Anal Dilator Research Articles

The candle as an improvised anal dilator following surgery for anorectal malformation.

Anal dilation with Hegar dilator is recommended as part of the post-operative management following surgical correction of anorectal malformation (ARM) in children to prevent strictures. Parents usually continue dilation at home with a personal set of dilators. However, in low-resource settings, many parents cannot afford the Hegar dilator. Devices that have been improvised as dilators include appropriately sized candles, spigot from Foley catheter, rounded ball pen ends and mothers' fingers. We aimed to report our preliminary experience with the use of candle as an improvised anal dilator following surgeries for ARM in our practice. A review of records of children who had surgery for ARMs and commenced on candle dilation between February 2018 and July 2019 at our centre was done. Relevant demographic information, type of anomaly, duration of dilation, availability of health insurance coverage, complications and parents' acceptance of improvised dilator (evaluated during scheduled follow up visits) were retrieved. The data were analysed using SPPSS version 21 (Chicago, Illinois). Nineteen patients underwent anal dilation with improvised candles during the period. Rectobulbar and rectovestibular fistulas were most frequent anomaly in boys and girls, respectively. The median age at surgery was 6 months. The median duration of dilation (completed in 9 patients) was 7 months. Candle dilation was well tolerated, and all parents were comfortable using the device. The candle as an improvised anal dilator following anorectal surgeries in children is a useful alternative to the conventional dilator. It is more affordable and gives satisfactory results.

Comparison of anal dilatation versus no dilatation with a standardized dilator in reducing pain after hemorrhoidectomy: a randomized control trial

BackgroundPost-operative pain is the main problem of hemorrhoidectomy. An adequate pain management can promote early mobilization, fast recovery, and reduce hospitalization costs. This study aimed to investigate the role of preoperative anal dilatation using a standardized anal dilator in reducing post-operative pain.MethodThis study was conducted using randomized prospective trial with a total of 40 subjects, who were divided into 2 groups. The first group received preoperative anal dilatation using a 33 mm anal dilator for 20 min, while the second group did not. The post-operative anal pain, edema, bleeding, and incontinence were observed in the first, second, and seventh day.ResultThe post-operative pain was significantly lower in the preoperative anal dilatation group for all days of observation (p < 0.05). The difference of post-operative bleeding and edema between groups were not significant. Fecal incontinence was initially significantly higher in the preoperative anal dilatation group, but the difference was insignificant at the seventh day (p = 0.500).ConclusionPreoperative anal dilatation significantly reduced post-operative pain. The side effect of fecal incontinence was only temporary until the seventh day after surgery.Trial Registration This trial was registered on Thai Clinical Trials Registry (TCTR) with TCTR identification number TCTR20220314002, on 14/03/2022 (retrospectively registered).

Indications, Feasibility, and Safety of TST STARR Plus Stapler for Degree III Hemorrhoids: A Retrospective Study of 125 Hemorrhoids Patients

BackgroundStapler hemorrhoidopexy (SH) has been widely accepted for hemorrhoids patients because of its low postoperative pain, but it is also associated with a high recurrence rate. The recurrence might be due to failure to completely remove the prolapsed tissue or insufficient removal capacity of the instruments. Removing more prolapsed tissue to reduce the recurrence is believed to benefit more severe prolapsed hemorrhoids patients.MethodsWe evaluated the short- and long-term safety and efficacy in 125 hemorrhoids patients who underwent SH in 2013–2015. Eighty patients had prolapsed tissue less than half of the circular anal dilator (CAD) and underwent a procedure for prolapsing hemorrhoids (PPH), while the remaining 45 patients with hemorrhoid prolapse greater than half of the CAD were treated with a tissue selection therapy stapler stapled transanal rectal resection plus (TST STARR+).ResultsThere were no significant differences between the two groups in terms of operative time, hospitalization time, overall satisfaction or complications. At follow-up of up to 4 years after surgery, there was no significant difference in recurrence rates between TST STARR+ group and PPH group (5.2% vs. 4.7%, p < 0.05). The mean width and volume of the resected tissues were significantly larger in the TST STARR+ group than in the PPH group (4.8 vs. 2.9 cm, 10.2 vs. 4.4 cm3, P < 0.05).ConclusionThe TST STARR+ procedure can remove more hemorrhoidal tissue than PPH and it is better suited for patients with severe annular prolapsed hemorrhoids greater than half of the CAD. It has the advantages of convenient to operate, rapid recovery, fewer complications, and long-term satisfactory results.

Redo stapled haemorrhoidopexy: our experience at max hospital, Gurugram

Stapled haemorrhoidopexy like any other surgical procedure can also fail due to error by surgeons or machine, the stapler. Experience of the surgeon plays the most important role in avoiding recurrence of haemorrhoid after stapled haemorrhoidopexy. A description of operative technique and patient’s demographics are presented. Ten cases of recurrence of haemorrhoid after stapled haemorrhoidopexy done elsewhere were managed by redo haemorrhoidopexy between 1st June 2011-1st June 2020 at Max hospital, Gurugram, Haryana. All cases were successfully operated though the reason of recurrence was different in these cases. Haemorrhoids or piles are common surgical problem a surgeon faces. The first known mention of this disease is from a 1700 BC Egyptian Papyrus. Stapled haemorrhoidopexy is a new and successful technique to treat haemorrhoids, was developed by Dr. Antonio Longo, Italian surgeon, in 1998.Stapled haemorrhoidopexy avoids formation of wound in the operative area, has the advantage of significantly reducing the post-operative pain. Inadequate knowledge and experience, over confidence, wrong patient selection, improper fixation of circular anal dilator, purse string at wrong site, are common causes of recurrence. We managed the recurrence with taking care of causative factors while doing redo-stapled haemorrhoidopexy successfully in all cases. No case of recurrence of haemorrhoids after stapled haemorrhoidopexy was considered for conventional haemorrhoidectomy. All cases were done with redo-haemorrhoidopexy.

The "reverse air leak test": a new technique for the assessment of low colorectal anastomosis.

PurposeAnastomotic leakage is a fearsome complication in rectal surgery. Surgeons perform the classic air leak test, although its real effectiveness is still debated. The aim of this study was to describe a personal technique of reverse air leak test in which low colorectal anastomosis was assessed transanally through the intrarectal irrigation of a few mL of saline solution.MethodsFrom October 2014 to November 2019, 11 patients with low rectal cancer (type 1 in Roullier classification) were included in this study. At the beginning of the procedure, a circular anal dilator was inserted into the anus. A side-to-end colorectal anastomosis was performed. A few mL of saline solution were injected into the rectum and the entire anastomotic line was directly explored. The appearance of bubbles was considered as an anastomotic defect and repaired with an interrupted suture. A fluorescence angiography after intravenous injection of indocyanine green was performed in order to evaluate the perfusion of the anastomosis.ResultsThe reverse air leak test was positive in 4 cases (36.4%). The defect was repaired and a confirmation test was performed. In all patients, near-infrared evaluation showed no perfusion defect (grade 0) in low colorectal anastomosis. No postoperative fistula was detected in cohort study. A protective stoma was performed in 10 patients. On day 90, there were no complications and stoma closure was performed as planned.ConclusionThe reverse air leak test is a simple, feasible, and effective procedure to identify anastomotic leaks in low colorectal anastomoses.

To study postoperative complications between circular stapler hemorrhoidopexy and conventional hemorrhoidectomy

Method: Per-rectal examination with gentle dilatation done after lubrication with xylocaine jelly. Rigid sigmoidoscopy is done to look for any pathology in recto sigmoid region. After doing preliminary painting and draping anal verge is held by three atraumatic forceps at the three points where the prolapse is smaller and the anoderm is slightly everted. Such a maneuver facilitates the introduction of circular anal dilator (CAD 33) after lubrication with xylocaine-Jelly. The introduction of the circular anal dilator-33 along with the obturator cause the reduction of the prolapse of the anoderm and points of anal mucous membrane. After removing the obturator prolapsed. All remaining prolapsing tissue should be pushed back with atraumatic forceps through the window of the circular anal dilator-33.Result: The comparison of mean age between the open hemorrhoidectomy and stapler hemorrhoidopexy groups. The mean age in the open hemorrhoidectomy group was 41.00 ± 6.47 years and in the stapler hemorrhoidopexy group was 41.55 ± 11.38 years. The comparison of age between the two groups was found to be statistically not significant (p>0.05), showing a comparable age between the two groups. Reactionary hemorrhage was seen in 30% patients of open hemorrhoidectomy, while it was seen in 20% patients of stapler hemorrhoidopexy group. There was a statistically no significant association seen between reactionary hemorrhage and the groups (p>0.05), showing a comparable distribution of patients with reactionary hemorrhage in both the groups.Conclusion: In stapler hemorrhoidopexy functional outcome is good as compared to conventional hemorrhoidectomy. Stapler hemorrhoidopexy is associated with less morbidity with fewer complications due to minimal tissue trauma and handling. Although the conventional hemorrhoidectomy is still performed in many higher centers but in this era of minimal invasive surgery the stapler hemorrhoidopexy is fast replacing the conventional hemorrhoidopexy.

Surgical key points of precision functional sphincter-preserving surgery

The principle of sphincter-preserving surgery is to preserve the anal sphincter function under the premise of radical resection. Due to low position of rectal tumor, conventional laparoscopic surgery has difficulties in operating in the deep and narrow pelvis, which may lead to inaccurate tissue dissociation, imprecise positioning of tumor edge, excessive stretch of the anal sphincter complex, and excessive removal of distal rectal mucosa. Moreover, pain from abdominal auxiliary incision has an unavoidable side effect for postoperative recovery. With the help of the Liu's transanal microsurgery system, precision functional sphincter-preserving surgery (PPS) can be successfully performed. PPS tries to preserve left colonic artery and pelvic autonomic nerve in the transabdominal operation. In the part of transanal surgery, measurement, localization and resection of the lower edge of the tumor are conducted under a clear and open visual field with the transparent screw anal dilator. After the rectum is cut off, the specimen is taken out through the anus to avoid abdominal incision. Inserting the intestinal supporter to support the bowel stump, full thickness of bowel stump is then sutured with anal canal by vertical mattress suture. Special transanal tube is placed afterwards without routine prophylactic stoma. PPS can achieve precise tumor resection and sphincter preservation simultaneously.

High-Volume Transanal Surgery with CPH34 HV for the Treatment of III-IV Degree Haemorrhoids: Final Short-Term Results of an Italian Multicenter Clinical Study.

The clinical chart of 621 patients with III-IV haemorrhoids undergoing Stapled Hemorrhoidopexy (SH) with CPH34 HV in 2012–2014 was consecutively reviewed to assess its safety and efficacy after at least 12 months of follow-up. Mean volume of prolapsectomy was significantly higher (13.0 mL; SD, 1.4) in larger prolapse (9.3 mL; SD, 1.2) (p < 0.001). Residual or recurrent haemorrhoids occurred in 11 of 621 patients (1.8%) and in 12 of 581 patients (1.9%), respectively. Relapse was correlated with higher preoperative Constipation Scoring System (CSS) (p = 0.000), Pescatori's degree (p = 0.000), Goligher's grade (p = 0.003), prolapse exceeding half of the length of the Circular Anal Dilator (CAD) (p = 0.000), and higher volume of prolapsectomy (p = 0.000). At regression analysis, only the preoperative CSS, Pescatori's degree, Goligher's grade, and volume of resection were significantly predictive of relapse. A high level of satisfaction (VAS = 8.6; SD, 1.0) coupled with a reduction of 12-month CSS (Δ preoperative CSS/12 mo CSS = 3.4, SD, 2.0; p < 0.001) was observed. The wider prolapsectomy achievable with CPH34 HV determined an overall 3.7% relapse rate in patients with high prevalence of large internal rectal prolapse, coupled with high satisfaction index, significant reduction of CSS, and very low complication rates.

PTU-006 Glove port trans anal excision of rectal tumours

Introduction Transanal glove port excision is a safe minimally invasive procedure for excising rectal tumours that avoids major rectal surgeries and its complications. The aim of this study is to review a single Centre experience with Trans Anal Glove Port excision of rectal tumours. Method Between 2011–2014, 11 patients underwent resection of benign (N = 9) or Malignant (N = 2) rectal tumours, located above the dentate line to 14 cm. The mean follow up period was between 6–12 months. Glove port was constructed using circular anal dilator, standard surgical glove and a wound protector retractor. Results All the patients underwent Glove port transanal excision of rectal tumours. Male: Female ratio was 10:1. Average age of patients was 63 years. None of the patients in the series underwent conversion to radical surgery. Full thickness excision of the tumour was performed in 9 patients and the other two underwent submucosal excision. During the follow up period between 6–12 months, 1 patient had recurrent tubulo villous adenoma, which needed further excision of the adenoma. In two patients who had a planned glove port excision for a presumed benign rectal polyp (Tubulo villous adenoma), The final histology showed an adenocarcinoma on a background of Tubulo-villous adenoma. Both the Patients underwent further staging investigations, one patient had a further chemo-radiotherapy and the other patient did not need any further treatment. Both are under close surveillance with no recurrence. Post-operative complications were only mild which included bleeding and mucus discharge. Conclusion Glove port Trans anal excision is a safe, effective and cheap technique useful in excising rectal tumours with good clearance and full thickness excision of the rectal wall where necessary. It helps avoid major rectal resections with its attendant complications, in many cases. Disclosure of interest None Declared. Reference Alessandro C, Daniela M, Michele M, et al . Glove port technique for transanal endoscopic microsurgery. Int J Surg Oncol . 2012;2012:Article ID 383025,1–4

Transanal endoscopic microsurgery by transanal glove port combined with colonoscopy for excision of rectal tumors

To evaluate the feasibility and efficacy of transanal endoscopic microsurgery (TEM) by transanal glove port combined with colonoscopy for excision of rectal tumors. Eight patients with rectal cancer eligible for local resection were chosen to receive a procedure performed via a "glove TEM port" from October 2012 to March 2013. This device was constructed on-table using a circular anal dilator (CAD), standard surgical glove, colonoscopy instruments and straight laparoscopic instruments. Procedures of all the patients were completed successfully by glove TEM. The median (range) diameter of tumor was 2.6(1.5-3.5) cm, the median (range) operative time was 55.6(30-110) min. Postoperative pathology included villous adenomas (n=3), tubular adenomas (n=2), tubulovillous adenomas (n=2), serrated adenoma (n=1), low-grade intraepithelial neoplasia (n=2), and high-grade intraepithelial neoplasia (n=1). All resection margins were negative. Two patients presented with postoperative minor bleeding. There were no serious intraoperative complications. No cancer recurrence was found during a follow-up of 1-5 (median 3.1) months. Transanal endoscopic microsurgery by transanal glove port combined with colonoscopy in the treatment of early rectal cancer is easy and safe.

Tailored prolapse surgery for the treatment of haemorrhoids and obstructed defecation syndrome with a new dedicated device: TST STARR Plus

The aim of the study was to assess the safety, efficacy and feasibility of stapled transanal procedures performed by a new dedicated device, TST STARR Plus, for tailored transanal stapled surgery. All the consecutive patients admitted to eight referral centres affected by prolapses with III-IV degrees haemorrhoids or obstructed defecation syndrome (ODS) with rectocele and/or rectal intussusception that underwent stapled transanal resection with TST STARR plus were included in the present study. Haemostatic stitches for bleeding of the suture line, specimen volume, operative time, hospital stay and perioperative complications were recorded. From 1 November 2012 to 31 March 2013, 160 consecutive patients (96 females) were enrolled in the study. In 94 patients, the prolapse was over the half of the circular anal dilator (CAD). The mean duration of the procedure was 25 min. The mean resected volume of the specimen was 13.3 cm(3), the mean hospital stay was 2.2 days. In 88 patients (55%), additional stitches on the suture line were needed (mean 2.1). Suture line dehiscence was reported in four cases, with intraoperative reinforcement. Bleeding was reported in seven patients (5%). Urgency after 30 days was reported in one patient. No major complication occurred. The new device seems to be safe and effective for a tailored approach to anorectal prolapse due to haemorrhoids or obstructed defecation.

Conservative versus surgical treatment for chronic anal idiopathic fissure: a prospective randomized trial

Anal fissure is a tear in the lining of the anal canal distal to the dentate line, which most commonly occurs in the posterior midline. Anal fissure was defined chronic if the patient presented with history of anal pain during defecation for at least 2 months with the observation of sphincter fibers at the base of the lesion. One hundred and forty-two consecutive patients with a chronic anal fissure with hypertonicity of internal sphincter on proctological examination were selected for this study from October 2008 to October 2010. Patients enrolled for the study were randomized to two groups by using a computer-generated list. Patients who underwent lateral internal sphincterotomy (LIS) were operated as day surgery procedures under local or epidural anesthesia. Patients randomized to conservative treatment were prescribed to use warm anal dilator with a nifedipine ointment 5 min twice daily for 4 weeks. Patients were clinically examined after 2, 4 and 8 weeks of treatment to evaluate if there was complete healing of the fissure. All patients were required to record pain after the first defecation, on 3rd and 7th postoperative day on a self-administered VAS scale in cm (0-10). Sixty-eight patients were randomly assigned to LIS, 74 to the conservative approach. Fifty-one patients of topical nifedipine group (68.9 %) and 60 patients of LIS group (88.2 %) presented an anal fissure healed at 8 weeks with a p value of 0.0077. As regards post-operative pain, 43 patients of LIS group (63.2 %) and 25 patients of topical nifedipine group (33.7 %) referred first defecation as painless. In the topical nifedipine group 43 (58.1 %) after 3 days since treatment and 35 (47.3 %) after 7 days had pain. In the LIS group 22 (32.3 %) after 3 days and 9 (13.2 %) after 7 days referred pain. There was no statistical difference between LIS and topical nifedipine group concerning side effects. Lateral internal sphincterotomy is an effective, less painful, fast recovery treatment for chronic anal fissure. Incontinence rate is overestimated and often the fear of a continence disturbance, albeit with a low incidence following surgery, may obscure the need to relieve symptoms which may be so severe as to make the patient's life intolerable.

Anal skin tags: removal made simple

Anal skin tags are a common finding. They are found in one-third of patients with bening anal disorders. We describe a simple method of anal skin tag removal during stapled anopexy. This involves utilizing the circular anal dilator provided with the stapling kit. Skin tags are brought through the perforations of the circular anal dilator of the stapling kit. The skin tags are removed by cautery. Minimal pain has been noticed in patients under going this procedure. Anal skin tags can be removed in a simple manner using components provided with the stapling kit. We decribe a simple method of anal skin tag removal during stapled anopexy. This involves utilizing the circular anal dilator provided with the stapling kit.

Transanal glove port is a safe and cost-effective alternative for transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of rectal tumours that avoids conventional pelvic resectional surgery along with its risks and side-effects. Although appealing, the associated cost and complex learning curve limit TEM utilization by colorectal surgeons. Single-port laparoscopic principles are being recognized as transferable to transanal work and hybrid techniques are in evolution. Here the clinical application of a new technique for transanal access is reported. Consecutive non-selected patients eligible for TEM over a 3-month period (and selected patients thereafter) were offered a procedure performed via a 'glove TEM port'. This access device was constructed on-table using a circular anal dilator (CAD), wound retractor and standard surgical glove, along with standard, straight laparoscopic trocar sleeves and instruments. Fourteen patients underwent full-thickness resection of benign (8) or malignant (6) rectal pathology. CAD insertion failed in one patient and conventional TEM assistance was needed in another, leaving 12 procedures completed successfully by glove TEM alone as planned (completion rate 86 per cent overall, 92 per cent after initiation). The median (range) duration of operation and resected specimen area were 93 (30-120) min and 12 (3-152) cm(2) respectively. There was no intraoperative and minimal postoperative morbidity, with a median follow-up of 5.7 (2.7-9.4) months. The glove TEM port is a safe, inexpensive and readily available access tool that may obviate the use of specialized equipment for transanal resection of rectal lesions.

Double stapled haemorrhoidopexy for haemorrhoidal prolapse: indications, feasibility and safety

Selected patients with haemorrhoidal prolapse undergoing double stapled anopexy with the procedure for prolapse and haemorrhoids (PPH03) were studied. Between March 2007 and March 2010, 235 patients referred with haemorrhoids were included in the study. Patients with obstructed defaecation were excluded. At surgery intraoperative evaluation for double stapled anopexy was carried out based on the criteria of prolapse occupying half or more of the anal circumference and redundant prolapsed tissue determined by the circular anal dilator. Patients fulfilling these criteria were submitted for double stapled anopexy with the PPH03 stapler. All clinical and operative data were recorded in a prospectively maintained database. Among the 142 patients with haemorrhoidal prolapse having surgery 91 had a single and 51 a double stapled technique. The mean operative time was 34.8 min with no major or minor intraoperative complications. Recurrence at 48 months was 1.9% and the mean satisfaction score was 8.9. The double stapled PPH03 technique in selected cases was as safe and effective as a single stapling technique with a lower incidence of recurrence over a medium-term follow-up.

Preclinical cadaveric study of transanal endoscopic da Vinci® surgery

Single-port platforms are increasingly being used for transanal surgery and may be associated with a shorter learning curve than transanal endoscopic microsurgery. However, these procedures remain technically challenging, and robotic technology could overcome some of the limitations and increase intraluminal manoeuvrability. An initial experimental experience with transanal endoscopic da Vinci(®) surgery (TEdS) using a glove port on human cadavers is reported. After initial dry laboratory experiments, the feasibility of TEdS and ideal set-up were further evaluated in human cadavers. For transanal access a glove port was constructed on-table by using a circular anal dilator, a standard wound retractor and a surgical glove. A da Vinci(®) Si HD system was used in combination with the glove port for transanal endoscopic resections. It was possible to perform all necessary tasks to complete a full-thickness excision and closure of the rectal wall, with cadavers in both prone and supine positions. The stable magnified view, combined with the EndoWrist(®) technology of the robotic instruments, made every task straightforward. Intraluminal manoeuvrability could be improved further by intersecting the robotic instruments. The glove port proved to be very reliable and the inherent flexibility of the glove facilitated docking of the robotic arms in a narrow confined space. Using a reliable and universally available glove port, TEdS was feasible and a preferred set-up was determined. Further clinical trials will be necessary to assess the safety and efficacy of this technique.

Prospective Study On Evaluation Of Stapler Hemorrhoidectomy

Objective: Aim of this study is to evaluate the results of stapler hemorrhoidectomy considering operative time, intra-operative bleeding, post-operative pain and analgesia, post-operative complications, post-operative recovery, return to activity and patient acceptability. Method: The study included 30 patients of all age groups and both sexes. The equipment used was the PPH-03 set (procedure for prolapse and haemorrhoids set) consisting of 33mm endosurgical circular stapler, circular anal dilator [CAD 33], purse string suture anoscope [PSA 33] & suture threader [ST 100]. Conclusion: Stapler hemorrhoidectomy is much superior in terms of post-operative pain, intra-operative blood loss and return to work. Stapler hemorrhoidectomy does not involve dissection and excision of the perianal skin and this undoubtedly contributes to the reduced pain scores. This reduction in pain and absence of perianal skin wounds helped better and rapid recovery. Early functional and symptomatic outcomes have been satisfactory.

Tips and tricks: hemorrhoidectomy with LigaSure™

The search of the most effective and less painful technique for the treatment of hemorrhoids is still a major concern for colorectal surgeons. The technique of LigaSure hemorrhoidectomy is just a new method to perform the classic operation described by Milligan and Morgan more than 70 years ago. This kind of surgical option still plays a significant role in the treatment of hemorrhoids, particularly for IV degree hemorrhoids [1], and is still considered the most effective treatment in term of hemorrhoid relapse [2]. Although this technique is considered ‘‘invasive’’ compared to other less painful methods [3, 4], it has been demonstrated to improve significantly postoperative pain, bleeding and, consequently, in-hospital stay compared to traditional diathermy Milligan–Morgan excision [5]. Besides the advantages for the patients, I would like to point out the major advantages for the surgeon. The possibility to perform a virtually bloodless operation makes the operation easier, quicker and safer thus justifying the increased cost of the LigaSure device compared to diathermy. The technique here described by Gianni Milito, one of the Italian pioneers of this surgery, is a detailed step-bystep description of the operation; however, it describes an ideal 3-pedicle hemorrhoidectomy which unfortunately is not the rule in our operating theatre. First of all I like to would add something about patient selection. Patients with congenital, acquired or drug-induced coagulative defects are good candidates for this technique which ensures a safe sealing of the hemorrhoid vessels. Even recurrent hemorrhoids or cases with one or two sides prolapsing hemorrhoids can be effectively treated with this technique, even in an ambulatory setting under local anesthesia. In this case, the prolapsing hemorrhoids are pulled out and its excision is performed as described by Milito but without the need of an anal dilator. I have also had some positive experience of this technique in some AIDS patients with bleeding IV degree hemorrhoids without complications. The forceps have recently been improved. The old device has been abandoned in favor of the most practice, effective and ergonomic forceps (LigaSure Precise mod 1200LS, Valleylab, Tyco Healthcare group LP, USA). This new devise has short and slim jaws which facilitate hemorrhoids dissection from the internal anal sphincter and further limiting the extent of thermal injury to just 1 mm. For completeness I would add that a similar operation could be performed using ultrasounds (Ultracision, Ethicon EndoSurgery) instead of radiofrequency energy. The procedure is just a little bit quicker (mainly because it is not necessary to transect the line of coagulum), but the temperature developed during the excision is higher than in radiofrequency and a painful edema of the residual skin tags is the rule. It could have been interesting to know Milito’s experience in case of intraoperative or postoperative bleeding. In case of uncontrolled bleeding one can prepare a classic diathermy on the operating setting, use a re-absorbable stitch or try again the LigaSure device. In the rare cases of persistent bleeding after repeated application of the LigaSure device, I put a re-absorbable stitch at the bleeding site. Another point to be stressed could be what to do in case of postoperative bleeding. An emergency re-operation, sometime during the night after the operation, is an This comment refers to the article doi:10.1007/s10151-009-0530-2.

New approach to large haemorrhoidal prolapse: double stapled haemorrhoidopexy

To verify if in large haemorrhoidal prolapse (independently from the degree) in patients with no symptoms of obstructed defaecation syndrome, the use of a stapled hemorrhoidopexy variant, comprising a double stapler haemorrhoidopexy (DSH), makes it possible to reduce the percentage of failures or relapses and to standardise an objective intraoperative parameter for the purpose of quantifying internal prolapses which can then be used as a guide in determining the type of treatment to be provided. Between June 2003 and June 2004, 353 patients were treated for haemorrhoidal prolapse. The patients suffering from large haemorrhoidal prolapse occupying more than half of the length of the anal dilator were intraoperatively selected for DSH. Eighty-three patients (23.5%) underwent a DSH. The degrees of the large haemorrhoidal prolapse intraoperatively selected for DSH were sub-divided as follows: 7.2% (second), 24% (third) and 68.6% (fourth). The follow-up period was 48 months. There were three cases (3.6%) of residual illnesses and five cases (6%) of a relapse. The following complications were recorded: urgency at <3 months (7.2%), haemostasis revisions (2.4%) and spontaneously draining anterior haematoma (1.2%). The results of the 270 haemorrhoidal prolapse (38 second degree, 159 third degree and 130 fourth degree) treated with the procedure for prolapse and haemorrhoids were: nine (3.3%) residual illness and 12 (4.44%) relapse illness. The following complications were recorded: urgency at <3 months (6.6%), haemostasis revisions (2.5%) and spontaneously draining anterior haematoma (0.7%). The intraoperative selection criterion was both efficacious and reproducible. This variant technique, which can be used in large haemorrhoidal prolapses, could allow us to further improve the quality of treatment for haemorrhoidal conditions using stapled haemorrhoidopexy, without increasing the complications.

MODIFIED STAPLED HAEMORRHOIDECTOMY: A SUGGESTED IMPROVED TECHNIQUE

Longo's technique of stapled haemorrhoidopexy has revolutionized management of symptomatic haemorrhoids. However, several problems have been identified in the original Longo's technique. In particular, recurrence of haemorrhoidal tissue has been found to be significantly higher. An improved technique with key differences to address these shortcomings is described. The modified stapled haemorrhoidectomy procedure described is carried out without the circular anal dilator and includes the placement of a low purse string of 2-3 cm. This technique is proposed as an improvement to the current stapled haemorrhoidopexy.