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What is PPH - Stapled Haemorrhoidopexy

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What are haemorrhoids?

Haemorrhoids or piles are swollen blood vessels in the anal canal (back passage). They are part of our normal anatomy and have a role to play in keeping us continent; 1 in 3 people however develop a problem with them at some stage of their life. They are usually caused through constipation. Straining causes congestion of and eventually enlargement of the veins within the anal canal. They are more common during or after pregnancy. They can bleed, cause discomfort, a feeling of incomplete evacuation and may prolapse out of the anal canal causing a mucus discharge or soiling.

A minimally invasive approach Stapled Haemorrhoidopexy or PPH developed in Italy in 1997 was introduced into the UK almost 5 years ago. The technique allows for patients to recover faster from haemorrhoidal surgery and with less pain and fewer complications when compared to conventional surgery.   PPH reduces/removes the prolapse, and in doing so pulls the haemorrhoids up into their normal position - a bit like a face lift.  It is used in secondary degree haemorrhoids when other measures eg repeated banding have failed and 3rd degree haemorrhoids (prolapse can be reduced manually). We have found it very useful in treating 4th degree (prolapsed out all the time) haemorrhoids.

All patients receive a phosphate enema to clear the rectum and distal colon. PPH is performed under a general anaesthetic with the patient paralysed. Although promoted as a day case procedure we prefer to keep our patients in over-night to ensure that they are pain free on discharge.

PPH reduces the prolapse of hemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane with the use of a circular stapling device. In PPH, the prolapsed tissue is pulled into a device that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. This restores the hemorrhoidal tissue back to its original anatomical position.

The introduction of the Circular Anal Dilator causes the reduction of the prolapse of the anal skin and parts of the anal mucous membrane. After removing the obturator, the prolapsed mucous membrane falls into the lumen of the dilator.

The Purse-String Suture Anoscope is then introduced through the dilator.

This anoscope will push the mucous prolapse back against the rectal wall along a 270° circumference, while the mucous membrane that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. By rotating the anoscope, it will be possible to complete a purse-string suture around the entire anal circumference.

The Hemorrhoidal Circular Stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string, which is then tied with a closing knot.

The ends of the suture are knotted externally. Then the entire casing of the stapling device is introduced into the anal canal. During the introduction, it is advisable to partially tighten the stapler.

With moderate traction on the purse-string, a simple maneuver draws the prolapsed mucous membrane into the casing of the circular stapling device. The instrument is then tightened and fired to staple the prolapse. Keeping the stapling device in the closed position for approximately 30 seconds before firing and approximately 20 seconds after firing acts as a tamponade, which may help promote hemostasis.

What are the Benefits of PPH over other Surgical Procedures?

  • Patients experience less pain as compared to conventional techniques.
  • Patients experience a quicker return to normal activities compared to those treated with conventional techniques.
  • Mean inpatient stay was lower compared to patients treated with conventional techniques.

What should I do when I get home? 

  • Patients go home with a supply of analgesia - paracetamol 4x day & ibuprofen 3x day. Very occasionally you may require something stronger from your Dr. 
  • After the treatment you may feel that you want to open your bowels. Usually this feeling wears off after a time. If you have to go, don't worry but try to avoid straining. 
  • Bath or shower as you wish. 
  • A warm bath and a glass of alcohol can help you relax. 
  • Avoid using any creams around the anus. 
  • Avoid strenuous exercise for 48 hrs eg, playing sport, jogging or riding a bike. 
  • Most will get back to their normal life after 3 days. 
  • Do not worry if you see bleeding (usually after 5 days) when the 'scab' comes away. 
  • You will be reviewed at 4 weeks to ensure that PPH has been successful.

Risks of surgery

As with any surgery there are potential risks. The following have been described. 

  • Too much tissue can be pulled into the instrument causing damage to the rectal wall and/or vagina in women. This can result in inflammation, infection or a fistula between the rectum and vagina. 
  • The fibres of the sphincter can be damaged causing short or long-term incontinence.

We have experience of over 500 PPHs and regularly teach other surgeons the technique. The problems we have observed include:

  • Bleeding requiring return to theatre (5.7 per 1000).
  • Hospital readmission for pain (8 per 1000)
  • Bleeding requiring A&E visit (5 per 1000)
  • Narrowing of the stapled anastomosis (2%)- responds to gentle dilatation.
  • Transient urgency during first week (35%)
  • Recurrent symptoms within three years (1%)

Can I prevent the haemorrhoids coming back?

Unfortunately having a PPH does not guarantee that they will never come back. Some Drs feel that the best way to prevent them coming back is to avoid straining to open your bowels and to go when you feel the urge rather than put it off. Try to increase the amount of water in your diet and bulk up the stools by eating more fibre.


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