Stapled hemorrhoidopexy or “procedure for prolapse and hemorrhoids” (PPH) for the treatment of hemorrhoidal disease was introduced in the last decade. In contrast to conventional hemorrhoidectomy that includes submucosal excision of prolapsing hemorrhoidal tissue, stapled hemorrhoidopexy introduced by Antonio Longo in 1998 involves simultaneous circumferential resection of excess hemorrhoidal mass with mucosal anastomosis, and residual hemorrhoidal tissue that plays a major role for continence is returned to its original position (1).

According to Goligher’s classification, PPH is ideally indicated in patients with grade III hemorrhoidal prolapse (2). As outlined in Table 4.1, PPH can also be performed in prolapsed second-degree hemorrhoids that have not responded to nonsurgical interventions (e.g., rubber band ligation) or in grade II hemorrhoids with full circumferential involvement (3). PPH is also suitable for patients with hemorrhoids-associated rectal mucosal prolapse.

The use of PPH in grade IV hemorrhoidal prolapse is more controversial (4,5). A prerequisite to its use is that the hemorrhoidal prolapse should be reducible under anesthesia. However, reflecting to the authors’ experience, PPH is not recommended for grade IV, fixed and nonreducible hemorrhoidal prolapse. Only in a minority of patients suffering from hemorrhoidal prolapse grade IV for whom residual external prolapse or skin tags would not be a significant concern, the application of PPH can be discussed individually if performed by an experienced surgeon. Alternatively, PPH can be combined with segmental excisional hemorrhoidectomy or excision of skin tags.

In general, there are a few contraindications to perform PPH, which were documented in a 2003 consensus paper produced by an international working party (6). Absolute contraindications for stapled hemorrhoidopexy include anal stenosis, presence of coexistent anorectal infection (perianal sepsis, complex anorectal fistula, or abscess), anal or rectal cancer, previous coloanal anastomosis, previous sphincter reconstruction,
intra-anal condylomata, coexistent proctitis (Crohn’s disease, radiation induced), and presence of anorectal sexually transmitted diseases (Table 4.2).

Derived from this consensus position paper, experience with anorectal surgery, understanding of anorectal anatomy, and experience with circular stapling devices have been defined as prerequisites to perform transanal stapling procedures (6). In the era of transanal stapling procedures for hemorrhoidal prolapse, the majority of procedures can be performed by transanal stapling techniques if strict criteria of indication and patient selection are respected (7). However, although strict selection criteria for a transanal stapling approach are respected, there is a minority of patients in whom a stapling procedure is not possible or appropriate (Table 4.3); in a personal series, a 4.6% rate of “conversion” to conventional hemorrhoidectomy was documented because of anatomical, clinical, and technical factors (8). Obviously, this fact has an impact on informed consent. Therefore, every patient should be informed about anatomical and technical reasons that can make a stapling approach difficult or lead to conversion to a conventional treatment option. Consequently, experience in patient selection and alternative procedures without a stapling device is mandatory.