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Stapled Haemorrhoidectomy

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Stapled Haemorrhoidectomy

Mr Vivek Datta MB BS BSc MD FRCS (Gen) is a Consultant Colorectal Surgeon at Guy’s and St Thomas’ Hospitals and Bupa Cromwell Hospital.

Haemorrhoids are found in over 50% of the population. They consist of vascular cushions whose function is thought to be in helping with stool control, and become pathological (piles) when swollen or inflamed. There are many causes, but constipation and straining are dominant features in a patient’s history, with painless bright red rectal bleeding being the main symptom.

The management of haemorrhoids has been described as far back as 1700 BC, and is even mentioned in the Bible. 1 and 2 degree (internal) haemorrhoids are usually treated with a combination of dietary modification and either rubber band placement or haemorrhoid artery ligation. 3 and 4 degree (external) haemorrhoids exhibit significant prolapse of the vascular cushions, and traditionally the management has involved formal excision of the haemorrhoidal cushion with part of the anal skin as well. This can be extremely painful post operatively, and there is the risk of permanent anal stenosis due to excess skin excision when several haemorrhoidal pedicles are involved, particularly when they are circumferential.

Stapled haemorrhoidectomy was first described in the early 1990’s, with final NICE guidelines published in 2003. Though suitable for all types of haemorrhoids it is usually reserved for the treatment of circumferential external haemorrhoids as no anal skin needs to be removed, and so should be the technique of choice in this situation.

Stapled haemorrhoidectomy
Figure 1.

The procedure involves inserting a device into the anus that places small titanium staples circumferentially into the anorectal mucosa above the dentate line away from the anal sphincter complex. This has two effects; firstly a circumferential strip of mucosa is excised from the proximal anal canal that effectively pulls up the haemorrhoid cushions back into their normal anatomical position. Secondly, the staples interrupt the blood supply to these cushions causing them to atrophy (Figure 1 ).

The level at which the staples are placed in the anal canal is crucial: too low and they will anchor into the anal sphincters, causing pain and urgency; too high and there is risk of transecting the rectum. Therefore surgical experience is the key to performing what should be a straightforward operation.

The procedure is performed under general anaesthetic, usually as a day case, and typically takes 20-30 minutes. Both post-operative pain and bleeding are much reduced compared to standard haemorrhoid excision, and return to normal activity has been shown to be significantly quicker.

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