PPH stands for Procedure for Prolapse and Hemorrhoids.  It is also known as a stapled hemorrhoidectomy and circumferential mucosectomy.

PPH was developed in the early 90’s to reduce the prolapse of hemorrhoidal tissue.  This is done by excising a band of prolapsed anal mucosa membrane with the use of a circular stapling device.  The prolapsed tissue is pulled into an instrument in PPH.  This allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled.  This should restore the tissue back to its normal anatomical position.

The main instrument used is called a circular anal dilator.  This dilator reduces the prolapse of the anal skin and parts of the anal mucous membrane.  After the obturator is removed, the prolapsed membrane falls into the dilator lumen.

Another instrument is then inserted through the dilator called a purse-string suture anoscope.  This instrument will push the prolapsed mucous back against the rectal wall 270 degrees around.  The mucous membrane that comes through the anoscope window can be contained in a suture that includes only mucous membrane.  By rotating the instrument it is possible to suture the entire anal circumference in a purse-string suture.

The hemorrhoidal circular stapler is then opened to its maximum position, and inserted through the dilator.  It is positioned proximal to the purse-string suture.  The ends of the suture are knotted externally.

With moderate traction on the suture, a simple maneuver draws the prolapsed membrane into the circular stapling instrument.  The instrument is tightened, and then staples the prolapse.  They will generally keep the instrument in the closed position for 30 seconds before firing, and 20 seconds after firing to act as a tamponade, which may help promote hemostasis.

When the stapler is fired, it releases a double staggered row of titanium staples into the tissue.  A circular knife then excises the extra tissue.  A circumferential column of mucosa is removed from the upper anal canal.  Finally, the staples are examined through the anoscope to check for bleeding.  If bleeding occurs, additional absorbable sutures may sometimes be placed.

In many cases hemorrhoids can be treated by dietary modifications, topical medications, and sitz baths (soaking in warm water).  There are other non-surgical methods that are worth trying as well.  However, in a number of cases surgical procedures are still neceassary for long term relief.  Especially cases that involve more serious hemorrhoids such as prolapsed hemorrhoids.

Milligan-Morgan Technique
This procedure was developed in the UK by Dr. Milligan and Dr. Morgan in 1937.  In this procedure the three major hemorrhoidal blood vessels are excised.  To avoid stenosis, three pear-shaped incisions are left open, separated by bridges of skin and mucosa.  This is the most popular hemorrhoid surgery procedure.  It is considered the gold standard that other hemorrhoid surgery techniques are compared against.

Ferguson Technique
This technique was developed in the United States by Dr. Ferguson in 1952.  It is a modified version of the Milligan-Morgan technique.  In this procedure the incisions are totally or partially closed with an absorbable running suture.  A retractor is used to expose the hemorrhoidal tissue, which is removed surgically.  The remaining tissue is sutured or sealed through coagulation.

The Ferguson technique brings no advantages in terms of wound healing (5-6 weeks), pain. or postoperative morbidity because of a high suture breakage rate.

This is not typically an out-patient surgery like a hemorrhoidectomy.  Normally an in-patient stay is required because of the high level of pain experienced after the procedure.  This stay is normally about 3 days.

Hemorrhoidectomy is outpatient surgery to remove hemorrhoids.  It is done using general anesthesia or spinal anesthesia for pain.  There are a couple of different ways to do a hemorrhoidectomy:

1. Incisions are made around the hemorrhoid.  The hemorrhoid is removed and the swollen vein inside is tied off to prevent bleeding.  The surgical area can be stitched back together or left open.
2. There is another procedure that uses a circular stapling device.  This device does not require any incisions.  The hemorrhoid is just lifted up, and then the device staples underneath it.

Surgery can be done with a scalpel, cautery pencil, or laser.

When is Surgery Used?

Hemorrhoidectomy is used when you have:

• Large internal hemorrhoids
• Recurring internal hemorrhoids
• Large external hemorrhoids that are very painful
• Exhausted all other means of hemorrhoid removal

Complications

• Pain
• Bleeding from the anal area
• Inability to urinate
• Hematoma (blood collecting in surgical area)
• Icontinence (uncontrollable bowel or bladder)
• Infection
• Fecal impaction (feces trapped in anal canal) Late Complications
• Narrowing anal canal
• Additional hemorrhoids
• Abnormal passage that forms between the rectal or anal canal and other areas
• Rectal Prolapse

Recovery

You will experience some pain after the surgery.  If your doctor provides a prescription for pain killers, take them as prescribed.  Ask your doctor what over the counter medication is ok for you to take.  Some bleeding is normal, but if you experience excessive bleeding, seek medical attention.  Numbing medicines can be applied before and after bowel movements to help with pain.  Ice packs applied to the anal area can help with swelling and pain.  Frequent soaks in warm water (sitz bath) are recommended to help with pain and muscle spasms.  Some doctors may prescribe an antibiotic to reduce the chance of infection.  Stool softeners are recommended to help keep bowel movements smooth.  Straining during bowel movements may cause recurrence of hemorrhoids.  Expect a follow-up exam with the surgeion 2 to 3 weeks after the surgery.

What to Consider

It is imperative that you make changes in daily habits to help reduce strain in bowel movements.  Hemorrhoidectomies may provide better long term results than other hemorrhoid treatments.  However, surgery is more costly and comes with a greater risk of complications and pain.

Most internal hemorrhoids can either be treated with home treatments and remedies, or fixative procedures.  Fixative procedures involve less risk, less pain, and require less time away from work when compared with surgery.