What is hemorrhoidopexy used for in the treatment of hemorrhoids?

Hemorrhoidopexy for Hemorrhoid Treatment

Stapled hemorrhoidopexy is a surgical technique specifically designed for treating grade III (and select grade IV) internal hemorrhoids that performs a circular excision of prolapsing rectal mucosa proximal to the dentate line, offering significantly less postoperative pain than conventional hemorrhoidectomy but with higher recurrence rates. 1, 2

Mechanism and Technique

• Hemorrhoidopexy (also called stapled hemorrhoidopexy or PPH procedure) works by excising a circular band of internal hemorrhoidal tissue and prolapsing rectal mucosa above the dentate line, which elevates the hemorrhoids back to their normal anatomic position 1, 2
• The procedure is performed under general anesthesia with the patient in lithotomy position, with mean operating times around 16 minutes 3
• Unlike conventional hemorrhoidectomy which removes hemorrhoidal tissue, this technique repositions the hemorrhoids by removing redundant proximal mucosa 2, 4

Primary Indications

• Grade III internal hemorrhoids are the ideal indication, particularly when hemorrhoids are circumferential in distribution 1, 2, 3
• May be considered for select grade IV hemorrhoids, though recent studies identify significant weaknesses in this application with higher failure rates 5, 3
• Can be employed in emergency situations of acute anal prolapse 5
• Not appropriate for isolated external hemorrhoids or mixed disease with significant external components 1

Advantages Over Conventional Hemorrhoidectomy

• Significantly reduced postoperative pain compared to excisional hemorrhoidectomy, which is the procedure's primary advantage 1, 2, 5
• Shorter operation time and hospital stay (mean 1.2 days) 5, 3
• Faster recovery with most patients returning to daily activities within 2-5 days, compared to 2-4 weeks for conventional hemorrhoidectomy 1, 5, 3
• Less requirement for narcotic analgesics postoperatively 2, 4

Disadvantages and Limitations

• Higher recurrence rates compared to conventional excisional hemorrhoidectomy (approximately 6.6% in studies vs. 2-10% for conventional hemorrhoidectomy) 1, 5, 3
• Risk of rare but severe complications that require thorough surgeon training before performing the procedure 6
• Less effective for grade IV hemorrhoids with significant external components 5, 3
• May not adequately address mixed internal and external hemorrhoidal disease 1

Common Complications

• Mild rectal pain occurs in approximately 5.8% of patients, lasting 5-12 days postoperatively 3
• Urinary retention in 5.8% of cases, managed with catheterization 3
• Fecal urgency in 13.3% of patients 3
• Gas incontinence in 5.8% of patients, typically resolving within 2-8 weeks 3
• Bleeding, anal stenosis, and infection can occur but are less common than with conventional hemorrhoidectomy 7

Management of Recurrence

• Recurrent disease after hemorrhoidopexy can be managed conservatively in mild cases 3
• Redo hemorrhoidopexy is an option for appropriate candidates 3
• Conventional hemorrhoidectomy may be required for failed hemorrhoidopexy 3

Critical Decision Points

• Choose hemorrhoidopexy over conventional hemorrhoidectomy when: patient has grade III circumferential hemorrhoids, rapid return to work is prioritized, and patient accepts slightly higher recurrence risk for reduced pain 1, 5, 3
• Choose conventional hemorrhoidectomy over hemorrhoidopexy when: patient has grade IV hemorrhoids, mixed internal/external disease, or when lowest recurrence rate is the priority despite longer recovery 1, 2
• Hemorrhoidopexy should only be performed by surgeons with thorough training in the technique due to risk of severe complications 6

Important Pitfalls to Avoid

• Do not use hemorrhoidopexy as first-line treatment—conservative management and office-based procedures (rubber band ligation) should be attempted first for grade I-III hemorrhoids 1, 8
• Avoid using this technique for predominantly external hemorrhoids or thrombosed external hemorrhoids, as it is designed specifically for internal hemorrhoidal prolapse 1, 6
• Do not assume hemorrhoidopexy is appropriate for all grade IV hemorrhoids—conventional hemorrhoidectomy remains superior for advanced disease 5, 3