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2 Hemorrhoids
Fig. 2.12 a CT-scan in a patient with rectal bleeding, obstruc-
ted defecation, and proctalgia 2 years after PPH. CT-scan
shows the hyperintense retained staples
Fig. 2.12 c Staples can be removed using a Kelly to transmit
diathermy, aimed at preventing tissue laceration and subsequent
bleeding
and bleeding. Fondran et al. (2006) reported that 11%
of their 82 PPH patients had late rectal bleeding due
to an inflammatory polyp. In all cases, the bleeding
resolved after the polyp was removed (Fig. 2.13).
2.4.5 Retropneumoperitoneum,
Pneumoperitoneum,
Pneumomediastinum, and Cervical
Emphysema
Cervical emphysema is manifested as subcutaneous crepitus and a bitonal voice. Various cases
Fig. 2.12 b One of the retained staples is visible in the rectal
lumen. The patient is in the lithotomy position
Fig. 2.12 d Removed staple
have been described in the literature, for example,
by Maw et al. (2002), and Filingieri and Gravante
(2005). They were usually due to dehiscence of the
staple line and air entry (Fig. 2.14). Only one of
the authors who observed this complication had to
fashion a colostomy; otherwise, conservative therapy (the patient supine, antibiotics, and intravenous fluids) is generally effective.
The same complication has been observed after
TEM and after transanal full- thickness excision of
a large rectal adenoma (Basso and Pescatori,
2003). Air insufflation during intraoperative
colonoscopy may contribute to its development.
2.4 Stapled Hemorrhoidopexy (PPH)
Fig. 2.13 a Patient with rectal bleeding and proctalgia after
PPH: granulomatous polyp (arrow) and removed staple (star)
29
Fig. 2.13 b Polyps are removed
Fig. 2.13 c Transanal ultrasonography with rotating probe of
the same patient a month after surgery. Other staples are visible
(arrows)
Fig. 2.14 a Retropneumoperitoneum after PPH
Fig. 2.13 d Endoanal and endorectal wounds have delayed ci-
catrization because of anal hypertonia, which is treated with calcium-antagonist ointment. Squares measure the diameter of the
internal sphincter, which is < 2 mm. The dotted line shows a post operative lesion of the internal sphincter
Fig. 2.14 b Pneumoperitoneum after PPH; the bowel loops are
separated by air
30
Fig. 2.14 c Pneumomediastinum after stapled hemorrhoido-
pexy. It is usually treated with conservative therapy
2.4.6 Rectal Inclusion Cysts
This complication was described by Raymond et al.
(2008) and by De Nardi et al. (2008) and consists of
a palpable, painful and tender perirectal nodule, usually filled with secretions. The suture line remains
intact. The nodule must be removed transanally.
2 Hemorrhoids
2.4.7 Total Obliteration of the Rectal Lumen
Obliteration of the lumen is caused by malpositioning of the purse-string, sometimes of two pursestrings, in a cavity that seems to be the rectal lumen
but is actually a false lumen resulting from intussusception (Brown et al., 2007) (Fig. 2.15). This
complication has been frequently reported, at least
five times between 2005 and 2009, by Cipriani
(2002) and Giordano (2008) and others. All
patients except one had to undergo a form of rectal
resection plus a Delorme mucosectomy. If this
complication is suspected, it is important to perform a careful digital rectal examination or rectoscopy to determine whether the lumen is patent
2.4.8 Rectal Diverticulum or Rectal Pocket Syndrome
In my experience (a few cases published with colleagues, Pescatori et al., 2007), this complication
Fig. 2.15 a, b Rectal lumen obliteration after PPH (from
Büyükaşik et al., 2009)
seems to arise if one or two stitches of the pursesting in the distal rectum are too superficial, so
that when the pouch is tightened the suture thread
cuts the small portion of mucosa that was included. What remains is a cavity partly isolated from
the lumen in which fecoliths and secretions
become trapped, dilating the rectal pocket/diverticulum and leading to tenesmus, pain,
burning sensation, prostatitis, and sepsis.
Treatment consists of laying open the cavity (Fig.
2.16).
The incidence of this complication is around
3%. The most recent cases were described by
Serventi et al. (2010) and by Boffi and Podzemny
(2011) (Fig. 2.17).
2.4 Stapled Hemorrhoidopexy (PPH)
a
31
Fig. 2.16 a Operation after PPH carried out to manage a “rectal poc-
ket syndrome”, with formation of coproliths and recurrent abscesses
causing chronic proctalgia. A Kelly was introduced in the pathological cavity, which is laid open with electrocautery. This syndrome
occurs in about 3% of the cases after stapled hemorrhoidopexy
b
d
Fig. 2.16 b-e A Hegar is inserted in the pathological cavity, partially laid open. b A retained staple is detected at the apex of the
pocket
2.4.9 Rectovaginal Fistulae
c
e
al., at St. Mark’s Hospital, reported a case in
2004. These fistulas sometimes necessitate re-
In a case series of Angelone et al. (2006), which I
cited in a review article (2008), the incidence of
rectovaginal fistula is only 0.2%. McDonald et
operation. I once observed a case of an almost
asymptomatic fistula that eventually closed spontaneously.
32
a
Fig. 2.17 a, b A fecaloma entrapped in a rectal diverticulum
after PPH
2 Hemorrhoids
b
How does a rectovaginal fistula form? It is most
likely not due to a direct lesion that occurs during
surgery, but to an area of ischemic tissue that
becomes an opening after a few days. Regardless,
it is important to protect the vagina with a retractor and to carefully palpate the posterior vaginal
wall before firing the stapler.
2.4.10 Trauma to the Penis in Passive
Anal Sex
Some cases have been described, including two by
Capomagi (1999), one by Kekez (2007), and one
by Mlakar (2007). The trauma was due to staples
retained in the rectum. Patients should be adequately warned of this potential problem.
2.4.11 Dysplasia and Cancer
Dysplasia or cancer in hemorrhoids is very rare but
cases have been described by Brusciano et al.
(2004) in articles on re-operations after PPH.
Hemorrhoids that may contain neoplastic foci must
be removed, not moved up with the PPH. For this
reason, I send all removed hemorrhoids to the
pathologist. In the patient of Annibali, (Brusciano
et al.) the tumor occurred at the level of the mucosal cylinder removed by the stapler.
2.4.12 Retro-rectal Hematoma
In one case of retro-rectal hematoma, described by
Vasudevan et al. (2007), the hematoma caused
complete obstruction of the rectum and a colostomy was required.
Thirteen cases of retro-rectal hematoma were
described in a study conducted by Naldini (2011) on
complications after PPH and STARR (46 of which
were major complications). A perisigmoid hematoma
requiring reoperation was reported by De Santis et al.
(2011). If the hematoma cannot be drained, a resection of the rectum or a laparotomy with ligation of
the internal iliac arteries may be necessary.
It is interesting to note that, shortly after
Vasudevan’s article was published, and almost at the
same time as the publication of Naldini’s, the same
journal published a systematic review article on PPH
(Burch et al., 2009). In the accompanying “Invited
Comment”, although the journal has published alarming reports about PPH, Ronan O’Connell wrote, “The
initial concerns about po tentially severe postoperative
complications (after PPH) have been shown to be
unfounded.”
A few months earlier, the Corriere della Sera, a
well-known newspaper in Milan, published an interview with Dr. Longo, conducted by Pappagallo, in
which PPH was advocated as a “gentle” and “sutureless” procedure. Boffi’s commentary on the interview, which emphasized how misleading it was, was
2.4 Stapled Hemorrhoidopexy (PPH)
33
published soon thereafter in Techniques in
Coloproctology, 2009. His letter gave rise to a series
of letters, under the heading “Ethical issues and
innovations”, by various authors, including presidents and editors of international societies and journals (Seow-Choen, Amato, Gupta, Madoff, Zbar,
Kodner). Among their conclusions: 1) there are also
companies that are very careful to behave in an ethical manner, 2) around half of the articles in which
the authors deny any conflict of interest are actually
subsidized by the industry, and 3) to protect patients
from misleading information, scientific societies
should not allow anyone who gives wrong information to the media to participate in scientific meetings/congresses. In addition, the board of the Italian
Society of Colorectal Surgery (Società Italiana di
Chirurgia Colo-Rettale SICCR) wrote to the director
of the newspaper and reported the debate on
“Ethical issues and innovations” on the society’s
website www.siccr.org.
I mention all this in order to demonstrate that
risks and complications may be underestimated by
the same people charged with providing accurate
information. Patients and surgeons who have not
been sufficiently alerted to possible problems associated with operations said to be simple and safe will
approach them without enough caution, which in turn
can increase the risk of complications. Conclusion:
correct information about complications is essential
in any attempt to effectively prevent them.
2.4.13 Hemoperitoneum
Fortunately, this is a rare complication. In the
patient described by Aumann et al. (2004), the
presence of a prolapsed pouch of Douglas and an
enterocele facilitated the development of hemoperitoneum, which was then successfully treated
with re-operation via abdominal access (Fig. 2.18).
During stapling, to avoid inclusion of the upper
part of the vagina, the peritoneum of a prolapsed
pouch of Douglas, or, even worse, the ileum or sigmoid colon (thus forming an enterocele), there is a
useful trick: Before placing the sutures of the
purse-string in the anterior part of the distal rectum,
i.e., the at-risk zone, inject physiological solution
into the submucosa so that the nearby bowel is distanced from the rectal lumen and the stapler.
2.4.14 Dehiscence of the Rectal Suture and
Rectal Lacerations with
Hemorrhage and/or Pelvic Sepsis
About 100 cases of dehiscence or rectal laceration,
possibly linked to instrument dysfunction, are reported on the website of the United States Food and Drug
Administration (FDA); http://www.fda.gov/cdrh/in dex.html. In general, these complications can be
treated by transanal suture placement, but sometimes
a defunctioning colostomy is required.
Fig. 2.18 Complications after PPH. In case of
enterocele, a bowel loop can be trapped in the stapler, with successive intestinal perforation and/or
peritonitis and/or hemoperitoneum
34
2 Hemorrhoids
2.4.15 Rectal Perforation and Pelvic Sepsis
The first case was described by Molloy and
Kingsmore (2000) and was successfully treated
with a Hartmann procedure. The authors recommended antibiotic prophylaxis before PPH. Fu’s
group, in China, described eight cases (Gao et al.,
2010), including five in which the perforation was
definitely above the anastomosis, and reviewed
those in the literature. Seven patients died (including one of his own) due to this complication and
pelviperineal gangrene.
The predisposing factors, according to Gao et
al., are: 1) a descent of the anterior wall of the rectum, which is perhaps injured by the pointed cone
of the anvil of a stapler inserted too forcefully, in
patients who have rectal prolapse or invagination,
and 2) ascites that causes the pouch of Douglas to
be pushed downwards by the liquid. These conditions thus define a group of high-risk patients.
Furthermore, there is clearly a need for staplers
with more rounded tips (Fig. 2.19).
According to Ravo et al. (2002), rectal perforation can be demonstrated in one out of every 1,300
cases of PPH. This is why, in their consensus article, Corman et al. (2006) recommended that PPH
be performed by colorectal surgeons who are wellinformed about the indications and the contraindications (including anal sepsis, high-grade enterocele, pregnancy) as well as the intra- and postoperative complications, and who are able to prevent
and treat adverse events.
In 10 years (2000-2010) almost 80 cases of rectal perforation after PPH were reported: 38 on the
FDA website (until 2007) and about 40 in various
articles. At least half necessitated a colostomy.
Seven patients died, as mentioned above. In spite
of these striking numbers, at www.comecurarele morroidi.it, consulted on 12/12/2010, “Lon go’s
operation” was described as a minimally invasive
procedure.
A new method of treating pelvic and/or perirectal sepsis after PPH was proposed by Durai and Ng
(2009), both working at Lewisham Hospital in
Fig. 2.19 Rectal perforation during PPH. In an ascitic patient,
the pouch of Douglas is shifted downwards and it pushes the
anterior wall of the distal rectum toward the cone of the stapler
“anvil” (from Gao et al., 2010, modified)
Fig. 2.20 VAC system (vacuum aspiration), with associated
Redivac drainage, to treat a postoperative pathological cavity
(from Durai and Ng, 2009)
2.5 Complications After Other Operations
35
London: VAC system, consisting of vacuum aspiration combined with a Redivac drain (Fig. 2.20).
This combined approach also seems to be useful
for similar complications after various procedures,
such as the sequelae of dehiscence after anterior
resection of the rectum. According to the authors,
it allowed the successful treatment of a septic presacral cavity that formed in a patient who underwent a Hartmann procedure for pelvic sepsis due
to rectal perforation after stapled hemorrhoidopexy.
2.4.16 Thrombosis of the Inferior Vena Cava
One case was described in a report by Nemati Fard
in 2006. In this patient, it was necessary to perform
a nephrectomy.
2.5 Complications After Other
Operations
There are many other operations for hemorrhoids.
The following sections describe the complications
associated with six operations, five of which I have
sometimes performed.
2.5.1 Semi-open or Semi-closed Hemorrhoidectomy
This is mostly used in Japan and Brazil and can be
performed in two ways: by removal of the external
hemorrhoid and suturing of the internal one (the
Reis-Neto technique) or by removing both and
marsupializing the surgical wound (the Pescatori
technique). Both methods were published, with
very clear illustrations, in Techniques in Coloproc tology, the first (which is semi-open) in 2002 and
the second in 2005.
The advantages of these procedures are good
hemostasis and rapid scar formation. In my experience with the semi-open procedure, the complications consisted of only slight bleeding, but a fair
amount of pain, with a VAS between 4 and 5 (more
than after PPH) 12 hours after surgery. The pain
occurred because of a suture in the sensitive
epithelium of the anal canal. For this reason I seldom perform this operation. However, it is useful
for removing two quadrants although it requires an
elastomere with continuous i.v. analgesics.
2.5.2 Farag Suturing of Internal Hemorrhoids
The technique is simple: stitches are used to make
the hemorrhoids ischemic. The advantages are that
it is quick, easy, and safe. There are no surgical
wounds and recovery is uneventful. The only complication, based on the more than 30 of these operations that I performed, was the need to suture a
hemorrhagic area in one patient. In addition,
stitches that are too deep will cause pain.
2.5.3 Hussein’s Manual Hemorrhoidopexy
When this procedure is used at our unit, it is often
combined with Ferguson hemorrhoidectomy to
treat the third nodule, when it is not external. It is
an inexpensive procedure since it does not require
the use of sophisticated instruments such as staplers. Hussein who invented it works in Egypt,
which may in part explain why the procedure has
yet to be more widely adopted.
The original version was described by Hussein
in 2010. I presented a modification of it in
Techniques in Coloproctology. It is indicated for
hemorrhoids that are mainly internal, which are
pulled upwards with a U-shaped stitch and then
sutured (Farag style). This results in a good
anopexy. The advantages of manual hemorrhoidopexy is that there are no surgical wounds in
the anal canal, which ensures rapid recovery.
Among the potential complications: the hemorrhoids can slide back down unless the sutures are
deep, but deep sutures can cause pain.
2.5.4 Whitehead-Rand
Hemorrhoidectomy
This operation removes external hemorrhoids,
internal hemorrhoids, and associated mucosal prolapse. It is indicated when the lesions are circum-
36
2 Hemorrhoids
Fig. 2.21 a Circumferential internal and external hemorrhoids
with concomitant rectal internal mucosal prolapse; WhiteheadRand technique. Polypoid internal and external hemorrhoids
should be sent for histologic analysis to determine if there is
potential dysplasia. Therefore, a stapled hemorrhoidopexy is
not indicated in this case. The patient is in the lithotomy position
Fig. 2.21 c Cutaneous flaps are fixed to the perianal skin and a
circumferential incision is performed immediately above the
dentate line
Fig. 2.21 b The piles are stretched. The patient had a recurren-
ce after PPH
Fig. 2.21 d Diathermic excision of external and internal hemor-
rhoids and mucosal prolapse. Note the internal sphincter and
rectal muscle, which are identified and left intact
ferential (Fig. 2.21). Currently, this is the perfect
indication for PPH, possibly not in constipated
patients, in order to reduce the risk of recurrence.
A modified version of this operation was used by
Wolff (1988) at the Mayo Clinic.
The Whitehead-Rand procedure is rather complex and knowledge of plastic surgery is required
because of the need to prepare skin flaps. Its
advantage is that it is very radical. The complications are not, as perhaps expected, associated with
stenosis or incontinence (in contrast to the old
Whitehead procedure). I have observed subclinical anal stenosis (treated with dilators) in only one
out of 25 patients. However, partial detachment of
the skin flap does occur (in 5 cases in my small
series) so that a large skin tag forms. In three
2.5 Complications After Other Operations
37
Fig. 2.21 e Mucosal cylinder of the distal rectum before anasto-
mosis with the anal canal
Fig. 2.21 g They are sutured to the distal rectum
Fig. 2.21 f Cutaneous flaps (i.e., distal anal canal) are preserved
Fig. 2.21 h The suture is completed
cases I had to remove the tag, although always in
an outpatient setting with the patient under local
anesthesia.
In cases of mucosal ectropion, the Sarafoff pro-
cedure (Dodi et al., 1999) can be helpful.
Fig. 2.21 i Final look: cutaneous flaps are pulled upwards by
the rectal sutures, with a -pexy effect
2.5.5 Parks’ Submucosal Hemorrhoidectomy
Few surgeons perform this procedure because it is
rather long and laborious and always involves intraoperative bleeding. It is the only one of the operations invented by Sir Alan Parks that is now only