BASIC INFORMATION

Date & Time: April 14, 2026, 17:00:04 Indian Standard Time

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY

This lecture provides a comprehensive overview of the Procedure for Prolapse and Hemorrhoids (PPH), commonly known as stapled hemorrhoidopexy. The session delineates the fundamental principle of the PPH stapler, which, unlike traditional hemorrhoidectomy, does not excise the hemorrhoidal cushions themselves. Instead, it performs a circumferential mucosectomy and anastomosis above the dentate line. This action achieves a "hemorrhoidopexy," or lifting, of the prolapsed vascular cushions back into their normal anatomical position, while simultaneously interrupting their primary blood supply. A significant portion of the lecture is dedicated to the critical steps of the procedure, with a particular focus on the correct technique for placing the purse-string suture to avoid common but potentially severe complications. The discussion covers surgical instrumentation, patient positioning, common technical errors, postoperative management, and potential complications such as bleeding, pain, and stricture. The procedure is presented as a popular option due to minimal postoperative pain and rapid recovery, although it is not without significant risks, including rare instances of sepsis and mortality if not performed meticulously.

KEY KNOWLEDGE POINTS

• Mechanism of Action: Stapled hemorrhoidopexy functions by excising a ring of redundant rectal mucosa above the dentate line, thereby pulling the prolapsed hemorrhoidal cushions upward (pexy) and reducing their blood supply.

• Pain Advantage: The procedure is associated with significantly less postoperative pain compared to conventional excisional hemorrhoidectomy because the staple line is located above the dentate line, an area with visceral innervation (lacking somatic pain fibers).

• Purse-String Suture Technique: The most critical step of the procedure is the creation of a precise and consistent purse-string suture. Errors such as taking bites that are too deep (involving muscle), too superficial, unequally spaced, or at varying levels (zigzag pattern) are the primary cause of complications.

• Instrumentation: Familiarity with the five components of the PPH stapler kit—the circular stapler gun with integrated anvil, the obturator, the anal dilator, the anoscope (port), and the suture-passer—is essential for a successful procedure.

• Complications: While offering benefits, the procedure carries risks of significant complications, including severe postoperative bleeding, rectal stricture, rectovaginal fistula, pelvic sepsis, and, in rare reported cases, death.

• Patient Selection: The procedure is indicated for Grade II and Grade III internal hemorrhoids and is particularly effective for circumferential mucosal prolapse. It is not suitable for Grade I hemorrhoids, large thrombosed external hemorrhoids, or severely fibrosed tissue.

INTRODUCTION

Hemorrhoids are pathologically altered vascular cushions located in the anal canal. Under conditions of increased intra-abdominal pressure, such as chronic constipation and straining, these cushions can become engorged, elongated, and displaced inferiorly, leading to symptoms of bleeding, prolapse, and discomfort. While traditional surgical approaches involve direct excision of these hemorrhoidal masses, they are often associated with significant postoperative pain and a prolonged recovery period.

The Procedure for Prolapse and Hemorrhoids (PPH), or stapled hemorrhoidopexy, represents a paradigm shift in the surgical management of hemorrhoidal disease. Introduced as a less painful alternative, this technique does not directly target the hemorrhoids. Instead, it addresses the underlying pathophysiology of mucosal and hemorrhoidal prolapse. By performing a circumferential mucosectomy and stapled anastomosis in the insensate upper rectum, the procedure restores normal anatomy and interrupts the hemorrhoidal blood supply. This lecture provides a detailed, step-by-step guide for postgraduate surgeons on the principles, techniques, and critical precautions associated with stapled hemorrhoidopexy.

LEARNING OBJECTIVES

• To understand the physiological basis and surgical principles of stapled hemorrhoidopexy.

• To master the step-by-step operative technique, with a special focus on the correct placement of the purse-string suture.

• To identify and avoid common technical errors that can lead to surgical failure and major complications.

• To recognize and manage potential intraoperative and postoperative complications associated with the PPH procedure.

CORE CONTENT

1. Principles of Stapled Hemorrhoidopexy

Stapled hemorrhoidopexy operates on two main principles:

1. Pexy (Lifting): A circular stapler is used to excise a ring of prolapsed rectal mucosa located approximately 2-4 cm above the dentate line. When the stapler is fired, it simultaneously creates a circular stapled anastomosis. This anastomosis pulls the descended hemorrhoidal cushions back up into their natural anatomical position within the anal canal.

2. Devascularization: The transection and stapling of the mucosa and submucosa interrupts the superior hemorrhoidal artery branches that supply blood to the hemorrhoidal cushions, leading to their subsequent shrinkage and involution.

This procedure is correctly termed a "hemorrhoidopexy" rather than a "hemorrhoidectomy," as it fixes the prolapse rather than excising the hemorrhoidal tissue itself.

2. Patient Selection and Indications

• Indications: The procedure is primarily indicated for symptomatic Grade II and Grade III internal hemorrhoids. It is also highly effective for patients with associated circumferential rectal mucosal prolapse.

• Contraindications:

  • Grade I hemorrhoids.

  • Large, thrombosed, or acutely inflamed hemorrhoids.

  • Isolated external hemorrhoids.

  • Anal stenosis or fibrosis.

3. Surgical Instrumentation

The standard PPH kit contains five essential components:

1. Circular Stapler: A 33 mm circular stapler with a fixed anvil. It features a safety lock that prevents firing unless the gap between the anvil and the cartridge is within a specified range (indicated by a green zone on the device).

2. Anal Dilator and Obturator: A transparent or white circular dilator used to gently open the anal canal. The obturator is inserted first to facilitate smooth entry and to push the hemorrhoidal masses cephalad.

3. Anoscope (Port): A half-cut anoscope that is inserted through the dilator. It retracts the rectal wall on one side, providing a clear window to place the purse-string suture on the exposed mucosa opposite it.

4. Suture-Passer: A hooked instrument used to retrieve the ends of the purse-string suture through the designated holes on the side of the stapler gun.

5. Suture: A 2-0 monofilament (e.g., Prolene) suture is typically provided. A monofilament is preferred due to its low friction coefficient, which allows the purse-string to be tightened smoothly without tearing the mucosa.

4. Operative Technique

4.1. Patient Positioning

The patient may be placed in either the lithotomy position or the prone jackknife position. The lithotomy position is more common.

4.2. Introduction of the Dilator

• The anal dilator, with the obturator fully inserted, is lubricated and gently introduced into the anal canal. The obturator ensures that the hemorrhoidal masses are pushed above the dilator.

• The dilator is then secured to the perianal skin with sutures placed through the four holes on its flange to prevent it from slipping out during the procedure.

• The obturator is removed, leaving the dilator in place.

4.3. Placement of the Purse-String Suture

This is the most critical and error-prone step of the entire procedure.

• The anoscope is inserted through the dilator. It provides a window for suturing while retracting the opposite wall.

• A 2-0 Prolene suture on a 17-22 mm forward-angulated needle is used.

• The purse-string is started at a chosen clock-face position (e.g., 3 o'clock) and placed circumferentially, ensuring it is at least 2 cm above the dentate line and above the apex of the highest hemorrhoidal mass.

• The suture must pass through the mucosa and submucosa only. Taking a deep bite that includes the rectal muscle can lead to severe pain, stricture, perforation, or rectovaginal fistula.

• Approximately 7-8 bites are taken at regular intervals (e.g., 3, 5, 7, 9, 11, 1, and 3:30 o'clock positions) to ensure even traction.

• To facilitate symmetric pulling of the mucosa into the stapler housing, a second, simple traction stitch is placed at the 9 o'clock position.

4.4. Introduction and Firing of the Stapler

• The circular stapler is fully opened by turning the knob counter-clockwise.

• The stapler is introduced through the dilator until the anvil is positioned proximal to the purse-string suture.

• The two ends of the main purse-string suture (at the 3 o'clock position) and the two ends of the traction suture (at the 9 o'clock position) are retrieved through the side channels of the stapler using the suture-passer.

• The sutures are gently pulled to draw the redundant rectal mucosa into the housing of the stapler, between the anvil and the cartridge. A gentle knot may be tied to secure the purse-string, but the primary tension comes from pulling the suture ends.

• The stapler is closed by turning the knob clockwise until the indicator on the handle enters the green zone. This confirms the correct tissue compression for proper staple formation.

• The safety catch is released, and the stapler is fired. This action simultaneously cuts the excess mucosa and deploys a double-staggered row of titanium staples to create a circular anastomosis.

• The stapler is kept in the closed, fired position for 20-60 seconds to aid hemostasis.

4.5. Removal of the Stapler and Inspection

• The stapler is opened by rotating the knob one-half to one full turn counter-clockwise to disengage the tissue.

• The stapler is then gently removed.

• The excised tissue ring ("donut") is inspected to ensure it is complete (360 degrees) and contains only mucosa and submucosa. An incomplete donut suggests an improperly placed purse-string and a high risk of failure or recurrence.

• The staple line should be inspected for any active bleeding using the anoscope. Any significant bleeders should be controlled with an absorbable suture.

SURGICAL PEARLS

• The Purse-String is Paramount: The success of the surgery depends almost entirely on a perfectly placed purse-string suture. Avoid the "five cardinal mistakes":

  1. Too Deep: Taking muscle in the bite.

  2. Too Superficial: Taking only mucosa, which will tear.

  3. Too Few Bites: Taking only 3-4 bites, which will cause the suture to cut through the tissue. At least 7 evenly spaced bites are required.

  4. Unequal Tissue Bridge: Taking very small "pricks" of mucosa that will easily tear when tension is applied.

  5. Zigzag Pattern: Placing bites at different vertical levels. The purse-string must be in a single, perfectly circular plane.

• Maintain Suture Level: When rotating the anoscope to place the next bite, ensure you maintain the same distance from the dentate line. In some models, markings on the anoscope can guide this.

• Rotation of Anoscope: When rotating the anoscope in a patient with large hemorrhoids, slightly withdraw it, rotate, and then re-advance to avoid tearing the prolapsed tissue.

• Suture Choice: Always use a monofilament suture (e.g., Prolene). Braided sutures like Silk or Vicryl have high friction and will tear the mucosa when tightened.

• Check the Donut: Always inspect the excised tissue ring. A complete, 360-degree donut of mucosa and submucosa confirms a successful transection. An incomplete or "half donut" indicates a technical failure.

COMPLICATIONS AND THEIR MANAGEMENT

• Intraoperative

  • Bleeding: Usually from an improperly placed suture or injury to a hemorrhoid. Manage with careful suturing.

• Early Postoperative

  • Bleeding (Most Common, 13-20%): The most common and serious complication. Minor bleeding can be observed. For significant bleeding, examination under anesthesia is required to identify and suture the bleeding point on the staple line. Never blind-pack the rectum, as this can conceal a large hematoma and lead to catastrophic secondary hemorrhage. A Foley catheter can be placed into the rectum, inflated, and placed on traction to tamponade the staple line while awaiting definitive management.

  • Pain (9%): Severe pain may indicate that the staple line is too close to or below the dentate line, or that a muscle fiber has been entrapped.

  • Urinary Retention: A rare complication due to parasympathetic nerve stimulation and pelvic pain.

  • Tenesmus: A feeling of rectal fullness or an urge to defecate, caused by the staple line. This usually resolves over time.

• Late Postoperative

  • Anal Stenosis/Stricture: Caused by fibrosis resulting from a staple line that is too low, or from deep suturing that incorporates the rectal musculature.

  • Rectovaginal Fistula: A devastating complication in female patients, caused by taking a full-thickness bite through the anterior rectal wall and posterior vaginal wall. A digital vaginal examination should be performed intraoperatively in female patients to ensure the posterior vaginal wall is not entrapped before firing the stapler.

  • Sepsis and Peritonitis: Extremely rare but life-threatening complications resulting from rectal perforation.

  • Recurrence (4-6%): Can occur due to improper technique, particularly an incomplete purse-string or one that is placed too low.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

• Stapled hemorrhoidopexy is a major procedure with the potential for life-threatening complications, including death, as reported in the literature. This must be clearly communicated to the patient during the informed consent process.

• Thorough knowledge of pelvic anatomy is mandatory. In female patients, placing a finger in the vagina while taking anterior bites of the purse-string is a crucial safety step to prevent rectovaginal fistula.

• Strict adherence to the principles of the procedure, especially the depth and level of the purse-string suture, is the most important factor in preventing medicolegal issues. The surgeon must be prepared to manage severe postoperative hemorrhage.

SUMMARY AND TAKE-HOME MESSAGES

• Stapled hemorrhoidopexy is a procedure for prolapse, not a direct excision of hemorrhoids. It works by lifting the prolapsed tissue (pexy) and reducing blood flow.

• The primary advantage is significantly reduced postoperative pain, leading to faster recovery and return to work.

• The single most important step for success and safety is the meticulous placement of a circumferential purse-string suture in the mucosa and submucosa, well above the dentate line.

• Surgeons must be vigilant for and prepared to manage serious complications, with postoperative hemorrhage being the most frequent and dangerous.

• Proper patient selection (Grade II/III hemorrhoids) and avoiding common technical errors are key to achieving excellent outcomes and minimizing risk.

MULTIPLE CHOICE QUESTIONS (MCQs)

1. What is the primary mechanism of action of stapled hemorrhoidopexy?

   a) Direct excision of hemorrhoidal cushions

   b) Ligation of the hemorrhoidal arteries using a Doppler

   c) Excision of rectal mucosa above the dentate line, leading to pexy and devascularization

   d) Sclerotherapy of the vascular cushions

2. Why is stapled hemorrhoidopexy generally less painful than conventional hemorrhoidectomy?

   a) It uses laser energy instead of a scalpel.

   b) The staple line is located in the insensate rectum above the dentate line.

   c) A smaller incision is made.

   d) It is a quicker procedure.

3. Which tissue layers should be incorporated into the purse-string suture?

   a) Mucosa only

   b) Mucosa and submucosa

   c) Mucosa, submucosa, and muscularis propria

   d) Full thickness of the rectal wall

4. Incorporating the rectal muscle in the purse-string suture can lead to which major complication?

   a) Recurrence of hemorrhoids

   b) Anal stenosis or stricture

   c) Incomplete "donut"

   d) Minor postoperative bleeding

5. What is the purpose of the anoscope (port) during the PPH procedure?

   a) To directly visualize the hemorrhoids for excision

   b) To retract the rectal wall and provide a window for suturing

   c) To insufflate the rectum with CO2

   d) To measure the pressure in the anal canal

6. A surgeon completes a PPH procedure and inspects the excised tissue, finding a "half donut." What is the most likely cause?

   a) The stapler was not fired correctly.

   b) The purse-string suture was incomplete or tore through the mucosa.

   c) The patient had Grade IV hemorrhoids.

   d) The stapler was opened too quickly after firing.

7. What is the most common and potentially dangerous early postoperative complication of stapled hemorrhoidopexy?

   a) Urinary retention

   b) Severe pain

   c) Hemorrhage from the staple line

   d) Tenesmus

8. What is a critical safety step to prevent rectovaginal fistula in a female patient undergoing PPH?

   a) Using a smaller stapler

   b) Placing the patient in the prone position

   c) Placing a finger in the vagina to check for entrapment before firing

   d) Administering prophylactic antibiotics

9. Why is a monofilament suture (e.g., Prolene) recommended for the purse-string?

   a) It is stronger than braided sutures.

   b) It dissolves more quickly.

   c) It slides easily and is less likely to tear the mucosa when tightened.

   d) It is blue, making it easy to see.

10. The safety mechanism on the PPH stapler prevents firing unless:

    a) The purse-string is perfectly tied.

    b) The tissue compression is within the optimal range (green zone).

    c) The anvil is more than 3 cm from the cartridge.

    d) The patient's blood pressure is stable.

11. What is the recommended immediate management for severe postoperative bleeding following PPH while awaiting definitive treatment?

    a) Immediately pack the rectum with gauze.

    b) Insert a Foley catheter into the rectum, inflate the balloon, and apply traction.

    c) Administer intravenous tranexamic acid and observe.

    d) Perform a diagnostic colonoscopy at the bedside.

12. The purse-string suture should be placed at what approximate distance above the dentate line?

    a) Exactly at the dentate line

    b) 1 cm above the dentate line

    c) At least 2-4 cm above the dentate line

    d) 6 cm above the dentate line

13. Which of the following is a primary contraindication for stapled hemorrhoidopexy?

    a) Grade II internal hemorrhoids

    b) Circumferential mucosal prolapse

    c) Thrombosed external hemorrhoids

    d) A patient desiring a rapid return to work

14. What is the purpose of the second simple stitch placed at the 9 o'clock position?

    a) To act as a marker for the dentate line

    b) To provide a backup in case the main purse-string breaks

    c) To facilitate symmetric, bilateral traction of the mucosa into the stapler

    d) To ligate the middle hemorrhoidal artery

15. Taking too few bites (e.g., 3-4) in the purse-string suture increases the risk of:

    a) The suture cutting through the tissue upon tightening.

    b) Creating a rectal stricture.

    c) Excessive devascularization of the rectum.

    d) Entrapping the anal sphincter.

16. How long should the surgeon wait after firing the stapler before opening and removing it?

    a) 0-5 seconds

    b) 20-60 seconds

    c) 3-5 minutes

    d) The time does not matter.

17. A "zigzag" purse-string refers to:

    a) Using a suture with alternating colors.

    b) Placing bites at varying vertical distances from the dentate line.

    c) Creating a suture line that intentionally avoids the hemorrhoids.

    d) Taking bites of varying depths.

18. What is the function of the obturator in the PPH kit?

    a) To cut the excised tissue donut

    b) To facilitate smooth insertion of the dilator and push hemorrhoids cephalad

    c) To retrieve the suture ends through the stapler

    d) To measure the diameter of the anal canal

19. Which finding upon inspection of the excised "donut" is most reassuring?

    a) Presence of muscle fibers

    b) A complete 360-degree ring of mucosa and submucosa

    c) An incomplete ring with a small gap

    d) The absence of the purse-string suture within the tissue

20. What is tenesmus?

    a) Inability to pass urine

    b) Sharp, stabbing pain in the rectum

    c) A feeling of incomplete evacuation or a foreign body sensation in the rectum

    d) Fecal incontinence

Correct Answers: 1-c, 2-b, 3-b, 4-b, 5-b, 6-b, 7-c, 8-c, 9-c, 10-b, 11-b, 12-c, 13-c, 14-c, 15-a, 16-b, 17-b, 18-b, 19-b, 20-c

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA

The most elegant incision is born not from a confident hand, but from a humble mind that has rehearsed the anatomy a thousand times before the first cut.

May your pursuit of surgical excellence be guided by both unwavering discipline and profound respect for the trust your patients place in you. My best wishes are with you all.