Stapled hemorrhoidopexy

Definition
Stapled hemorrhoidopexy, also known as the Procedure for Prolapse and Hemorrhoids (PPH), is a surgical technique used to treat symptomatic internal hemorrhoids, particularly those classified as grade III or IV. The procedure utilizes a circular stapling device to excise a circumferential strip of prolapsed rectal mucosa and submucosa above the dentate line, thereby repositioning the hemorrhoidal tissue and reducing prolapse.

Medical Indications

• Symptomatic internal hemorrhoids (grade III–IV) causing bleeding, prolapse, discomfort, or stool leakage.
• Patients seeking an alternative to conventional hemorrhoidectomy with the aim of reduced postoperative pain and quicker return to normal activity.

Contraindications

• External hemorrhoids without significant internal component.
• Presence of anal fissure, fistula, or active infection in the operative field.
• Severe coagulopathy or uncontrolled systemic disease that precludes surgery.

Surgical Technique

1. Preparation: The patient is placed in the lithotomy or prone jackknife position under regional or general anesthesia.
2. Insertion: A circular anal dilator is introduced to expose the anal canal.
3. Resection: A specially designed circular stapler (typically a 33‑mm or 34‑mm device) is inserted above the dentate line, usually 2–4 cm into the rectum.
4. Stapling: The stapler is closed, drawing a circumferential “purse‑string” of mucosa into the device. Upon activation, a double‑stapled ring of tissue is removed, and a stapled anastomosis is created, pulling the prolapsed hemorrhoidal tissue back into its anatomic position.
5. Completion: The excised tissue ring is retrieved, hemostasis is confirmed, and the patient is observed for immediate complications.

Outcomes and Efficacy

• Pain: Postoperative pain is generally less severe than that reported after conventional excisional hemorrhoidectomy.
• Recovery: Most patients resume normal diet and activity within 2–4 days.
• Recurrence: Long‑term follow‑up studies indicate a higher recurrence rate for hemorrhoidal symptoms compared with conventional hemorrhoidectomy, particularly beyond 3–5 years post‑procedure.
• Quality of Life: Early postoperative quality‑of‑life scores are typically higher due to reduced pain and faster return to work.

Complications

• Immediate: Intra‑operative bleeding, stapler malfunction, or incomplete excision.
• Early postoperative: Staple line bleeding, urinary retention, transient urgency or tenesmus.
• Late postoperative: Staple line dehiscence, rectal stenosis, pelvic sepsis, fecal urgency, and recurrence of hemorrhoidal prolapse.
• Rare: Perirectal abscess, fistula formation, or mucosal prolapse.

Comparative Assessment

• Compared with conventional open or closed hemorrhoidectomy, stapled hemorrhoidopexy offers reduced postoperative pain and a shorter convalescence period.
• However, systematic reviews and meta‑analyses have noted a trade‑off with increased rates of symptom recurrence and certain serious complications (e.g., pelvic sepsis).

History
The technique was first described by Italian colorectal surgeon Antonio Longo in 1998. The original device, the “PPH stapler,” received CE marking in Europe and later FDA approval in the United States. Since its introduction, several variations of the stapling device have been developed, but the core principle of mucosal resection and elevation remains unchanged.

Current Clinical Use
Stapled hemorrhoidopexy is incorporated into colorectal surgical practice worldwide, particularly in centers emphasizing minimally invasive approaches. Selection of patients is guided by hemorrhoid grade, sphincter function, and the surgeon’s experience with the stapling system.

References
(References are omitted in this summary but would typically include peer‑reviewed articles from surgical journals, systematic reviews, and guideline statements from colorectal surgery societies.)