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Stapled haemorrhoidopexy

Stapled haemorrhoidopexy. Ian Botterill Dept Colorectal Surgery St James’ University Hospital Leeds. Barry Wood Lancashire & England. Dennis Lillee Western Australia & Australia. Ideal surgical treatment of haemorrhoids.

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Stapled haemorrhoidopexy

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  1. Stapled haemorrhoidopexy Ian Botterill Dept Colorectal Surgery St James’ University Hospital Leeds

  2. Barry Wood Lancashire & England Dennis Lillee Western Australia & Australia

  3. Ideal surgical treatment of haemorrhoids Minimal pain, short stay, rapid recuperation, low morbidity, lasting benefit

  4. The Longo procedure Antonio Longo 1st performed 1993 1st reported 1998

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

  6. Premise • haemorrhoids contribute to continence • haemorrhoids worth preserving • weakened of suspensory lig of rectum • ‘pexy’ addresses the prolapse

  7. 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

  8. Serious adverse events • persistent faecal urgency • persistent anal pain • recto-vaginal fistula • retroperitoneal perforation • rectal perforation • pelvic sepsis • Fournier’s gangrene • rectal pocket syndrome

  9. 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

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

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

  12. Patient selection-indications • prolapsing / prolapsed haemorrhoids • circumferential haemorrhoids

  13. Patient selection-relative contraindications any haemorrhoid operation • diabetics / immuno-suppressed • bleeding diasthesis • faecal incontinence • Crohn’s specific to stapled haemorrhoidopexy • deep ‘funnel shaped’ perineum • large anal skin tags • narrow gap between ischial spines

  14. Consent for open / stapled Prone jack-knife allows ↓engorgement of anal cushions Pre-op GTN / diltiazem

  15. Positioning / placement 4 quadrant sutures Lubrication anal canal

  16. Gentle dilation with obturator alone Reduction haemorrhoids

  17. Insertion CAD & obturator Fixation of CAD

  18. 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

  19. 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

  20. Complete gun closure check vagina - saline infiltration helpful Ensure closed gun @ ‘4cm’ on housing prior to firing

  21. ½ turn to release gun sutured haemostasis (4/0 vicryl) – much less common using newer PPH03 avoid diathermy

  22. 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 Post-op pain relief Discharge instructions -pain / retention urine / fever -avoidance anal intercourse See @ 4-6/52 in case need dilation

  23. Role of pathology • audit -correlation with outcome -inclusion of glandular / squamous -inclusion of smooth m deep to squamous epithelium • unexpected pathology

  24. Role of pathology • n=84 • 19/84 squamous epithelium in donut (M>>F) - 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 Shanmugam et al Colorectal Dis 2005;7:172-5

  25. Role of pathology • n=68 • 64/68 contained smooth muscle • 24/64 had smooth muscle with overlying squamous cell / transitional epithelium • no outcome difference Kam et al. DCR 2005:48:1437-41

  26. results • >25 RCTs • 4 reviews (inc. 2 position statements) • forthcoming meta-analysis • 1 NICE appraisal (2nd planned)

  27. Operation duration: -stapled haemorrhoidopexy superior

  28. Pain – favours stapled haemorrhoidopexy Pain: stapled haemorrhoidopexy superior

  29. Persistent mid-term pain: stapled haemorrhoidopexy superior

  30. Hospital stay: stapled haemorrhoidopexy superior

  31. Recurrent prolapse: conventional superior

  32. Redo surgery: - stapled haemorrhoidopexy & closed equivalent - open superior to stapled haemorrhoidopexy

  33. Post-operative incontinence: no difference

  34. Anal stenosis: no difference

  35. 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

  36. 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

  37. Choose your tools appropriately

  38. 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 dil’n / chem. sphincterotomy / LA block • ? pre-existing anal sphincter injury

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