Prolapse of haemorrhoidal tissue and Longo surgery: indications and limitations

Haemorrhoidal disease is one of the most common anorectal diseases worldwide. Among medical professionals, two main theories about the cause of haemorrhoidal disease.
The first theory holds that HD is a result of varicose vein enlargement. According to this theory, haemorrhoids are venous clusters that have expanded and deformed due to blood flow stagnation in the venous plexuses located in the submucosal layer of the lower rectum and under the skin of the anal canal.
The anal canal is the last four centimeters through which stool passes, moving from the rectum to the outside world. The anus is the opening of the anal canal to the outside world.
The second, widely spread, theory explains that haemorrhoidal pathology forms as a result of displacement of Thompson’s anal cushion. According to this theory, haemorrhoids are originally a normal anatomical structure of the anal canal.
Thompson’s vascular cushions normally are located inside and outside the dentate line, performing an important function: they tightly close the anus, helping the anal sphincter prevent the involuntary exit of fecal matter from the anus.
The cushions are part of the haemorrhoidal vascular plexus, situated at the junction of the venous and arterial pathways. Haemorrhoidal disease arises when there is an anomaly in the tissues and cavernous spaces that are part of the structure of the anal cushion, which is accompanied by symptoms characteristic of the severity of the condition.
HD must be treated . The goal of treatment is to relieve symptoms and eliminate pathological changes. There are many factors that predispose to haemorrhoids.

Classification of haemorrhoids

Haemorrhoids are classified into internal, external, and mixed — depending on the location of occurrence. At the junction of the skin of the anal canal and the mucous membrane of the rectum, there is an uneven visible line called the dentate or pectinate line of the anal canal.
Above the dentate line are located the internal haemorrhoids. In this case, pathological changes or displacements affect the supporting structures of the anal cushion, venous plexuses, and arteriovenous anastomoses covering the mucous membrane of the rectum.
Due to the contraction of the internal sphincter, the anal cushion is divided Y -with a U-shaped groove on three internal haemorrhoids: 

• on the left;
• on the front right;
• on the right at the back.

External haemorrhoids lie below the dentate line. They are covered by the mucosa of the anal canal and the surrounding skin. There are connective tissue, varicose, and thrombosed external haemorrhoids.

Mixed haemorrhoids occur when internal haemorrhoids merge with the corresponding external haemorrhoids through anastomoses of the upper and lower venous plexuses. This results in pinched haemorrhoids in the anus.

Internal haemorrhoids are divided into 4 grades

For haemorrhoids I degrees Characteristic bleeding during bowel movements, which can be stopped. Haemorrhoids do not protrude from the anus.
At II degree of haemorrhoids Bleeding often occurs and the nodes come out, outside the anus, during bowel movements. They spontaneously return to their place after defecation.
III degree of haemorrhoids requires manual repositioning of haemorrhoids that fall out during defecation, lifting heavy objects, coughing, sneezing, bending over and other activities accompanied by tension. The condition is accompanied by bleeding from the anus.
At IV degree of haemorrhoids the nodes cannot be moved inside the anus. At the same time, together with the nodes, often rectal mucosa falls out. The condition is usually accompanied by severe pain and heavy bleeding.
Among patients with internal haemorrhoids IV degrees, mixed haemorrhoids are common. Symptoms of internal and external haemorrhoids coexist. Pain and discomfort occur. Itching is caused by viscous discharge that appears when haemorrhoids prolapse.

What is stapled haemorrhoidopexy?

Stapling haemorrhoidectomy (SH) – this is a surgical method haemorrhoid treatment with prolapse of III and IV degrees – a relatively new technique, introduced in 1998. Currently, there is sufficient clinical evidence of its advantages compared to other surgical methods for treating prolapsed haemorrhoids.

Among the newer surgical options currently available – haemorrhoidectomy, performed By Milligan-Morgan, And according to Ferguson. Interventions are still often performed for symptomatic grade III and IV haemorrhoids.
Unfortunately, these methods are associated with a high complication rate, including:

• urinary retention;
• bleeding;
• constipation;
• fecal plugs;
• long-term wound healing;
• significant postoperative pain due to wide external wounds on sensitive anal skin.

This significantly limits the patient’s ability to resume normal daily activities: perianal skin wounds heal slowly, prolonging bleeding and discomfort for several weeks.
To reduce postoperative complications, Italian doctor Antonio Longo proposed a stapling procedure in 1998, as an alternative to surgical haemorrhoidectomy. The name of this intervention has undergone many changes.
The operation is a fixation procedure. Stapled haemorrhoidectomy is not entirely correct, since the operation does not remove haemorrhoids, but the abnormally loose and overgrown supporting tissue of the haemorrhoids, which allowed them to prolapse downward.
Therefore, the international working committee adopted the name “Stapled Haemorrhoidopexy . Subsequently, this name began to be used most frequently. The aim of this new operative approach is to reduce the size of internal haemorrhoids by interrupting their blood supply.

The size of vascular cushions decreases. A circular section of the rectal mucosa is removed, which eliminates the potential possibility of prolapse. The method reduces postoperative pain, as the mucosa of the rectal wall above the dentate line has no pain sensitivity, and no perianal wound remains after the procedure.

Staplers, as a mechanical addition to surgery, replacing traditional sutures, have revolutionized surgical procedures worldwide over the past decades, due to their simplicity, ease, and standardization of intestinal anastomosis.

Significant reduction in pain observed after ST , promotes the rapid recovery of patients. In this regard, the Longo method, using a circular anal stapler, has advantages over excisional methods, as it does not require either cutting or excising the perianal skin.

How is stapled haemorrhoidopexy performed?

In stapled haemorrhoidopexy, a round hollow tube is inserted into the anal canal. Through this tube, a suture, actually braided from a long strong thread, is placed circumferentially inside the anal canal above the internal haemorrhoids. The ends of the thread exit through the anus via the hollow tube.
The stapler is a single-use instrument with a circular stapling device at the end — they insert it through the first hollow tube, then pull out the ends of the suture material. When the surgeon pulls on the thread, the pathologically stretched haemorrhoidal supporting tissue is pulled into the stapler jaws. The haemorrhoidal cushions are pulled inward and return to their normal position in the anal canal.
Then the stapler fires. When it fires, a 2–3 centimeter ring of mucosa and submucosal haemorrhoidal tissue, captured in the stapler jaws, is excised. Simultaneously with the circular resection, the stapler stitches together the upper and lower edges of the tissue from which the ring was removed.
Circular stapled resection of the mucosa of the upper part of the rectum is suitable for the treatment of grade III and IV haemorrhoid prolapse, mixed circular haemorrhoids, and some grade II internal haemorrhoids accompanied by severe bleeding.

The operation restores the normal anatomical structure, that is, it returns the anal cushion to its place. Resection of the submucosal tissue blocks the flow of blood from the superior haemorrhoidal artery into the haemorrhoidal blood supply. After surgery, haemorrhoids atrophy.

Stapled haemorrhoidopexy is a minimally invasive technique that provides effective treatment in one short session.
Longo’s operation is preferable to traditional haemorrhoidectomy in patients with grade III and IV haemorrhoids, due to the short duration of the operation and better results: minimal likelihood of postoperative pain, no need for postoperative analgesia, extremely rare postoperative bleeding.
Our specialists confirm in the course of daily clinical work that stapled haemorrhoidopexy is:

• a simple method, which ensures a shorter intervention time;
• safe, minimally invasive surgery, which reduces the time and intensity of postoperative pain and reduces the risk of complications;
• an effective treatment method with an extremely low probability of headache recurrence.

The stitching technique reduces the patient’s length of stay in the hospital. There are no serious complications. The key to success is proper patient selection and good surgical technique.

If you have even minor problems with bowel movements, anal itching, pain and bleeding, do not delay and consult a doctor. The more advanced the disease, the more difficult it is to treat, and the worse the prognosis.
Consult for free with the doctors of our clinic and get recommendations for treatment and prevention.
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