What is the role of PPH in the treatment of hemorrhoids?

Updated: Sep 24, 2019
  • Author: Kyle R Perry, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Answer

Stapled hemorrhoid surgery, or PPH, was first described in 1997-1998 and has become prominent. [24, 47, 48] This procedure is mainly used to treat internal hemorrhoids that are not amenable to conservative and nonoperative therapies. PPH is suggested for patients with large internal hemorrhoids and minimal external component. This procedure can be done in an outpatient setting with local anesthesia, [49, 50, 51, 52] similar to the protocol used for conventional hemorrhoid surgery. Narcotic use and recovery is significantly decreased compared with conventional operative hemorrhoid surgery.

During this procedure, a specially designed circular stapler with smaller staples is used. The technique involves placing a suture in the mucosal and submucosal layers circumferentially, approximately 3-4 cm above the dentate line. The stapler is placed and slowly closed around the purse string. Care is taken to draw excess internal hemorrhoidal tissue into the stapler. The stapler is fired, resecting the excess tissue and placing a circular staple line above the dentate line, resulting in resection of excessive internal hemorrhoidal tissue, pexy of the internal hemorrhoidal tissue left behind, and interruption of the blood supply from above.

PPH does not directly affect the external tissue. Reports have described shrinking of external hemorrhoidal tissue after PPH, probably from decreased blood flow. Good results from PPH combined with judicial excision of occasional skin tags also have been reported.


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