Haemorrhoidal disease (HD) is the most common proctologic condition. It is considered a lifestyle disease and multiple treatment modalities, both conservative and surgical, have been developed for its management. Stapled haemorrhoidopexy, also known as ‘procedure for prolapse and haemorrhoids‘ (PPH), is one of them.

Haemorrhoidopexy using a stapler was first presented in 1998 by Antonio Longo (1). By design, haemorrhoidopexy does not involve haemorrhoid excision, but instead is intended to cut off its arteriovenous blood supply and, by excising a doughnut of mucosa above the dentate line, cause retraction and collapse of the prolapsed haemorrhoids. After the initial period of delight over the method, it was avoided by many surgeons for several years due to complications, which are most often related to improper qualification of patients for the procedure.

However, there has been a renewed interest in haemorrhoidopexy for several years now. The method has undergone a variety of modifications, and various staplers have been used.

The indications have been limited to:

– circumferentially prolapsing hemorrhoids and rectal mucosal prolapse (fig. 1),

– partial rectal mucosal prolapse.

Contraindications for PPH include:

– large, hypertrophied anorectal folds (in such cases classical approach to excise the folds may be needed),

– fixed, irreducible prolapsed haemorrhoids.

A dedicated set of tools is needed for this method (fig. 2). Currently, staplers with various diameters and volumes of housing to accommodate redundant mucosa are available. It is important to know how a given stapler works before using this technique.

The procedure begins with slow, progressive dilation of the anus using the anoscopes provided with the set. After dilation, an anoscope with a collar is inserted into the anal canal, covering the anal canal and revealing the tissues located above the stapler. In the next stage, a continuous purse-string suture is placed on the mucosa at a height of approximately 3-5 cm above the dentate line. Single sutures (the “parachute” technique) may be used instead of a continuous suture; when this is the case, it is important that the spaces between punctures are not large in order to obtain a circular excision without tissue loss. In the next stage, the stapler is inserted and, pulling the sutures accommodates the excess tissue in the stapler housing. The stapler is tightened with taut sutures subject to traction through the channels on the stapler housing. The tissue specimen should have a rectangular shape, which indicates the correct technique of the procedure. The staple line should be checked and if bleeding occurs, it is sometimes necessary to add a few haemostatic sutures. Once the anoscope is removed, the procedure may be considered finished.

Conventional haemorrhoidectomy was described in 1937 by Edward Milligan and Clifford Morgan, surgeons from St Mark’s Hospital in London, which means that it is 50 years “older” than stapled haemorrhoidopexy (2). Nevertheless, it is still the most commonly used surgical approach for haemorrhoids in Europe. Due to the development of many alternative treatment methods for HD, the indications for its use have been significantly limited and include:

– persistent, profuse haemorrhoidal bleeding causing anaemia,

– grade 3 and 4 haemorrhoids (especially in the case of irreducible prolapse of grade 4 haemorrhoids),

– large hypertrophied anodermal folds causing permanent cosmetic defects and difficulties in maintaining hygiene,

– acute conditions: prolapse of thrombosed, inflamed or strangulated haemorrhoids.