The Procedure for Prolapse and Hemorrhoids (PPH), also called a stapled hemorrhoidopexy, is a surgical technique for internal hemorrhoids that have prolapsed, or slipped down from the anus. It differs from traditional methods by focusing on repositioning the hemorrhoidal tissue rather than excising it.
This procedure corrects the anatomical issue of prolapse and reduces symptoms of bleeding and discomfort. The technique is performed higher in the anal canal, an area with fewer pain-sensitive nerve endings, which can result in a less painful recovery period.
The PPH Procedure Explained
The PPH procedure is performed under general, regional, or local anesthesia with sedation. The operation begins with the insertion of a circular anoscope, which allows the surgeon to view the internal hemorrhoidal tissue and protects the anal sphincter muscles.
A key step is placing a “purse-string” suture, a circumferential stitch, into the mucosal lining of the rectum. This suture is placed about 4 to 5 centimeters above the dentate line, an anatomical landmark separating the upper and lower parts of the anal canal. The suture gathers the excess, prolapsed tissue without incorporating the deeper muscle layers of the rectal wall.
With the suture in place, a circular stapling device is introduced through the anoscope. The ends of the suture are pulled, drawing the redundant hemorrhoidal tissue into the stapler’s housing. The surgeon then fires the device, which simultaneously excises a circular ring of excess tissue and deploys a row of small titanium staples.
These staples connect the cut edges of the tissue, pulling the hemorrhoidal cushions back into their normal anatomical position. This repositioning also interrupts the small arteries that supply blood to the hemorrhoids, causing them to shrink over the following weeks. The entire operation is completed in about 15 to 25 minutes.
Ideal Candidates for PPH
The PPH procedure is most effective for individuals with Grade III and Grade IV internal hemorrhoids. Grade III hemorrhoids prolapse during a bowel movement and must be manually pushed back into place. Grade IV hemorrhoids are tissues that have prolapsed and can no longer be manually repositioned.
PPH is not designed to treat purely external hemorrhoids, which are located on the skin around the anus. Patients with significant or thrombosed external hemorrhoids, which involve a painful blood clot, require a different surgical approach.
Certain anatomical conditions may make a patient ineligible for PPH. For example, individuals with anorectal stenosis (a narrowing of the anal canal) may not accommodate the stapling device. The procedure is also not recommended for patients with complex anorectal conditions or active infection. A thorough evaluation by a specialist is necessary to determine if PPH is the most appropriate treatment.
Recovery and Post-Operative Care
Recovery from PPH is often less painful than from a traditional hemorrhoidectomy. Instead of sharp pain, patients may report feelings of pressure or an urge to have a bowel movement, which usually subsides within a few days. Pain is managed with prescribed medications, and patients should rest for the first few days.
Post-operative care focuses on ensuring soft bowel movements to avoid straining the surgical site. A diet high in fiber, plenty of fluids, and a stool softener are recommended for the first few weeks. This helps protect the staple line as it heals.
Most individuals can return to non-strenuous work within one to two weeks. Strenuous activities and heavy lifting should be avoided for at least two to four weeks to allow for proper healing. The small staples are expelled naturally with bowel movements over several weeks to months and do not need to be removed.
Potential Risks and Outcomes
PPH carries potential risks, including bleeding from the staple line; significant bleeding requires medical attention. Urinary retention, or the inability to urinate, can also occur as a side effect of anesthesia. Postoperative pain can occasionally be more intense than expected for some individuals.
There are also risks specific to the stapling technique. The healing process can lead to rectal stenosis, a narrowing of the rectal passage that may interfere with bowel movements. Other risks include damage to the rectal wall or a persistent sense of rectal urgency that can linger beyond the recovery period.
Long-term outcomes for PPH are positive for relieving the symptoms of prolapse and bleeding. However, studies suggest the rate of hemorrhoid recurrence may be higher with PPH compared to a traditional hemorrhoidectomy. The trade-off is between the lower postoperative pain of PPH and the potentially lower recurrence rate of the traditional procedure.