Stapled hemorrhoidopexy

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Relevant surgical anatomy

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    (1) Tunica muscularis, longitudinal sublayer, (2) Tunica muscularis, circular sublayer, (3) levator ani, (4) puborectalis, (5) external anal sphincter, deep part, (6) anal columns, (7) external anal sphincter, superficial part, (8) external anal sphincter, subcutaneous part, (9) Kohlrausch’s fold, (10) internal anal sphincter, (11) proctodeal gland, (12) corrugator cutis ani

    Rectum

    From a functional point of view, the rectum is a storage reservoir for feces preventing its continuous discharge. The rectum directly adjoins the sigmoid colon and resembles it in that it has an S-shaped anteroposterior and lateral curvature (sacral, anorectal and sacral flexure). Typically, the rectum is divided into three segments:

    1. Rectal ampulla (main reservoir, anterior to the sacrum)
    2. Anal canal (see below, sealing zone between the anorectal flexure and the cutaneous orifice)
    3. Between 1. and 2. an unspecified section which emerges perpendicularly from 1. and joins 2., also at right angles. Here, the mucosa presents with typical folds (Kohlrausch's folds).

    Posteriorly the rectum is related to the sacrum and coccyx, laterally to the internal iliac arteries and veins, regional lymph nodes, sacral plexus and parts of the autonomic nervous system, as well as both ureters and uterine adnexa. In the female, the uterus and vagina lie anteriorly, while in men this is true for the bladder and prostate/seminal vesicles. Inferiorly the rectum is related to the pelvic floor.

    Anal canal

    The interaction of three muscles in the lower rectum creates a sphincter mechanism:

    1. The internal anal sphincter represents a thickening of the last annular fibers of the smooth colon muscles and is innervated by the sympathetic nervous system.
    2. The levator ani, however, has voluntary innervation (sacral plexus) and includes the puborectalis arising from the symphysis pubis. Since the course of the puborectalis creates a sling (deficient anteriorly) around the rectum, the latter becomes angulated.
    3. The external anal sphincter is also a striated muscle and extends from the center of the perineum (centrum perinei, perineal body) to the coccyx. Its somatic innervation is supplied by the pudendal nerve. With its contraction it completely seals off the anal canal.
      The different innervation of the three muscles involved in the sphincter mechanism provides additional protection against failure and resulting incontinence.
      The mucosa of the anal canal is plicated into numerous longitudinal folds (anal columns) displaying a dense arterial (!) plexus with venous drainage. When the sphincter muscles contract, these plexuses fill up quickly distending the mucosa and pushing the folds against each other, thereby ensuring a gas-tight seal. Hemorrhoids and venous thromboses are well known vascular complications in this region.
      Defecation involves not only relaxation of the sphincter mechanisms (initiated by voluntary muscle action, drainage of the cavernous bodies) but also active abdominal press and intestinal peristalsis.
    Blood supply

    Three main arteries supply the rectum with blood:

    • Superior rectal artery (from the inferior mesenteric artery) via the sigmoid mesocolon (Caution: Transection of this artery at the level of the sigmoid colon results in ischemia of the upper rectum!)
    • Medial rectal artery (from the internal iliac artery), coursing craniad of the levator ani
    • Inferior rectal artery (from the internal pudendal artery) inferior to the levator ani.

    Venous drainage is via the venous rectal plexus underneath the mucosa of the rectum. The superior rectal vein drains the blood of the upper rectum via the inferior mesenteric vein into the liver, while the medial and inferior rectal veins drain the blood of the middle and lower rectum via the internal iliac vein into the lower vena cava (portocaval anastomosis). Medications administered as suppositories therefore only enter the body without being metabolized, if they are not advanced up into the region drained by the superior rectal vein.
    Lymphatic drainage of the rectum parallels the rectal blood vessels: The large cluster of inferior mesenteric lymph nodes forms a separate group at the upper rectum (superior rectal lymph nodes); the internal iliac lymph nodes filter lymph from the middle rectum (from the pararectal lymph nodes) and the superficial inguinal lymph nodes from the lower anal region, anus and perineal skin.

    Perineum

    The perineum includes the region inferior to the pelvic diaphragm (genitourinary and anal region) and is delimited:

    • Craniad by the fascia of the inferior pelvic diaphragm
    • Anteriorly by the symphysis pubis
    • Laterally by the ischium
    • Posteriorly by the inferior edge of the gluteus maximus.

    The posterior perineum corresponds to the anal region and is known in the nomenclature as ischioanal fossa, while the anterior perineum corresponds to the pubic region and can itself be divided into three segments lying on top of each other: At the most superficial level a subcutaneous perineal pouch (Colles space) (between the stratum membranosum telae subcutaneae perinei = Colles fascia and the perineal fascia), a superficial perineal pouch between the perineal fascia and perineal membrane (Buck), and a deep perineal pouch superior to the perineal membrane.

    Below the skin the posterior ischioanal fossa consists mainly of fatty tissue and numerous vessels/nerves (branches of the inferior rectal and internal pudendal artery and the pudendal nerve to the anal region). At the transition to the sacral region, a space lined with epithelium may develop in the gluteal fold and form a sinus between the tip of the coccyx and the anal verge. It may be encapsulated like a cyst (dermoid cyst) or have an external orifice (pilonidal sinus).

    The anterior superficial perineal space comprises the superficial muscles of the perineum and the blood vessels and nerves to the external genitals (perineal artery and artery of bulb of vestibule, as well as branches of the pudendal nerve to the labia/clitoris and scrotum respectively).
    The deep anterior perineal space is less clearly delimited, merges with the ischioanal fossa posteriorly and comprises the deep perineal muscles and other deep vessels/nerves.

  • Herr Prof. Dr. med. Alexander Herold

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 25.09.2009
  • Herr Prof. Dr. med. Alexander Herold

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  • Verifying the indication and dilating the anal sphincter

    32-4

    Check, whether the hemorrhoids can be reduced, and if so, intraoperatively verify the indication for stapled hemorrhoidopexy. Carefully dilate the anal sphincter.

  • Purse string suture

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    With the PPH set (Procedure for Prolapse and Hemorrhoids), place a circular, submucous purse string suture just superior to the hemorrhoidal base, markedly proximal to the dentate line and sparing the muscles.

  • Inserting the stapler

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    With the stapler fully opened, close and tie the purse string suture below the anvil. Digitally examine the anal canal and stapler position.

  • Resecting the hemorrhoidal tissue

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    When the stapler is being closed, it is pulled 3-4 cm into the anal canal, thereby ensuring that the distal part of the cartridge is safely positioned proximal to the dentate line. The hyperplastic hemorrhoidal tissue is resected by triggering the stapler. Open the stapler just a few millimeters and gently remove the device. Inspect the resectate. In 50-60% of cases there will be tangentially transected fibers of the muscularis propria on the extraluminal aspect of the resectate.

  • Terminating the procedure

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    Digitally examine the suture line for potential broader wound dehiscence. Visually inspect the suture line for bleeding. Usually hemostasis only requires a few suture ligations. Packing the anal canal with a tamponade (e.g. anal tampon) is optional.

  • Herr Prof. Dr. med. Alexander Herold

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  • Intraoperative complications

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  • Postoperative complications

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  • Herr Prof. Dr. med. Alexander Herold

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Literature search

    Literature search under: http://www.pubmed.com