Stapled haemorrhoidopexy

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Stapled haemorrhoidopexy

• Ian Botterill
• Dept Colorectal Surgery
• St James University Hospital
• Leeds

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Barry Wood Lancashire England
Dennis Lillee Western Australia Australia
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Ideal surgical treatment of haemorrhoids
Minimal pain, short stay, rapid recuperation, low
morbidity, lasting benefit
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The Longo procedure
Antonio Longo
1st performed 1993 1st reported 1998
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terminology

• Stapled haemorrhoidopexy
• Stapled haemorrhoidectomy
• Circular stapled haemorrhoidectomy
• Circular stapled anoplasty
• PPH
• Stapled prolapsectomy
• Transverse mucosal prolapsectomy
• Longo procedure

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Premise

• haemorrhoids contribute to continence
• haemorrhoids worth preserving
• weakened of suspensory lig of rectum
• pexy addresses the prolapse

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Surgical rationale

• excision of cylinder of rectal mucosa ?
  replacement of haemorrhoids in anal canal
• vascular interruption ? shrinkage of prolapsed
  component
• avoidance of anal wound reduces pain
• haemorrhoidectomy only treats the consequence of
  prolapse

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Serious adverse events

• persistent faecal urgency
• persistent anal pain
• recto-vaginal fistula
• retroperitoneal perforation
• rectal perforation
• pelvic sepsis
• Fourniers gangrene
• rectal pocket syndrome

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Major complications of OP care

• phenol prostatitis sclero
• pelvic cellulitis sclero / band
• retroperitoneal abscess sclero
• clostridial infection band
• tetanus band
• systemic sepsis band
• severe pain band

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New technology

• apparent benefits pitfalls
• obvious parallels -laparoscopic
  cholecystectomy -laparoscopic colorectal
  surgery -laparoscopic hernia repair
• learning curve
• NICE 2003 ( Sept 2007)

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Training

• training centres Leeds, Dundee, Guildford,
  Colchester, Hamburg
• preceptorship
• audit -local (pathology / outcomes) -national
  (ACPGBI PPH database)

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Patient selection-indications

• prolapsing / prolapsed haemorrhoids
• circumferential haemorrhoids

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Patient selection-relative contraindications

• any haemorrhoid operation
• diabetics / immuno-suppressed
• bleeding diasthesis
• faecal incontinence
• Crohns
• specific to stapled haemorrhoidopexy
• deep funnel shaped perineum
• large anal skin tags
• narrow gap between ischial spines

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Consent for open / stapled Prone jack-knife
allows ?engorgement of anal cushions Pre-op GTN /
diltiazem
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Positioning / placement 4 quadrant
sutures Lubrication anal canal
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Gentle dilation with obturator alone Reduction
haemorrhoids
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Insertion CAD obturator Fixation of CAD
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Sequential placement of 2/0 prolene pursestring
via pursestring anoscope -2cm above upper end of
haemorrhoids keep at constant height Insertion
contralateral belt stitch if prolapse asymmetrical
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Insertion fully opened PPH03 gun (along axis of
rectum) Crochet hook retrieval of pursestring
(each side of gun housing) Traction on
pursestring during gun closure
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Complete gun closure check vagina - saline
infiltration helpful Ensure closed gun _at_ 4cm
on housing prior to firing
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½ turn to release gun sutured haemostasis (4/0
vicryl) much less common using newer
PPH03 avoid diathermy
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(No Transcript)
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Post-op pain relief

• Perineal field block -40ml 0.475
  ropivicaine -6 x 5ml columns ant post
  -2 x 5ml submucosal columns
• voltarol paracetamol pr
• lactulose
• ?metronidazole
• no anal canal dressing

Discharge instructions -pain / retention urine /
fever -avoidance anal intercourse See _at_ 4-6/52
in case need dilation
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Role of pathology

• audit -correlation with outcome -inclus
  ion of glandular / squamous -inclusion of
  smooth m deep to squamous epithelium
• unexpected pathology

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Role of pathology

• n84
• 19/84 squamous epithelium in donut (MgtgtF) - no
  difference in Cleveland Clinic continence score
• 6/19 had smooth m deep to squamous epithelium -
  no difference in Cleveland Clinic continence
  score
• 79/84 contained smooth muscle Shanmug
  am et al Colorectal Dis 20057172-5

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Role of pathology

• n68
• 64/68 contained smooth muscle
• 24/64 had smooth muscle with overlying squamous
  cell / transitional epithelium
• no outcome difference
• Kam et al. DCR 2005481437-41

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results

• gt25 RCTs
• 4 reviews (inc. 2 position statements)
• forthcoming meta-analysis
• 1 NICE appraisal (2nd planned)

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Operation duration -stapled haemorrhoidopexy
superior
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Pain favours stapled haemorrhoidopexy
Pain stapled haemorrhoidopexy superior
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Persistent mid-term pain stapled
haemorrhoidopexy superior
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Hospital stay stapled haemorrhoidopexy superior
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Recurrent prolapse conventional superior
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Redo surgery - stapled haemorrhoidopexy
closed equivalent - open superior to stapled
haemorrhoidopexy
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Post-operative incontinence no difference
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Anal stenosis no difference
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Cost-benefit modelling

• gun cost 350
• bed cost / night 200
• theatre / hr 1000
• if the above factors are assumed - cost
  equivalence to provider
• disregards out of hospital costs

Leeds Colorectal
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Summary

• early concerns not sustained based on the
  evidence
• proven benefits - ?operative time / ? I-P
  stay / ? return to work - ?post-op pain / ?
  bleeding / ?analgesia - ?stenosis
• but - ? recurrent prolapse (definitions
  vary) - ? rate redo surgery

Leeds Colorectal
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Choose your tools appropriately
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Causes of urgency

• ? loss anal transitional zone - not proven
• ? loss of RAIR - disproven
• ? loss of upper part of IAS possible - long
  anal canal
• ? IAS fragmentation - possible -
  gentle diln / chem. sphincterotomy / LA block
• ? pre-existing anal sphincter injury