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Haemorrhoidal Mucosectomy

The haemorrhoidectomy; was introduced in 1998 by Longo, It’s a mucosal haemorrhoidal prolapse cure by stapling, used by our department for managing the evolution of haemorrhoidal diseases (stage) III and IV. It allows to raise haemorrhoids inside the anal canal and to disconnect their vascular afferents. This method also represents the treatment of the anal prolapse, without associated skin tags.

Technique

The patient is placed in the Lloyd - forced Davies position, the thighs are folded to the stomach, permitting to rest on the third sacral vertebra and not on the buttocks. We divide the intervention in four steps:

The 1st step, after digital dilation and anal lubrication, a dilator and its transparent crown are introduced. This step permits to expose the anal canal and the origin of the haemorrhoidal cushions.

The 2nd step continues with the introduction of a cutaway valve that allows the realization of a submucosal purse string, between 2.5 and 3 cm above the dentate line. If there is a severe mucosal prolapse, one can perform a second purse string, 5 mm above the first one (1, 2, 3); The head of the stapler is then removed and ensures the regularity of the award.

The 3rd step is the introduction of the body of the mechanical stapler designed specifically for this operation, following the axis of the rectum. The purse string is then tightened and knotted on the axis of the stapler. This is then triggered and performs the haemerrhoidal mucosal resection. The mucosa sectioned crown is controlled after removal of the stapler (2, 4, 7).

The 4th step is to check attentively the hemostasis. In principle stapling is hemostatic in itself. Sometimes it needs to be complemented by separate points of an absorbable thread (suture) (5, 6).

After surgery an impregnated hemostatic sponge with ointment is placed in the anal canal. During the Longo procedure, the used anesthesia can be either general or spinal. A posterior perineal block according to the Geneva Marti technique can be used in association, the drain is removed the night of the operation.

The post-operative analgesia is usually sufficient with 1g of paracetamol during the first six to eight hours after post-operatively.

Discussion

The Longo technique transformed the treating of haemorrhoidal disease. Haemorrhoid surgery carries indeed a bad reputation, mainly because of the intense post-operative pain. The conventional Milligan-Morgan technique left mucosa bridges open and patients spent days and weeks fighting off pain. The later Parks technique (which included the closure of mucosal flaps) had improved patients comfort. The Longo technique is virtually painless due to stapling above the dentate line. Therefore patients avoid interrupting their intestinal transit. And hospitalization is then short, up to two days in general.

References

  1. 1.Oi BS, Ho YH, Tang CL Seow-Choen F. Results Haemorrhoidectomy from stapling and conventional. Tech Coloproctol. 2002; 59-60
  2. 2.Lloyd D, KS Ho, Seow-Choen F. Longo's Modified haemorrhoidectomy. Dis Colon Rectum. 2002; 45: 416-7.
  3. 3.Ho YH, Seow-Choen F, Tsang KW Eu. Assessing randomized trial injuries of anal sphincter after stapled haemorrhoidectomy. Br J Surg. 2001; 88: 1449-1455.
  4. 4.Ho YH Cheong WK Tsang C, J Ho, Eu KW, Tang CL Seow-Choen F. Stapled haemorrhoidectomy - and cost effectiveness. Controlled randomized trial, Including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments up to three months. Dis Colon Rectum. 2000; 43: 1666-1675.
  5. 5.Seow-Choen F. Stapled haemorrhoidectomy: pain or gain. Br J Surg. 2001; 88: 1-3.
  6. 6.Ho YH, Seow-Choen F. Randomized clinical trial of micronized flavonoids in the early control of bleeding from acute internal haemorrhoids. Br J Surg. 2000; 87: 1732-3.
  7. 7.Ho YH, C Tsang, Tang CL, Nyam D, Eu KW, Seow-Choen F. Anal sphincter injuries form stapling instruments trans-anally Introduced: randomized, controlled study with anorectal manometry and endoanal ultrasound. Dis Colon Rectum. 2000; 43: 169-73.

Dr Xavier Delgadillo
EBSQ coloproctology