Transanal Stapling Techniques for Anorectal Prolapse (eBook)

David G Jayne MB BCh FRCS MD, Academic Surgical Unit, St James’ University Hospital, Leeds, UK. Clinical Editor of International Journal of Medical Robotics & Computer Assisted Surgery, John Wiley & Sons (2004-)

Foreword 4
Contents 5
Contributors 6
Introduction 8
References 9
Historical Background: Treatments for Hemorrhoids and ODS Prior to Transanal Stapling Techniques 10
Treatment of Hemorrhoids Prior to PPH 10
Treatment of ODS Prior to STARR 12
NonSurgical Treatment of ODS 12
Surgical Treatment of Rectocele 12
Surgical Treatment for Rectal Prolapse/Intussusception 13
The Development of Transanal Stapling Techniques 14
The Concept of Mucosal Prolapsectomy and Hemorrhoidopexy 15
Stapled Hemorrhoidopexy (PPH): The Early Years and Controversy 16
The Acceptance of Stapled Hemorrhoidopexy (PPH) 17
The Recognition of Abnormalities Associated with ODS 18
Cadaver Dissections 18
Imaging in Patients with ODS 19
Ultrasonography 19
Radiology 19
The Development of Stapled Transanal Rectal Resection 22
Summary 23
References 23
Anatomy and Physiology of Anorectal Prolapse 26
Introduction 26
Essential Anatomy 26
Anal Canal 26
Rectum 27
Arterial and Venous Drainage 28
Epithelial Lining 29
Microstructure of the Anal Cushions 29
Anal Sphincters, Pelvic Floor Muscles, and Ligaments 30
Nerve Supply 31
Sympathetic and Parasympathetic Innervation 31
Somatic Innervation 31
Anorectal Sensation 31
Physiology of Defecation 31
Maintenance of Continence 31
Defecation 32
Pathophysiology of Hemorrhoids 33
Diminished Rectal Sensitivity 34
Failure to Relax the Internal Sphincter 34
Failure to Relax the Pelvic Floor 34
Mechanical Outlet Obstruction 34
Inefficient Force Vector 34
Rectocele 35
Descending Perineum Syndrome 35
Summary 35
References 35
Diagnosis of Hemorrhoids and ODS 37
Introduction 37
Classification of Hemorrhoids 38
Hemorrhoidal Symptoms 40
Bleeding 40
Prolapse and Lump 40
Mucous Discharge, Pruritis, and Hygiene Difficulties 40
Pain and Discomfort 40
Hemorrhoids: Differential Diagnosis 41
Clinical Assessment 41
Inspection 41
Palpation 41
Proctoscopy 41
Sigmoidoscopy and Colonoscopy 42
Anorectal Physiology and Endoanal Ultrasound 42
The Diagnosis of Hemorrhoidal Complications 42
Internal Hemorrhoidal Thrombosis 42
Anemia 43
Perianal Hematoma 43
Perianal Dermatitis 43
Obstructed Defecation Syndrome 43
Definition of Obstructed Defecation Syndrome 43
Symptoms of Obstructed Defecation Syndrome 43
Clinical Assessment 45
References 46
Evaluation of Patients with Symptomatic Hemorrhoids and Obstructed Defecation 48
Introduction 48
Investigation of HemorrhoidalDisease 48
Rigid Sigmoidoscopy and Proctoscopy 48
Flexible Sigmoidoscopy and Colonoscopy 48
Anorectal Physiology 49
Endoanal Ultrasound 50
Defecography 50
Electromyography 50
Investigation of Obstructed Defecation 50
Introduction 50
Anorectal Physiology 50
Plain Radiology 51
Colonic Transit Studies 51
Dynamic Defecography 52
Dynamic Magnetic Resonance Imaging 54
Measurement of Perineal Position with an External Plastic Cylinder 56
Electromechanical Rectal Barostat 56
Endosonography 56
Rectal Expulsion Tests 56
Electromyographic Studies 57
Pelvic Floor Dyssynergia (Anismus, Nonrelaxing Puborectalis Syndrome, Pelvic Floor Dysfunction) 57
Predictive Factors for Therapeutic Intervention 58
Conclusion 59
References 59
Patient Selection for Stapled Hemorrhoidopexy and STARR 63
Patient Selection for Stapled Hemorrhoidopexy 63
Indications for Stapled Hemorrhoidopexy 63
Contraindications for Stapled Hemorrhoidopexy 65
Absolute Contraindications 65
Relative Contraindications 65
Special Considerations 65
Patient Selection for STARR 65
Definition of ODS 67
Diagnostic Assessment and Patient Selection for STARR 67
Treatment Options After Dynamic Imaging with Special Reference to the STARR Procedure 68
Contraindications for STARR 70
Summary 71
References 71
Stapled Hemorrhoidopexy: The Technique 74
Stapled Hhemorrhoidopexy 74
Preoperative Preparation 74
Patient Selection 74
Patient Preparation 74
Patient Positioning 74
Technique for Stapled Hemorrhoidopexy 74
Circular Anal Dilator Insertion 74
Placement of the Purse-String Suture 75
Stapler Insertion 76
Stapler Closure 76
Firing the Stapler 76
Removing the Stapler 77
Checking the Staple Line 78
Postoperative Care 78
The Double-PPH Technique 78
Tips and Tricks 79
Patient Positioning 79
Assessment of Hemorrhoidal Prolapse 79
Insertion of the Circular Anal Dilator 79
Purse-String Placement 79
PPH03 Insertion, Closure, and Firing 79
Assessment of the Resection Specimen 80
Checking for Staple Line Bleeding 80
Complications and How to Avoid Them 80
Early Complications 81
Bleeding 81
Urinary Retention 82
Fecal Impaction 82
External Hemorrhoidal Thrombosis 82
Anastomotic Dehiscence 82
Anorectal Sepsis 82
Anal Fissure 83
Sphincter Injury 83
Persistent Anal Pain 83
Other Complications 83
Late Complications 83
Recurrent Hemorrhoidal Prolapse 83
Fecal Incontinence 84
Fecal Urgency 84
Anorectal Stricture 85
Pruritis 85
Summary 85
References 85
Stapled Transanal Rectal Resection Procedure 87
Introduction 87
The Original Technique 87
Tips and Tricks 90
Complications and How to Avoid Them 90
Variations on the Original Technique 91
The Contour Transtar Device: STARR with Transtar 92
Surgical Technique 92
A Cautionary Note 94
References 95
The Evidence for Stapled Hemorrhoidopexy and STARR 96
Stapled Hemorrhoidopexy (PPH) 96
Introduction 96
Patient Selection 100
The PPH Technique and Its Modifications 100
Clinical Outcomes Following PPH 101
Pain 101
Histological Assessment 101
Anorectal Physiology 102
Recovery 102
Patient Satisfaction 102
Quality of Life 102
Complications 102
Recurrence Rate 103
Cost Effectiveness 103
Conclusion 103
Stapled Transanal Rectal Resection 104
Patient Selection 106
The STARR Technique and Its Modifications 107
Results 107
Pain 107
Histological Assessment 107
Anorectal Physiology 108
Defecographic Assessment 108
Recovery 108
Patient Satisfaction 108
Quality of Life 108
Complications 108
Recurrence Rate 108
Cost Effectiveness 109
Conclusion 109
References 109
Areas of Controversy and Future Research 117
Introduction 117
Stapled Hemorrhoidopexy 117
The Current Status of Stapled Hemorrhoidopexy 118
Controversies in Surgical Technique 119
Stapled Hemorrhoidopexy: Quality of Life and Cost Effectiveness 120
Stapled Hemorrhoidopexy and Grade of Disease 121
Stapled Transanal Rectal Resection for Obstructed Defecation Syndrome 122
European STARR Registry 123
Future Assessment of STARR by Randomized Comparison 126
Controversies Specific to STARR 127
Double-Stapled PPH01 or Contour30 (Transtar) for ODS? 129
Summary 130
References 130
Index 133