What is Stapler Hemorrhoidopexy?
Stapler hemorrhoidopexy (also called stapled anopexy, prolapsectomy, or circumferential mucosectomy) is a surgical technique that removes a ring of redundant rectal mucosa above the anal canal and proximal to the hemorrhoids themselves, using a modified circular stapling device, with the dual goals of resuspending prolapsing hemorrhoidal tissue back within the anal canal and interrupting arterial inflow through the excised segment. 1
Fundamental Mechanism
The procedure was introduced by Longo in 1998 as an alternative to conventional hemorrhoidectomy by adapting the circular stapling device commonly used for low rectal anastomoses. 1 The technique differs fundamentally from traditional hemorrhoidectomy in that:
- It does not directly excise the hemorrhoidal tissue itself 1
- External hemorrhoids and skin tags are not removed, unlike conventional hemorrhoidectomy 1, 2
- The procedure works by lifting and repositioning prolapsed tissue rather than cutting it out 1
Technical Execution
The critical technical step involves placing a purse-string suture in the rectal mucosa above the hemorrhoids, then using the circular stapler to excise a circumferential ring of mucosa and submucosa. 1 The stapler simultaneously creates an anastomosis that pulls the hemorrhoidal cushions back into their normal anatomical position. 3
The purse-string must be placed at the correct distance from the dentate line in the proper submucosal plane to avoid the most serious complications. 3 The procedure typically takes 16-42 minutes to complete. 4, 3, 5
Clinical Advantages Over Conventional Hemorrhoidectomy
Based on eight randomized controlled trials, stapler hemorrhoidopexy demonstrates:
- Significantly reduced postoperative pain in all eight trials 1
- More rapid return to normal activities (within 8-12 days versus 2-4 weeks for conventional surgery) 1, 2
- Shorter operating times 1
- Shorter hospital stays (typically 1-2 days) 1, 6, 4
- Comparable complication, continence, and recurrence rates to conventional hemorrhoidectomy 1
Most patients require only oral analgesics after the initial postoperative period, rather than the intensive pain management needed after conventional hemorrhoidectomy. 2
Critical Safety Concerns and Complications
The most serious complications share a common denominator: inadvertent excision of full-thickness rectal wall rather than mucosa and submucosa only. 1, 2 This technical error can lead to:
Additional complications include:
- Internal anal sphincter fragmentation in 14% of patients when using the standard 37-mm anal dilator 1, 2
- Smooth muscle fibers detected in variable percentages of specimens 1
- Postoperative anal stenosis (2.7-6.7% depending on technique) 7
- One suspended trial reported persistent pain and fecal urgency lasting up to 15 months in 5 of 22 patients, though this has not been replicated 1
Standard hemorrhoidectomy complications still occur but at similar rates: urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%). 1, 2
Appropriate Patient Selection
The procedure is indicated for:
- Grade III (second-degree) and Grade IV (third-degree) internal hemorrhoids 4, 5
- Symptomatic prolapsing hemorrhoids 6, 4
Patients must understand that external hemorrhoids and skin tags will not be addressed by this technique. 1, 2 If external disease is significant, conventional hemorrhoidectomy may be more appropriate. 1
Long-term Efficacy Considerations
A systematic review concluded that efficacy compared to conventional hemorrhoidectomy could not be determined due to paucity of long-term data. 1 However, individual studies report:
- Recurrence rates of approximately 6.6% at long-term follow-up 5
- Global satisfaction rates of 94% 4
- Higher recurrence rates compared to conventional hemorrhoidectomy 8
The procedure can be safely performed as day surgery with appropriate patient selection and monitoring protocols. 6