Journal of Surgery (ISSN: 2575-9760)

short commentary

Preliminary Experience with PPH(Hemorrhoidopexy) At Butaro Hospital Rwanda

Jack M. Omondi*

Department of Surgery, Butaro Hospital, Rwanda 

*Corresponding author: Jack M. Omondi, Department of Surgery, Butaro Hospital, Butaro Sector, Rwanda. Email: omondijack47@gmail.com

Received Date: 06 March, 2018; Accepted Date: 02 April, 2018; Published Date: 09 April, 2018


 1.            Introduction

       Butaro Hospital is situated to the north of Rwanda. It is a cancer Hospital, but we also treat non-cancer related illnesses.

       This is a two years retrospective study of the outcome of 12 patients who were done PPH (Procedure for Prolapse and Hemorrhoids) from June 2015 to June 2017.

       Out of the 12 patients, four were female and eight were male. There were no deaths and no intra-operative complications. Discharge from hospital was between 1 to 2 days. Majority of the patients were satisfied with the operation

2.            What Are Haemorrhoids?

Hemorrhoids are venous cushions or congestion around the anus. The cushions help to maintain stool and gas continence. Symptoms appear when these cushions are over distended with blood (Figure 1).

3.            Symptoms

          Rectal bleeding

          Perianal discomfort

          Pruritis ani

          Protruding mass

          Severe pain when thrombosis occurs in the external hemorrhoids

          Always try to rule out rectal cancer by doing Proctoscopy/sigmoidoscopy

4.            Causes of Hemorrhoids

          Causes are largely unknown but may be due to

          Chronic constipation

          Pregnancy

          Standing for a long period of time

          Heredity?

          Straining like in weight lifting

          Portal hypertension does not cause hemorrhoids

5.            Classification

       FIRST DEGREE: Patient presents with rectal bleeding only

       SECOND DEGREE: Patient gets a prolapsing mass on defecation but the mass returns spontaneously into the rectum afterwards.

       THIRD DEGREE: The mass protrudes on defecation and can only be returned manually by the patient.

       FOURTH DEGREE: There is protruding mass all the time which cannot be returned into the rectum

6.            Anatomy

        The ano-rectum blood supply is from 3 sources.

i.            inferior mesenteric artery (thro’ superior hemorrhoidal artery/vein)

ii.            Internal iliac artery (middle rectal artery/vein)

iii.            Pudendal artery (inferior rectal artery/vein)

While superior rectal vein belongs to the portal venous system, the latter 2 empties into the systemic veins.

Consequently, the ano- rectum is an area of portal-systemic anastomosis. Logically one would expect hemorrhoids to be caused by portal hypertension. However, normally, portal hypertension does not cause hemorrhoids.

7.            Anatomy Con’t

       The right superior rectal artery divides into two branches before it reaches the anus, the anterior and the posterior branch.

       This represents the 7 o’clock and the 11 o’clock. The left superior rectal artery approaches the rectum as a single branch and this represents 3o’ clock.

       These are the areas where the hemorrhoids are normally found (Figure 2).

8.            Treatment

      First degree: change in diet, use of fibers and bulk formers like Fybogel. Hydrocortisone creams, anal inserts like anusol, stool softeners,

      Second to fourth degree

i.            Sclerotherapy

ii.            Barron band ligation

iii.            Laser

iv.            MAD is now obsolete

v.            open hemorrhoidectomy

       A Milligan Morgan

       Hill Ferguson

9.            Current Operative Treatment

       PPH (procedure for prolapse and hemorrhoids) also called hemorrhoidopexy. Was first done by an Italian called Antonio Longo in 1993. since then it has been popularized in Europe and North America.

       The procedure resects the redundant rectal mucosa above the dentate line and consequently brings up the prolapsing hemorrhoids to their anatomical position.

       Advantages

o    1 it is painless

o    No bleeding

o    Fast recovery period

o    Disadvantage. It is? expensive 

10.            Patient Preparation

               Anesthesia: spinal anesthesia is adequate but general anesthesia can also be used

               Don’t give enema. Enema makes the operation messy

               Position: prone jack-knife/some patients can be done in lithotomy position

               In our series only one patient was done in lithotomy position

               Retract the buttocks with strappings to improve exposure

               Left handed operator stands on the left side of the table (Figure 3)

11.            Procedure

       Lubricate and dilate the anus with CAD (Circular Anal Dilator)

       Anchor the circular anoscope in four places with stay sutures. The anoscope stays in place throughout the operation.

       Make a purse string suture above the dentate line with 2/0 prolene 26mm RBN

       Lubricate and introduce the opened gun to bypass the purse string suture. Knot the purse sting suture behind the anvil. Close the gun tightly and wait for 20 seconds

       Remove the lock and fire the gun. Wait for 30 seconds

       unlock the gun and make 180 degrees turn. Check for any bleeding in the staple line Check for a complete dough nut (Figure 4).

12.            Data Analysis for Twelve Patients Operated

               Sex

               Female 4

               Male 8

               Age

               25 years to 60 years

               symptoms

               Rectal bleeding 80%

               Anal mass 100%

               Rectal pain 10%

               Pruritis ani 6%                                 

13.            Results

               Mild postoperative pain 2

               Post-operative bleeding 0

               Post-operative itching 1

               Hospital stay 1-2 days

               Patient satisfaction 95%

               Recurrence 

14.            Conclusion

PPPH is an effective and efficient method of treating second, third and fourth degree hemorrhoids. It has many advantages over the traditional open methods. General surgeons are encouraged to learn and master the method for the benefit of our patients. The cost of the equipment may be high but the overall cost to the hospital is much less compared to the traditional methods


Figure 1: It is estimated that 30% of the population get hemorrhoids at one time in their life.



Figure 2: Consequently, hemorrhoids are found at 3,7&11 o’clock.



Figure 3: Prone Jacknife Position.



Figure 4: Hemorrhoidal prolapse is excised as a ring or ‘donut’ of tissue above the hemorrhoidal cushions and immediate re-anastomosis of the mucosa is performed.