Hemorrhoid disease is one of the most common problems family physicians encounter. But the long, painful healing process associated with traditional excisional surgeries can be a scary proposition for many patients. Some opt to suffer for years with advanced hemorrhoid problems before finally getting the treatment they need.

A minimally invasive surgical option for treating hemorrhoid disease, known as stapled hemorrhoidopexy, or procedure for prolapse and hemorrhoids (PPH), may be an option for patients with advanced hemorrhoidal disease. In randomized clinical studies, PPH provided patients with an equivalent outcome to traditional surgery, with the added benefits of:

• Significantly less postoperative pain
• Less anal discharge and earlier bowel movement
• Shorter recovery time
• Shorter hospital stay

Unlike traditional hemorrhoidectomies, such as Ferguson or Milligan-Morgan, PPH does not involve excising either the hemorrhoidal tissue or the anal mucosa.

With PPH, a ring of mucosa, submucosa, and hemorrhoidal vasculature is excised proximal to the dentate line. A mucosal anastomosis is also performed using a circular surgical stapler, raising the vascular cushions to a more normal anatomic location within the anal canal. The hemorrhoids are circumferentially devascularized, so they eventually shrink and involute.

A primary reason PPH causes significantly less pain and patient "downtime" is that the excision is performed above the dentate line in the anal canal, removed from sensitive nerve endings.

(Flash Animation: PPH versus traditional hemorroidectomy)

Patients who may benefit from PPH include those with:

• Grade III hemorrhoids (protrusion outside the anal canal that requires manual reduction)
• Uncomplicated grade IV hemorrhoids (irreducible and constantly prolapsed)
• Lower-grade hemorrhoids that have not responded adequately to other treatment modaliti

Contraindications include active sepsis, anal stenosis, and full-thickness rectal prolapse.

As with all operative procedures, be sure to discuss surgical risks with your patients.