Severe Rectal Bleeding Following PPH-stapler Procedure for Haemorroidal Disease

Surgical Stapler Introduction

Haemorrhoidal disease is the most frequent and ancient proctological pathology. Haemorrhoidectomy is always feared for intensive post-operative pain and complications.
Surgical techniques have advanced more and more with the aim of reducing the post-surgical complications and to help a faster recovery. “Open hemorrhoidectomy”, according to Milligan-Morgan procedure, has been the most used method in Europe, also in the “Ligasure” and “Ultracision” variants. “Closed hemorrhoidectomy”, according to Ferguson procedure, has been the most used method in the USA. Stapled hemorrhoidopexy (PPH-stapler) is an alternative method to conventional surgical procedures. It has many advantages such as less pain, faster recovery and a quicker return to normal activities. PPH stapler procedure for treatment of haemorrhoidal prolapse classified P4E4 is an important improvement, but may be followed by severe postoperative complications of which haemorrhage is one of the most serious early events.

Prevalence of Hemorrhoids

Although hemorrhoids occur in everyone, they become large and cause problems in only 4% of the general population. Hemorrhoids that cause problems are found equally in men and women, and their prevalence peaks between 45 and 65 years of age.

What is stapled hemorrhoidectomy?

Stapled hemorrhoidectomy is surgical technique for treating hemorrhoids, and is the treatment of choice for third-degree hemorrhoids (hemorrhoids that protrude with straining and can be seen on physical exam outside the anal verge. Persistent or intermittent manual reduction is necessary). Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward.
For stapled hemorrhoidectomy, a circular, hollow tube is inserted into the anal canal. Through this tube, a suture (a long thread) is placed, actually woven, circumferentially within the anal canal above the internal hemorrhoids. The ends of the suture are brought out of the anus through the hollow tube. The stapler (a disposable instrument with a circular stapling device at the end) is placed through the first hollow tube and the ends of the suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their normal position within the anal canal. The stapler then is fired. When it fires, the stapler cuts off the circumferential ring of expanded hemorrhoidal tissue trapped within the stapler and at the same time staples together the upper and lower edges of the cut tissue.

Specification

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