Stapled Hemorrhoidopexy as the Likely Culprit
The procedure most likely performed was stapled hemorrhoidopexy (Option D), as this is the only hemorrhoid surgery technique specifically associated with life-threatening pelvirectal/retroperitoneal sepsis as a recognized complication. 1, 2
Why Stapled Hemorrhoidopexy is the Answer
Unique Association with Retroperitoneal/Pelvirectal Sepsis
Stapled hemorrhoidopexy has a well-documented association with retroperitoneal sepsis and pelvic sepsis, complications that do not occur with photocoagulation, rubber band ligation, cryotherapy, or HAL-RAR procedures 1, 2
The mechanism involves inadvertent excision of full-thickness rectal wall rather than mucosa and submucosa only, leading to rectal perforation and subsequent deep pelvic/retroperitoneal infection 1, 3
A systematic review of 13 patients across seven countries requiring emergency abdominal exploration after stapled hemorrhoidopexy documented 9 cases of perforation and 6 cases of sepsis, with 3 deaths from septic complications 2
Temporal Pattern Matches Clinical Presentation
70% of patients requiring emergency intervention after stapled hemorrhoidopexy developed complications within 3 days, and 90% within 5 days 2
The classic warning triad consists of abdominal pain, urinary retention, and fever in the immediate postoperative period 2, 4
Retroperitoneal sepsis specifically has been reported as early as postoperative day 2, requiring emergency colostomy 5, 6
Technical Factors Contributing to This Complication
Incomplete excision rings ("doughnuts") of rectal tissue noted intraoperatively correlate with subsequent septic complications, as the staple line integrity determines whether full-thickness perforation has occurred 2
The complication occurs more frequently early in a surgeon's experience (under 10 cases), suggesting a technical learning curve issue 2
Internal anal sphincter fragmentation occurs in 14% of cases using standard 37-mm anal dilators, but this does not explain pelvirectal abscess formation 1
Why Other Options Are Excluded
Photocoagulation (Option A)
- This is a minimally invasive office procedure using infrared or laser energy that causes superficial tissue coagulation 7
- Does not involve deep tissue manipulation or create pathways for retroperitoneal infection 7
Rubber Band Ligation (Option B)
- Complications are limited to bleeding and thrombosed external hemorrhoids 7
- The procedure is superficial and does not access deep pelvic spaces 7
Cryotherapy (Option C)
- Complications include pain, tissue necrosis, and incontinence, but not deep pelvic sepsis 7
- This technique has largely been abandoned due to persistent bleeding and high recurrence rates 7
HAL-RAR (Option E)
- While noted to have lower complications but higher recurrence, there is no literature linking this procedure to retroperitoneal or pelvirectal abscess formation 7
Critical Clinical Pitfall
The most dangerous error is dismissing early postoperative abdominal pain, urinary retention, and fever as "normal" postoperative symptoms rather than recognizing them as harbingers of life-threatening sepsis requiring immediate imaging and potential emergency laparotomy with fecal diversion 2, 4. The mortality rate in reported cases is approximately 23% (3 deaths among 13 patients requiring emergency intervention), emphasizing the urgency of recognition 2.