Prolapsed hemorrhoids is a frequent pathology that surgeons must treat. Open hemorrhoidectomy (Milligan-Morgan) is classically used in many centres, although it has a major disadvantage which is post-operative pain. Because of this excessive pain, other techniques are being used more often by many surgeons worldwide. One of them is stapled hemorrhoidopexy or procedure for prolapsed haemorrhoids (PPH).
Its major advantages are less post-operative pain and faster recovery when compared to open hemorrhoidectomy. However, Milligan-Morgan still has the best long term outcomes with minor complications. Additionally PPH is associated with adverse effects collectively referred to as "PPH syndrome". Life-threatening complications such as pelvic sepsis, rectal bleeding and rectal perforation are associated with stapled hemorrhoidopexy. Several case reports can be found in literature, many of them treated with laparotomy and diverting stoma.
In November 2016, Seokyong Ryu et al published in the "International Journal of Surgery Case Reports" a case of a rectal perforation occurring 5 days after stapled hemorrhoidopexy in a 28yo male, successfully treated by laparoscopic repair and transanal tube positioning without creating a diverting stoma. Two possible factors are pointed by the authors to justify the rectal perforation:
1 - purse-string placed beyond the submucosa including rectal muscle
2 - staple line was too high, where full-thickness anterior rectal wall can be easily excised
Although it is easily to conclude that the correct positioning of the staple line is crucial to have good outcomes, rectal perforation is a possibility following PPH. According to Seokyong et al most cases (29 between 2000 and 2011) are managed by open laparotomy and creation of a diverting stoma. In this case report the authors present laparoscopic repair and transanal tube positioning as a valid therapeutic option in cases of rectal perforation after stapled hemorrhoidopexy.
The authors present in the discussion section opposite studies about laparoscopy in bowel perforation. However different conditions were included in the studies. In cases of colonoscopic perforation or leakage after minimally invasive colorectal surgery laparoscopy is feasible and safe, according to C. Coimbra et al. and CM Lee et al. respectively. In the presence of perforated diverticulitis conclusions diverge. Seokyong et al state that the choice between laparotomy and laparoscopy should be determined by the state of the patient. Young age patient and minimally rectal inflammation are presented by the authors as factors indicating feasibility of laparoscopy.
Although this article emphasize the safety of laparoscopic repair without diverting stoma in a rectal perforation after stapled hemorrhoidopexy (PPH), I think the most important message from this case report is the possibility of a life-threatening complication such as rectal perforation, after treating a benign condition using a technique with the unique advantage of less pain, in a world where all pain is treatable.
Offering open hemorrhoidectomy (Milligan-Morgan) the best long term results with minor complications, is it worth the risk?
Think about it... Some times the old is the best!
Link to the article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon