a cannulated obturator, a stapling cartridge, and a handle.
Anoscope Insertion:
A dedicated PPH anoscope is inserted into the anal canal to visualize the anal canal and rectum
The anoscope has a central lumen and graduated markings to guide the depth of insertion.
Mucosal Dissection And Ressection:
The stapler is loaded with a new staple cartridge and passed through the anoscope
The prolapsed rectal mucosa is gathered into the stapler's cannulated obturator above the dentate line
The number of hemorrhoidal columns to be treated and the amount of tissue to be resected are judged by the surgeon, typically aiming for about 4-5 cm of mucosa
The pursestring suture is then secured around the gathered mucosa, and the stapler is fired, excising the tissue and creating a continuous staple line.
Staple Line Reinforcement:
After firing the stapler, the staple line should be inspected for hemostasis
Some surgeons reinforce the staple line with interrupted sutures, especially if there is any concern for bleeding
The purse-string suture is tied securely to complete the closure.
Completion:
The stapler is then unlocked and removed
The resected specimen within the stapler head is examined
The procedure is completed by inspecting the staple line and anal canal for any bleeding or other complications
A dressing may be applied, or the patient may be allowed to mobilize as tolerated.
Postoperative Care
Pain Management:
Postoperative pain is typically less severe than with excisional hemorrhoidectomy but can still be significant
Analgesics, including NSAIDs and opioids, are prescribed as needed
Sitz baths can provide relief
Topical anesthetics may also be used.
Bowel Function:
Patients are encouraged to have their first bowel movement within 24-48 hours
Stool softeners (e.g., docusate sodium) and adequate hydration are crucial to prevent constipation and straining, which can compromise the staple line or lead to recurrence.
Monitoring:
Patients are monitored for signs of bleeding, infection, urinary retention, and severe pain
Discharge instructions should include warning signs that necessitate immediate medical attention, such as heavy rectal bleeding, fever, severe pain, or inability to pass urine.
Follow Up:
Routine follow-up appointments are scheduled, typically at 2-4 weeks postoperatively, to assess wound healing, symptom resolution, and address any concerns
Further follow-up may be required to monitor for recurrence.
Complications
Early Complications:
Bleeding (most common, usually mild and self-limiting, but can be severe)
Pain (can be severe, especially if staple line extends too distally)
Urinary retention (transient and common, often managed with catheterization)
Infection (perianal cellulitis or abscess)
Rectal pressure or tenesmus.
Late Complications:
Bleeding (delayed, from staple line dehiscence)
Rectal stricture (rare, usually related to excessive resection or infection)
Anal stenosis
Fistula formation (rare)
Recurrence of hemorrhoids or prolapse
Sensation of incomplete evacuation
Staple extrusion (rare, may require removal).
Prevention Strategies:
Meticulous surgical technique, ensuring the staple line is placed above the dentate line and not too close to the anal verge
Adequate pain control and bowel management to prevent straining
Careful patient selection
Prompt recognition and management of any signs of complications.
Prognosis
Factors Affecting Prognosis:
The success of PPH depends on the appropriate selection of patients, the surgeon's experience, and the degree of hemorrhoidal prolapse
Recurrence rates can vary depending on technique and patient factors.
Outcomes:
Generally, PPH offers good symptom relief for bleeding and prolapse in carefully selected patients
Pain is typically less severe than with excisional hemorrhoidectomy, leading to a faster recovery and return to normal activities
Long-term success rates are reported to be between 75-90% for symptom control.
Recurrence And Alternatives:
While PPH is effective, recurrence can occur, particularly if lifestyle modifications are not adopted or if initial prolapse was severe
Alternative surgical techniques like Milligan-Morgan hemorrhoidectomy or Lord's procedure may be considered for recurrent disease or if PPH fails.
Key Points
Exam Focus:
PPH is a key procedure for managing prolapsed internal hemorrhoids
Understand its mechanism: stapling above dentate line to elevate prolapsed mucosa and interrupt vascularity
Key complications include bleeding, pain, and urinary retention
Postoperative care emphasizes pain control and early, soft bowel movements.
Clinical Pearls:
Always ensure the staple line is proximal to the dentate line to minimize pain
Careful assessment of hemorrhoid grade and prolapse is critical for patient selection
Communicate potential for recurrence and the importance of lifestyle changes to patients.
Common Mistakes:
Mistakes include stapling too distally, leading to significant pain
Inadequate bowel preparation or management, causing straining and staple line dehiscence
Failure to consider contraindications, leading to complications
Underestimating the potential for recurrence and not counseling patients appropriately.