Stapler hemorrhoidectomy 3

DR ABDULMENEM ABUALSEL

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631 -671H
1255-1300G

3. 1
ST
annul surgical symposium

STAPLED
HEMORRHOIDECTOMY
Dr. Abdulmonem Abualsel
KAMC –NGHA- ALHASA
MRCS Gen. Surgery

4. DEFINITION
Haemorrhoids :-
(Greek: haima=blood, rhoos=flowing)
Piles (latin: pila=a ball)
They may be external or internal
When the two varieties are associated
they are known as interoexternal.

5. Anatomy
The anal canal, 4 cm long, extends
from the pubo-rectalis passes
downwards and backwards, to the skin
of the perineum.
The upper two-thirds is derived from the
cloaca (endoderm), the lower one-third
from the anal pit (ectoderm) .

7. Blood Supply
 Of the cloacal part from the superior
rectal artery (Portal).
 The sphincters, outside the mucosa,
are supplied by the middle and inferior
rectal arteries (systemic).
 The mucosa of the lower third is
supplied by the inferior rectal artery.

8. The site of Hs

9. Venous return
 Above the dentate line to the portal
system through the superior rectal vein.
 Below the dentate line , the external
hemorrhoidal plexus drains via the
middle and inferior rectal veins, to the
internal iliac vein.

10. Classification
1-By location:
 External: from the inferior hemorrhoidal
plexus, covered by modified squamous
epithelium.
 Internal: they occur above the
pectinate line, may prolapse
Mixed: from both plexuses.

11. Classification
2-By degree:
1
st
. Degree :Simple projection.
2
nd
.degree: Present to the outside
during defecation.
3
rd
.degree: Mixed protrude outside &
require manual reduction.
4
th
.degree: Prolapsed & irreducible.

12. Aetiology
The correct treatment of Hs can only be
found upon sound etiological concept.
Suggested by some to be due to the
adoption of the erect posture by Man.
A consequence of the aging process.
However 4 major theories to be
mentioned

13. Aetiology
1-Abnormal dilatation of the veins of the
internal hem. venous plexus.
2-Abnormal distension of the arterio-
venous anastomoses.
3-Downward displacement or prolapse
of the anal cushions.
4-Destruction of the anchoring
connective tissue system.

14. parks AG the surgical treatment
of hemorrhoids BrJ1956 43-51
Parks 1956, maintained the aetiology
was compression of the low pressure
superior Hs veins by efforts to expel
constipated stool. ARTERIAL pressure
allows blood to enter the internal Hs
plexus which becomes distended and
congested. Followed by partial prolapse

15. Impaired v drainage

16. Aetiology
 The role of transient increase in intra-
abdominal pressure, e.g. during
defecation and in pregnancy.
 The high rectal pressure in patients
suffering from piles.

17. Theories
Stewart 1963, divided internal Hs into
2 main groups:
1-Vascular Hs with extensive dilatation
of the internal Hs plexus a variety
commoner in the young.
2-Mucosal Hs and consists of sliding
downwards of thickened mucous
membrane, in the old i.e prolapse

18. thompson WH .the nature of
hemorrhoid 1975 surg 62- 542
1975, Thomson postulated the theory of
Vascular cushions, which protect the
anal canal during the act of defecation
 The submucosa is not a continuous
ring, but rather a discontinuous series
of cushions, rich in blood vessels and
muscle fibers, which adheres the
mucosa and submucosa to the internal
sphincter and supports the blood
vessels.

19. thompson WH .the nature of
hemorrhoid 1975 surg 62- 542
Straining causes these cushions to
slide downwards and internal Hs
Develop Prolapse of the anal mucous
and hemorrhoidal cushions is a very
common condition over the age of 50.

20. thompson WH .the nature of
hemorrhoid 1975 surg 62- 542
Aetiology
Thomson demonstrated that the
fragmentation of the supporting tissue is the
cause for the Prolapse, affecting the
hemorrhoidal tissue and the anal mucosa.
The collapse of Park’s ligament causes a
permanent downward sliding of the anal
mucosa that loses its normal topographic
relationship with the sphincters.

21. Aetiology
Under this circumstance the mucosa of
the rectal ampulla occupies the
muscular anal canal permanently, while
the anal mucous membrane and the
piles are distally displaced.
The anal prolapse cause an alteration
of the vascular arrangement and of the
anatomical relationship between the
……

22. Internal and external hemorrhoidal
plexuses.
Based on the previous theories a
stapler hemorrhiodectomy was one of
the modalities of treatment of piles.

23. It is assumed that the technique of stapled
hemorrhoidectomy aims to preserve the anal
mucosa and the hemorrhoidal tissue,
however, maintaining the suture carried out
above the anorectal ring.
Under some circumstances the transection of
some anal mucosa is necessary.

24. longoA1998 treatment of
hemorhoidal disease
Longo A (1998) Treatment of haemorrhoidal
disease
 Introduction of stapled
hemorrhoidopexy by Longo in 1998 [1]
represented a radical change in the
treatment of hemorrhoids.
By avoiding multiple excisions and
suture lines in the perianal region, SH is
intended to offer less postoperative pain
than with conventional techniques

25. DR :ANTONIO LONGO

26. Definition and Principles
The operation is based on the principle
of a mucosectomy at least 3-4 cm
above the dentate line where:
A purse string suture placed at that
level and tied around the stapler shaft
then resection and stapling of the
mucosa are carried out, simultaneously.

27. Cont…
This procedure effectively reduces
mucosa
Blocks the end of branches of the upper
rectal artery thus stopping venous and
arterial blood flow of hemorrhoidal
plexus.

40. Medical treatment
Fibres
Over the counter
daflon

41. Nonoperative treatment
Sclerotherapy
Cryotherapy
Rubber band ligation
Bipolar diathermy and infrared
photocoagulation

42. Surgical treatment
Excision
Anal dilatation
stapler

43. قشمد يف يوملا دجسملا

44. Study from April
2003 till January
2009

45. Abstract
Objectives: present our
retrospective results of circular
stapler hemorrhoidcetomy (SH) for
the treatment of haemorrhoids.
Data collection:160 patient operated
in national guard from 2003 up to
January 2009.

46. The goals of the study were to evaluate
the efficacy and reproducibility of
stapled hemorrhoidectomy .

47. The indication for surgery
 bleeding and / or prolapsed of
2nd ,3rd and 4
th
degree piles

48. Results:
 96 male(60%)
64 female(40%)
The age between 20- 80 year with
average (35,5) year

49. DR: Ahmad Salman

50. METHODS
160 pt
Complication
Hospital length
Operation time.
Follow up 2 week ,0ne
month,3month,6month one year and 2
year.

51. Total Number of Patient - 160
Youngest – 20 years old
Oldest – 80 years old
Average – 35.5 years old

52. (71%)of pts with 3ed degree
(28%) ==== 4
th
degree
 (1%) ==== 2ed degree

53. Operative Time
Quickest – 8 minutes
Longest – 70 minutes
Average Time – 32 minutes
 4 case stapler + peri anal fistula

54. 0
10
20
30
40
50
60
male
female

55. Those patients were operated by 6
surgeons
 4 consultant .
2 senior registrar.
 Dr salman is the first one who start this
and the one teach us .

58. Visual analogue scale
Post operative was managed according to guideline
of VAS (0-no pain)to (10-mexionir pain)
The aim was to keep down to VAS score <3
Analgesic, was given according WHO system.
During operation immediately of the recovery.((IM)
NSAID. Or mepridine )
During hospital stay:
VAS<3 class1 analgesic paracetamol tab.
VAS<3-5 class 11 paracetamol + NSAID
(tab)
VAS<5 class 111  mepridine IM injection

59. Analgesia

60 % received a single does. Pethidine
inj only.
15 % received. only 1 dose Voltaren inj.
10 % received.acetaminophen and
voltaren tab.
15% received. acetaminophen tab only.

60. complications
Complications during the first 24 hours
were
fecal urgency (25%),
 urinary retention (10%),
rectal bleeding (2%).
Pruritus ani (5%)??

61. Complication
Post anal fissure –6 case 3,7%
Anal stricture – 5 cases 3.1
 perianal fistula &Thrombosed pile
– 2 case 1.6%
Reintervension
*2 case for bleeding
*5 cases for anal dilation

62. Anal pain – 6 cases 3,75%
4 cases low stapler line .
Recurrance : 4 cases after 2 year
Satisfaction – 94%
•- 60%. by asking the patient during
clinic visit
•-40%. by telephone

63. Hospital Length of Stay
75% 1 days
15% 2 days
10% > 2 days
–Causes: a. bleeding
b. Anal pain
c. Social.

64. Return to work:
10 days post op in more than 95%

65. They were no cases of
 permanent incontinence,
 chronic pain
 or deaths in this series

66. literatures

67. Department of Surgery, Università Tor
Vergata, Rome, Italy,
: 171 patients (95 cases in SH group
and 76 cases in MMH group) entered
the study:
 83 cases were III degree hemorrhoids,
88 IV degree.
Surgical time was 28.41 +/- 10.78 for
MMH and 28.30 +/- 13.28 min in SH

68. during the following 6 days, patients
treated with SH had less pain (4.63 +/-
2.04 in MMH vs 3.60 +/- 2.35 in SH;

69. Colorectal Surgery Division, Hospital
Santa Helena, Sao Paulo (SP), Brazil.
A series of 108 patients
76 Patients who underwent stapled
hemorrhoidectomy were compared to
32 patients submitted to closed
diathermy-excision hemorrhoidectomy
due to
, median and maximum daily pain
scores were lower in the stapled group
(P < 0.001).

70. days Resumption of activities occurred
after 9 days (mean; range 2 to 17 days)
after stapling and 14 days (7 to 24) after
diathermy surgery - P < 0.001. After
one
year, 45 (80.4%) patients in the stapled
group and 18 (78.3%) in the diathermy
group were asymptomatic

71. Many center in France
*CHU Rangueil, Toulouse, France; CHU
Nantes, Nantes, France; CHU
Trousseau, Tours, France; Clinique
Charcot, Lyon, France; Polyclinique de
Franche Comté, Besancon, France;
CHU Limoges, Limoges, France,
Angers, France

72. A series of 134 patients were included
at 7 hospital centers. They were
randomized according to a single-
masked design
The mean follow-up period was 2.21
years
Hospital stay was significantly shorter in
the SH group (SH 2.2 ± 1.2 [0; 5.0]
versus MM 3.1 ± 1.7 [1; 8.0] P < 0.001

73. No patient needed a second procedure
for recurrence within 2 years
 A clear difference in morphine
requirement became evident after 24
hours
 the overall incidence of complications
was the same,

74. Rev Gastroenterology Mex. 2006 Oct-
Dec;71(4):422-7 Mexico
In a 27 months period, 160 patients were treated (105 men and 55
women),
 mean age was 44.1 years (range: 24 to 72 years),
110 patients had grade III hemorrhoid disease.
 Non procedure complications were noted,
early complications were detected in 5% of patients
late complications were detected in 10% of patients.
mean follow-up of 18.8 months,
82.5% of the patients remained asymptomatic and 94.4 of the
patients reported a good satisfaction score.
A second surgery was required in three patients because of
recurrence.

75. Conclusion
This study confirms the feasibility of
circular stapler hemorrhoidectomy
complication and post-operative pain
were minimal and goes with most of the
international studies.

76. SH is safe and simple procedure,
 SH can eliminate hemorrhoidal bleeding,
 SH successfully eliminates pain in
hemorrhoidal disease,
 SH successfully eliminates hemorrhoidal
prolapse
 SH is a minimally invasive surgical
procedure.

77. 1. Longo A (1998) Treatment of haemorrhoidal
disease by reduction of mucosa
and haemorrhoidal prolapse
Rome, Italy, pp 3–63
2. Lacerda-Filho A, Da Silva RG. Stapled
hemorrhoidectomy: present status. Arq Gastroenterol
2005;42:191–4.
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84. Thank
you