How I do it.

P. Ronan O’Connell, MD, FRCSI

Mater Misericordiae Hospital,

Dublin, Ireland

and

Angelo Stuto, MD

Ospedale ‘s Maria degli Angeli’

Pordenone, Italy

Learning Objectives

1) Patient selection and preparation for PPH

2) Technique of performing PPH

3) Key points to avoid mishaps

Background

The great majority of patients who present with anorectal symptoms attribute their

symptoms to hemorrhoids. Therefore a careful clinical history and proctological

examination is needed to identify those patients with hemorrhoidal disease most likely

to benefit from hemorrhoidectomy.

The etiology of hemorroidal disease is uncertain and the subject of several

hypotheses. Thompson et al have shown that hemorroidal cushions are part of normal

anatomy (1). Fluctuations in the volume of the hemorrhoidal cushions may parallel

changes in intra abdominal pressure and play a role in preventing leakage of stool

during periods of increased intra rectal pressure. Abnormal enlargement of the

hemorrhoidal cushions may occur with constipation, chronic straining at stool and in

the presence of raised intra abdominal pressure, e.g. pregnancy. In these situations

venous distension leads to hemorrhoidal enlargement, mucosal thinning, stretching of

the hemorroidal suspensory ligaments resulting in bleeding and prolapse.

Conventional hemorrhoidectomy, either by open Milligan-Morgan or the closed

Ferguson technique, is designed to excise all potentially symptomatic hemorrhoidal

tissue. In doing so both external skin tags and internal hemorrhoids are excised,

including part of the highly sensate anoderm below the dentate line. Postoperative

pain is a frequent and often prolonged problem. Recent studies have shown that

perioperative laxative (2) and antibiotic (3) use can reduce the severity of

postoperative pain, nevertheless postoperative pain is problematic.

The procedure for prolapse and hemorrhoids originally developed by Dr Antonio

Longo, represents a radical alternative in surgical treatment of hemorrhoids (4). The

object is not to excise the haemorrhoids but to reposition the prolapsed distal anorectal

mucosa, including the hemorrhoidal cushions, to their original anatomic site by the

excision and stapling of a cuff of redundant distal rectal mucosa. In doing so the blood

flow to the hemorroidal cushions may be reduced. To date six randomised clinical

trials attest to the efficacy of the procedure, reduced postoperative pain and earlier

return to work (Table 1 refs 5 – 10) .

Technique

Patient Selection:

The PPH operation is suitable for patients with Grade III or Grade IV hemorrhoids

and selected patients with symptomatic rectal mucosal prolapse. The patient must be

suitable for either general or regional anaesthesia. Patients with large external

hemorrhoids or skin tags must know that these will not be excised as part of the

operation but that most reduce in size in the weeks following surgery. Occasionally

later excision of residual tags maybe required. The internal hemorrhoidal component

should be reducible under anaesthetic. The final decision concerning which

operative technique to be used (PPH or conventional) must be made in the

operating room. Informed consent of the potential risks, benefits and alternative

treatments must be provided. Patient information leaflets are helpful.

Patient Preparation:

There is evidence that perioperative use of lactulose reduces post-operative pain in

patients undergoing conventional hemorrhoidectomy (2). No data exist concerning

use in stapled hemorrhoidectomy but until proven otherwise it would seem reasonable

practice to recommend use in patients undergoing PPH. A more persuasive argument

can be made for use of perioperative metronidazole (3). Again a randomised clinical

trail has shown benefit in open hemorrhoidectomy, however pelvic sepsis has been

reported as a complication of stapled hemorrhoidectomy (11). It is the authors’

practice to use a cleaning enema on the morning of operation.

Patient Positioning:

The PPH operation may be performed in either the prone jack-knife or lithotomy

positions depending on surgeon preference and patient physique. In the lithotomy

position it is important that the hips are fully flexed to expose the entire perineum.

This position has the advantage in women of facilitating vaginal examination during

the operation. This is important to prevent accidental inclusion of the posterior vaginal

wall in the staple line. Skin preparation and draping is standard. A gauze swab can

usefully be inserted into the lower rectum and withdrawn to show the extent of

hemorrhoidal and mucosal prolapse.

Step 1: CAD insertion

Four quadrant nylon sutures are inserted at the anal verge, cut long and held with

hemostat forceps. Traction on these sutures facilitates insertion of the Circular

Anal Dilator (CAD) and obturator (Ethicon Endosurgery) . The obturator is

inserted first without the circular anal dilator then withdrawn and reinserted with the

circular anal dilator. The obturator is then removed. Full insertion of the dilator is

important. The nylon sutures are now tied to hold the dilator in place. The top of the

hemorrhoidal columns and the lower rectal mucosa should be visible (Fig 1)

Figure 1: CAD inserted in anal canal

Step 2: Purse string

The purse string suture in next inserted. A 2/0 polypropylene suture on a 30mm round

bodied needle is suitable. Great care must be exercised to position the suture

correctly 2 cm above the top of the hemorrhoidal columns. This is a more reliable

landmark as the height of the hemorrhoidal columns is variable and the dentate line

may not be clearly visible. The object is not to include the hemorrhoidal tissue itself,

rather a cuff of rectal mucosa directly above the hemorrhoidal complex. The suture is

mucosal and submucosal and should not include rectal muscularis propria (Fig 2). The

operator must ensure a continuous mucosal purse string and avoid gaps that might

later lead to bridges of stapled mucosa. In women a digital vaginal examination is

performed to ensure the purse string has not tethered the posterior vaginal wall.

It is important not to pull the purse string closed while checking its position as this

may make insertion of the stapler more difficult.

Figure 2: Insertion of purse

string suture

Step 3: Stapler insertion

A suitable circular stapling instrument (PPH 33mm, Ethicon Endosurgery) is opened

to its full extent and inserted into the anal canal ensuring the head is positioned above

the purse string. The purse string is then tied with a single throw and the ends pulled

through the holes in the stapler head using the suture-threading instrument (Fig 3).

Figure 3: Tying the

purse string

Step 4: Stapler Closure

The suture ends may then be held or tied with a double throw to allow easy traction on

the purse string. The head is then closed to its fullest extent by rotating the closure

mechanism on the end of the shaft in a clockwise direction (Fig 4). It is important to

ensure proper alignment of the instrument in the axis of the anal canal. Using the

PPH 33mm instrument, closure is confirmed by the presence of the red position

marker within the green firing zone on the handle of the instrument. Care is taken in

females that the posterior vaginal wall is not included within the head of the

instrument.

Figure 4: Stapler closure

Step 4: Firing the Stapler

The stapler is fired by releasing the safety mechanism and closing the handles in a

single motion. The purse string suture is not divided as it is during anterior resection

because the suture remains within the instrument head and the ends are within the

shaft. Many surgeons prefer to keep the instrument fully closed for 30 seconds to

improve hemostasis and to allow staple formation.

Step 5: Removing the Stapler

The instrument is removed by opening the head and rotating the closure mechanism

one half turn in an anticlockwise direction. A common error is to open the stapler

head too widely at this point, which may trap mucosa within the opened instrument

head. This makes removal difficult and can damage the anastomosis. A gauze swab

should be inserted into the anal canal to facilitate hemostasis while excised doughnut

of mucosa is removed from the instrument head and sent for histological examination.

The CAD should not be removed with the stapling instrument as this facilitates

checking the staple line for bleeding.

Step 6: Checking the Staple Line

The staple line is checked for bleeding by reinsertion of the proctoscope. Hemostasis

is confirmed in each quadrant. Bleeding points should be under sewn using a 3/0

absorbable suture.

On completion of the operation it can be seen that a hemorrhoidectomy has not

actually been performed, instead the rectal mucosal prolapse has been excised and the

hemorrhoidal cushions repositioned within the anal canal. The operation is completed

by insertion of a degradable sponge dressing.

Step 7: Post operative Care

Post-operative analgesia in the form of a non-steroidal anti-inflammatory drug is

appropriate (the authors favour tenoxicam or diclofenac). Lactulose 30ml up to three

times daily and metronidazole are continued orally for five days. Patients may be

discharged on the evening of or day following operation. Urinary retention is an

occasional problem in males, who should be discouraged from drinking excess fluids

on the evening of operation. Patients should be warned that passage of small amounts

of blood is common in the days following operation. Patients should be told to contact

their surgeon if there is increasing anorectal pain, fever or impaction of feces as these

symptoms may indicate perineal infection. Patients should be encouraged to resume

normal daily activities as soon as possible.

Table 1: Results of randomised clinical trials of PPH versus conventional

hemorrhoidectomy No pain hospital return to

patients stay normal activity Mehigan et al 5 40 less same sooner Rowsell et al 6 22 less shorter sooner Ho et al 7 119 less same sooner Ganio et al 8 100 less shorter sooner Boccasanta et al9 80 less shorter sooner Shalaby & Desoky10 200 less shorter sooner

References:

1. Thompson WHF. The nature of haemorrhoids. Br J Surg, 1975; 62:542-5

2. London NJ, Bramley PD, Windle R. Effect of four days of preoperative

lactulose on posthaemorrhoidectomy pain: results of placebo controlled trial.

BMJ 1987; 295:363-4

3. Carapeti EA, Kamm MA, McDonald PJ, Phillips RK. Double –blind

randomised controlled trial of effect of metronidazole on pain after day-case

haemorrhoidectomy Lancet 1998; 351: 169-72.

4. Longo A. Treatment of haemorrhoidal disease by reduction of mucosa and

haemorrhoidal prolapse with a circular suturing device: a new procedure.

Proceedings of the 6th World Congress of Endoscopic Surgery, Rome, 1998

5. Mehigan BJ, Monson JRT, Hartley JE. Stapling procedure for haemorrhoids

versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial.

Lancet 2000; 355: 782-5

6. Rowsell M, Bello M, Hemmingway DM. Circumferential mucosectomy

(stapled haemorrhoidectomy) versus conventional haemorrhoidectomy:

randomised controlled trial. Lancet, 2000; 355:779-81

7. HoY-H, Cheong WK, Tsang C, Ho J, Eu KW, Tang CL et al. Stapled

hemorrhoidectomy – cost effectiveness. Randomized controlled trial including

incontinence scoring anal manometry and endoanal ultrasound assessments at

up to three months. Dis Colon Rect, 2000; 43: 1666-75

8. Ganio E, Altomare DF, Gabrielli F, Milito G, Canuti S. Prospective

randomised multi-centre trial comparing stapled with open

haemorrhoidectomy. Br J Surg, 2001; 88: 669-674

9. Shalaby R, Desoky A. Randomised clinical trial of stapled versus Milligan-

Morgan haemorrhoidectomy. Br J Surg, 2001; 88: 1049-53

10. Boccasanta P, Capretti PG, Venturi M, Cioffi U, De Simone M, Salamina G et

al. Randomised controlled trial between stapled circumferential mucosectomy

and conventional circular hemorrhoidectomy in advanced hemorrhoids with

external mucosal prolapse. Am J Surg, 2001; 182:64-8

11. Molloy RG, Kingsmore D. Life threatening pelvic sepsis after stapled

haemorrhoidectomy Lancet, 2000; 355:810

Acknowledgement:

The video to accompany this text was produced with the technical assistance of

Johnson and Johnson and Ethicon Endosurgery, Europe. The figures are reproduced

from the video with permission of Ethicon Endosurgery, Europe.