PROCEDURE FOR PROLAPSE & HEMORRHOIDS (PPH PROCEDURE)

Stapled Hemorrhoidopexy (PPH Procedure)

Also known as the Procedure for Prolapse & Hemorrhoids (PPH), the Stapled Hemorrhoidectomy, and the Circumferential Mucosectomy. PPH is a technique developed in the early 90s that reduces prolapse of hemorrhoidal tissue by excising a band of the prolapsed anal mucosa using a circular stapling device. In PPH, the prolapsed tissue is pulled into a device that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. This restores the hemorrhoidal tissue to its original anatomical position.

Insertion of the Dilator

The introduction of the Circular Anal Dilator causes the reduction of the prolapse of the anal skin and parts of the anal mucous membrane. After removing the obturator, the prolapsed mucous membrane falls into the lumen of the dilator.

Purse-String Suture

The Purse-String Suture Anoscope is then introduced through the dilator. This anoscope will push the mucous prolapse back against the rectal wall along a 270° circumference, while the mucous membrane that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. By rotating the anoscope, it will be possible to complete a purse-string suture around the entire anal circumference.

Open the Circular Stapler

The Hemorrhoidal Circular Stapler is open to its maximum position. Its head is introduced and positioned proximal to the purse-string, which is then tied with a closing knot.

partially tighten the knot

The ends of the suture are knotted externally. Then the entire casing of the stapling device is introduced into the anal canal. During the introduction, it is advisable to partially tighten the stapler.

Pull the mucous membrane into the casing

With moderate traction on the purse-string, a simple maneuver draws the prolapsed mucous membrane into the casing of the circular stapling device. The instrument is then tightened and fired to staple the prolapse. Keeping the stapling device in the closed position for approximately 30 seconds before firing and approximately 20 seconds after firing acts as a tamponade, which may help promote hemostasis.

Fire the stapler

Firing the stapler releases a double staggered row of titanium staples through the tissue. A circular knife excises the redundant tissue. A circumferential column of mucosa is removed from the upper anal canal. Finally, the staple line is examined using the anoscope. If bleeding from the staple line occurs, additional absorbable sutures may be placed.

Benefits of PPH over other Surgical Procedures

1) Patients experience less pain as compared to conventional techniques.

2) Patients experience a quicker return to normal activities compared to those treated with conventional techniques.

3) The mean inpatient stay was lower compared to patients treated with conventional techniques.

RISKS AND COMPLICATIONS OF PPH

1) If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall.

2) The internal muscles of the sphincter may stretch, resulting in short-term or long-term dysfunction.

3) As with other surgical treatments for hemorrhoids, cases of pelvic sepsis have been reported following stapled hemorrhoidectomy.

4) PPH may be unsuccessful in patients with large confluent hemorrhoids. Access to the anal canal can be difficult, and the tissue may be too bulky to fit within the stapling device housing.

5) Persistent pain and fecal urgency after stapled hemorrhoidectomy, although rare, have been reported.

PAIN-FREE HEMORRHOID TREATMENT