Hemorrhoids are a common condition. We are all born with hemorrhoids but some of us will suffer from them occasionally. The main complaints are bleeding and protrusion (prolapse). This may lead to pain but usually hemorrhoids are painless.

Surgery is indicated for advanced cases (3rd and 4th degree – for a classification of hemorrhoids please refer to Hemorrhoids). Hemorrhoid surgery (hemorrhoidectomy) is painful. The reason for pain is that during surgery, the hemorrhoids are cut off the anus. These wounds hurt. Most patients stay in hospital overnight and sometimes they will take up to 2 weeks off work.

For many years, surgeons have tried everything to make hemorrhoidectomy less painful. Patients have tried everything to avoid surgery. They prefer to suffer from hemorrhoids in silence.

As we age the anal tissue becomes loose and may slide out when we have a bowel movement. This sliding of tissue is called prolapse. Straining at a BM increases this prolapse and straining damages this tissue. This damage causes bleeding.

PPH stands for “Procedure for Prolapse and Hemorrhoids.” PPH or stapled hemorrhoidectomy - there is no need to cut out the hemorrhoid tissue at the anus. Instead, this procedure removes the loose tissue above the anus – this is like an “anal facelift.” The area above the anus does not have the same nerve endings as outside the anus. The patient will not feel the sharp pain of conventional hemorrhoidectomy. Since the nerve endings are different, the patient may feel a dull but tolerable ache for a few days.

The preparation for surgery is the same as for conventional hemorrhoidectomy. No special bowel prep is needed. The patient eats a normal diet the day before surgery. No food or water is allowed after midnight before surgery. A Fleet enema is used at night before going to bed and again an hour before leaving for the hospital. Antibiotics are not routinely used.

Stapled hemorrhoidectomy can be done under local anesthesia with sedation, general anesthesia or spinal/epidural anesthesia. The patient is placed in the prone position – lying on pillows on the OR table. A special hemorrhoid stapler is used to remove the excess loose tissue above the anus. This stapler cuts off the tissue and sutures (or staples) the remaining tissue edges together. These are special microscopic titanium staples. These staples will fall off over the next few months. The patient will not be aware of these staples. There is no sharp pain as there are no anal wounds. External hemorrhoids are usually left alone and these shrink over the next 2 months as the stapling procedure interrupts the blood supply to these hemorrhoids.

The patient usually goes home on the same day. He/she is able to go to work within 4 days. Painkillers are prescribed.

The complication rate is similar to that of conventional hemorrhoidectomy. Significant bleeding occurs in only about 2%. Wound infection is rare. Fecal incontinence is rare. Narrowing of the anus (stricture) occurs in 9% but this is easily and painlessly treated with finger dilatation in the office. Because these are not dealt with, the external hemorrhoids will persist after surgery.

One center (Cheetham. Lancet 2000;356:730) reported that 31% in their small series of 22 patients developed severe pain for up to 15 months. This is the only report of severe pain with this new surgery. Most centers with large numbers of patients in Italy, Germany and Singapore have not seen this complication.

Over 210,000 stapled hemorrhoidectomies have been performed worldwide.

In 2001 Dr. Khoo was fortunate to study with Professor Thorolf Hager in Kronach, Germany. Dr. Hager is an internationally renowned colon and rectal surgeon. Dr. Khoo has performed over 400 stapled hemorrhoidectomies. In Colorado, he trained over 3 dozen U.S. surgeons to perform this surgery. In 2003 he broadcast this procedure live to the American College of Surgeons meeting in New Orleans. He has trained surgeons in the North Bay in this procedure.

Each patient has to be evaluated as he or she may not be a candidate for this procedure and may need conventional hemorrhoid surgery.

Randomized trials have been published demonstrating the safety and high satisfaction with stapled hemorrhoidectomy.

This picture is a cross section of the anus and lower rectum. It shows the loose tissue above the hemorrhoids and this loss of support allows the hemorrhoids to prolapse out.

A dilator is placed inside the anus which pushes the hemorrhoids and the loose tissue back inside.

Through a special anoscope which holds the anus open, I place a suture which grabs the loose rectal mucosa above the hemorrhoids. I will use this purse-string to draw the loose rectal tissue into the stapler.

The hemorrhoid stapler is now in place and the I am pulling on the purse-string and drawing the loose rectal mucosa into the stapler. The stapler is then closed and when it is fired, the circular knife inside cuts of the loose mucosa circumferentially and the a row of micro staples close the mucosa back together. The staples fall off after a few weeks.

This is what the anorectum looks like after the stapler is removed. You can see the looseness above the hemorrhoids is gone - the hemorrhoids are lifted back inside the anus. The stapling also reduces the blood flow to the hemorrhoids, so they start to shrink.

Here are some patient perspectives:
Harold Katz, an accountant with a busy practice in Los Angeles, was interviewed by General Surgery News he had suffered discomfort from third-degree hemorrhoids for 35 years, but refused to have surgery. Then he heard about the PPH approach from a surgeon at Cedars-Sinai.

"I had great faith in him, and so I said, 'Go for it.' I would tell anyone who suffers from hemorrhoids to go for it. There is no reason to suffer any more," said Mr. Katz. "There is slight discomfort for a couple of days after the surgery, but absolutely no pain in any way. I had it done on a Tuesday at 4 in the afternoon, and I went to work on Wednesday. I had some discomfort sitting on my chair, so I took Thursday off, and Friday I went back to my normal schedule."

One Dr. Khoo's patients, Vivian L., told us, "The surgery went very smooth, I am very happy with my results. My recovery was painless. I didn't even need to take the pain pills Dr. Khoo prescribed. It was better than I expected, just follow the post-op pamphlet his staff gives you and you are set to go."

She adds, "I have already recommended him to all my friends. Dr. Khoo is wonderful!"

Another patient, Thomas P. who is 73 had the stapled hemorrhoidectomy recently. He says, "I am very pleased. I had no pain at all. I took just 2 pain pills after the surgery. My friends who saw me after the surgery were amazed how quickly I recovered."

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