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Official Journal of the American Society of Abdominal Surgeons, Inc.

This article originally appeared in the Winter 20011 / Spring 2012 issue of the Journal.

Our Experience with (CSH) Circular Stapled Hemorrhoidopexy as a Surgical Treatment of Piles

Dr.Faris Dawood Alaswad
Specialist General Surgeon

Dr.Sukrett Shetty
Specialist General Surgeon


Background: Hemorrhoidectomy is a common surgical procedure which is usually associated with post operative pain Circular Stapled Hemorrhoidopexy (CSH) is with less pain than the conventional hemorrhoidectomy and can be used in the management of second, third and fourth degree hemorrhoidal disease.

Objective: To show the effectiveness of Circular Stapler Hemorrhoidectomy as an effective method of treatment of piles.

Methods: The medical records of 200 patients who had under gone Circular Stapled Hemorrhoidopexy for symptomatic hemorrhoidal disease from July 2007 to September 2010 were evaluated in our hospital (New Medical Center Specialty Hospital – Dubai) data regarding complications, residual symptoms and recurrence were reviewed, the fellow up was for 18 months.

Results: The study included 200 patients (150 men, 50 women) between 22 and 74 years old (median age 39 years). Concomitant lateral sphincterotomy, skin tags, excision, and thrombus removal were done in 44 (24.0%), 36 (18%), and 8 (4%) patients, respectively. The operating time was around 30 minutes. The median hospital stay was 40 hours (11–72 hours). Complications during the first 24 hours were fecal urgency (25%), urinary retention (8%), and rectal bleeding (1%). Pruritus ani (21%), thrombosed external hemorrhoids (4%), meanwhile the staple line stenosis (2%), rectal bleeding (2%), anal fissure (1%), and persistent skin tags (3%) were the symptoms seen during the long term follow up. The follow up was for 18 months. The recurrence rate was 1%.

Conclusion: Circular stapled hemorrhoidopexy can be safely performed with low recurrence and complication rates while offering a relatively painless postoperative period for the patient.


Circular stapled hemorrhoidopexy (CSH) for hemorrhoidal disease has become popular among surgeons because of the absence of perianal wounds and comparable short-term results with standard Milligan Morgan hemorrhoidectomy. There are limited data about the long-term postoperative results of CSH. The aim of this study was to collect data and evaluate the long-term outcomes of patients who underwent CSH for second-, third-, and fourth-degree hemorrhoidal disease.1, 2


From July 2007 to September 2010, the medical records of 200 patients who had underwent circular stapled hemorrhoidopexy in New Medical Center Specialty Hospital, Dubai, UAE) for symptomatic hemorrhoidal disease were evaluated retrospectively regarding pre-operative indication of surgery and post operative outcome. After obtaining ethical approval from New Medical Center Specialty Hospital Ethics Committee, the Visual Analogue Scale (VAS) scores, analgesic requirements, and other information were gathered from the patients, files and a computerbased data system for outpatient clinics. Hemorrhoidal disease was considered symptomatic if the patient reported symptoms of rectal bleeding, pain during defecation, anal discharge, and Pruritus ani. All the patients were preoperatively evaluated by rectoscopy. All operations were performed by the surgical team in New Medical Center Specialty Hospital – Dubai). Phosphate enema was used before the operation, and single-dose antibiotic prophylaxis was given before the induction of general anesthesia.

Postoperative pain was assessed with a linear visual analogue pain scale (VAS) on postoperative days 1 and 7. The VAS scores were grouped as mild (0-3), moderate (4-6), and severe (7-10). The patients were called for another control visit at the time of the study. Patients who could be reached were included in the final evaluation. These patients were asked about residual symptoms (i.e., skin tags, bleeding, anal pain, prurits, and constipation) and were examined. Patients were called and asked if they were satisfied with the CSH procedure. The patients were asked to choose one of the following degrees of satisfaction: poor, moderate or well.

All the patients with pain scores higher than 3 were given analgesia with metamizole sodium. Nonstereoidaln antiinflammatory agents (NSAIDs) were used in case of additional need for analgesia. Oral laxatives were used if the patient could not defecate on the second day of operation. All the patients were advised not to strain during defecation to prevent edema and bleeding in the staple site.


The study included 200 patients .There were 50 women and 150 men with a median age of 39 years (22-74years). The follow-up was 18 months. Clinical features are shown on the Table 1. The median operating time was 30 minutes. The median hospital stay was 40 hours (11-72 hours). Concomitant lateral internal sphinterotomy, skin tag excision, and thrombus removal were done in 48 (24%), 36 (18.5%), and 8 (4.5%) patients. respectively. Postoperative outcomes were defined as short term (during the first postoperative week) and long term (after the first postoperative week).

Short-term postoperative outcome Altogether, 50 (25%) patient required postoperative analgesia with metamizole sodium during the first 24 hours, and 25 of these patients needed additional analgesia with NSAIDs. Operative data and VAS scores on postoperative days 1 and 7 are shown in Table 2.

Complications during the first 24 hours were fecal urgency (25%, n= 50), urinary retention (8%, n= 16), and rectal bleeding were (1%, n=2). One of the two patients with rectal bleeding was managed with hemostatic sutures in the operating room under general anesthesia. The bleeding stopped spontaneously in the other patient. All patients with postoperative urinary retention required urinary catheterization.

Long-term postoperative outcome The most frequent complaint was Pruritus ani (21%, n=42), staple line stenosis (2%, n=4), rectal bleeding (2%, n=4), and anal fissure (1%, n=2). Of the six patients with rectal bleeding, two required intervention. Hemostatic sutures were applied to control bleeding from the staple line under general anesthesia in one patient on postoperative day (POD) 22. Epinephrine injection was used to manage the bleeding point in another patient on POD 14. Bleeding stopped spontaneously without admission to hospital in three patients. External hemorrhoidal disease developed in 2 (1%) patients within 2 to 10 months after the operation. Thrombosed external hemorrhoids were seen in 8 of these patients. The thrombus was removed in each case.

The most common late complication was prurits ani, seen in 42 patients (21%). most of these patients had undergone concomitant sphincterotomy and skin tag excision. Anti inflammatory topical agents resolved the symptoms. Only four patients complained from persistent itching, but no underlying pathology was found. Anal fissure was recognized in two patients 4 to 24 months after the operation, and they were subjected to lateral internal sphincterotomy.

Stable line stenosis occurred in four patients (2%) and was recognized 6 to 10 weeks after the operation. Two patients were treated with digital dilatation in the outpatient clinics. Other two of them required dilatation under general anesthesia 6 and 9 months after CSH, respectively. Two patients (1%) had recurrence of the hemorrhoidal disease but none required surgery. Patient satisfaction is shown in Table 4.


Excisional hemorrhoidectomy has long been the most effective treatment for symptomatic third- and fourth-degree hemorrhoidal disease; however, a painful postoperative period is common and often limits the resumption of normal daily activities. CSH is a newer alternative with a relatively painless postoperative period, and it has been shown to be equally effective as the standard Milligan Morgan hemorrhoidectomy in randomized controlled clinical trials.1,2

Table 1

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Table 2

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Table 3

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Table 4

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The CSH is performed in the lower rectum above the dentate line, and no dissection or excision of the perianal skin is required. As the radix of the hemorrhoidal cushions is fixed above the dentate line, prolapsed hemorrhoids are reduced within the anal canal. Interrupted blood supply to the hemorrhoidal vessels leads to further shrinkage of the cushions. However, Doppler ultrasonography did not show any difference before and after the CSH procedures. Theoretically, CSH is painless because the sensitive anoderm is spared. Although the procedure is not totally painless. Randomized studies that compared CSH with excisional hemorrhoidectomy reported that pain scores were lower, analgesic consumption was less, and the hospital stay was shorter after CSH.3, 4

In our study, 50 patients received postoperative analgesia with metamizole sodium during the first 24 hours, and 25 of them needed additional analgesia with NSAIDs. The sensation of pain was defined as dull, rather than sharp by the patients. The patients with removed perianal skin tags were more likely to experience pain and needed additional analgesia, whereas sphincterotomy and thrombus removal did not alter pain scores, as in other series. Only 13 patients in our study described severe pain (VAS score 7-10) during the early postoperative period. After 1 week only two patients with VAS scores 7 were reported.

The rate of severe pain (VAS scores 7) was around 5%. None of our patients suffered from persistent pain. Some authors have indicated that inclusion of smooth muscle fibers in the excised doughnut may be related to the development of pain. Alto mare et al. Reported that smooth muscle fibers found in the resected specimens were not related to long- term sever pain or incontinence. They also investigated internal anal sphincter function in the long term with anorectal anemometry, rectoanal inhibitory reflex testing, and endoanal ultrasonography and concluded that CSH does not affect the function of the internal anal sphincter. However many reports have indicated that internal sphincter injury may occur while stretching the anal canal during insertion of a 33 mm stapler or when firing the stapler.5, 6, 7

It has previously been reported that either lateral internal sphincterotomy or pharmacologica reduction in anal sphincter tone did not significantly affect postoperative pain. On the other hand. It is clear that the level of the mucosal purse-string suture is important to avoid internal sphincter injury. It should be at least 3 cm above the dentate line, as it was reported in Longs technique. We think that the purse-string suture applied to (4 – 5) cm is optimal for minimizing the risk of postoperative pain while allowing sufficient reduction of the prolapsed mucosa. Another factor contributing to postoperative pain is the number and depth of hemostatic sutures. The VAS scores were higher in patients in whom hemostatic sutures were needed, as reported by Mlakar and Kosorok. 1, 7

In patients with bulky prolapsing fourth-degree hemorrhoids, reduction of the prolapsed mucosa is insufficient because of the inability to insert the instrument adequately. This might compromise a patient’s satisfaction even though not resulting in persistent symptoms. We have tried to solve this problem in our patients by placing the traction sutures to the anocutaneous line and apply moderate traction of the anal verge while inserting the circular anal dilator. In this way, hemorrhoidal cushions can be placed under the anal retractor, which makes the application of purse-string sutures easier. Residual skin tags were especially seen in patients with grade IV hemorrhoidal disease. Although the patients did not have any residual symptoms, some were not happy with the cosmetic outcome. That is why we began to excise the residual skin tags when the patient requested it. In our experience with bulky hemorrhoids, the external components do not eventually regress after the operation, as suggested by Longo. We rather agree with Ganio et al. and Mlakar and Kosorok, who reported that CSH partially restores the anal verge in the presence of bulky fourth-degree hemorrhoids. Some authors resported that recurrent rectal prolapsus was significantly more frequent in patients with fourth-degree hemorrhoids may not represent an appropriate indication for CSH procedure. In two meta-analyses, recurrence of the hemorrhoidal disease was reported to be higher than in our study. In a Cochrane review, the number of patients with recurrent bleeding, prolapsed, soiling, fecal urgency, skin tags, recurrent hemorrhoids, and additional operations were higher for CSH than for conventional hemorrhoidectomy. However, pain and Pruritus ani numbers were more favorable in CSH. This review was collected form a number of studies without uniform follow-up periods, however, with various patient characteristics and different colorectal surgeons.8, 9, and 10

Fourth-degree hemorrhoids can be especially challenging, and inadequate reduction of the hemorrhoidal cushions may be a reason for future recurrence and prolapsus. Additional interventions such as excision of skin tags and removal of thrombosed hemorrhoids helps make longterm results better, with decreasing persistent skin tags and a lower rate of thrombosed external hemorrhoids.11,7

We think that the long-term results are also good in terms of patient's satisfaction who suffered from fourth-degree hemorrhoids. The rates of persistent skin tags were reported to be 8% by Mlaker and Kosorok and 4% in another study. In our series the of persistent skin tags was 3%.12, 13

One of the most common problems with Circular Staplar Hemorrhoidectomy (CSH) is stapler line bleeding. It was reported to range from 0.01% to 25% in the literature. Bleeding, which has been shown to be more common with Circular Staplar Hemorrhoidectomy in two meta-analyses, can be decreased with meticulous hemostatic control during the operation. The operation should be considered finished only when the minor bleeding points are hemostatically controlled. We had 6 (3%) patients with bleeding. We believe that the most effective way to control bleeding is meticulous control during the CSH procedure. Singer et al. concluded that bleeding should be considered a routine part of the operation rather than a complication. All bleeding points should be controlled with Vicryl sutures. We eventually discovered that waiting for some time after closing the jaws of the stapler device before firing was helpful for decreasing the number of bleeding points. It is important to recommend that the patients not to strain during defecation to prevent bleeding and pain due to edema and stapler line dehiscence.14, 7

Generally, CSH is used for grade III and IV hemorrhoids. In our study, 30patients (8%) with grade II hemorrhoids whose symptoms did not resolve with other measures (e.g., rubber band ligation) have undergone the CSH procedures. The results were comparable to those of patients with grade III and IV hemorrhoids, unlike the data reported by others. Ho et al. Reported that fewer patients experienced pruritus ani was present in 21% (n= 42 of the patients in our study. All of the patients with pruritis ani after the operation had anal wounds due to perianal wound. The symptoms were relived with topical anti inflammatory agents, and most of the patients recovered completely by 8 weeks, although residual anal pruritis was seen in two patients. No underlying cause has been identified.14, 15, and 2

Urinary retention was seen in 16 (8%) patients in our study. It has reported to be less frequent with CSH than with open Milligan-Morgan hemorrhoidectomy {4}. Staple line stenosis is another issue seen in a considerable number of patients. However, severe stenosis is rare, and the stenoses are usually filmy and easily dilated digitally in outpatient settings. Arnuad et al. Asserted that muscle fibers should not be included in the resected tissue as it can predispose to stricture.16, 17

The major limitations of this study are that there was a high rate of secondary interventions. However we have shown that CSH can be performed concomitantly with additional procedures—particularly sphincterotomy—without an increased complication rate or VAS scores. Another limitation is the possibility of personal bias because the patients were questioned and examined by the same surgical team.


Circular stapled hemorrhoidopexy is a safe and effective treatment for selected second-, third-, and fourth-degree hemorrhoidal disease. The postoperative period is not entirely pain-free. Patients describe a sensation of fullness and a dull ache that is well tolerated. The results of the operative procedure are directly related to the correct operative technique. The level of the purse-string suture, avoiding sliding of the suture line, and meticulous intra operative homeostasis are the key points. Additional procedures such as sphincterotomy and skin tag excision do not significantly alter the pain scores and can be safely performed without increased complications. Despite the limitations of the present study, we believe that circular stapled hemorrhoidopexy has a low recurrence rate and is a good alternative to conventional hemorrhoidopexy.


1. Johnson DB, DiSiena MR, Fanelli RD Circumferential mucosectomy with stapled proctopexy is a safe, effective outpatient alternative for the treatment of symptomatic prolapsing hemorrhoids in the treatment of symptomatic prolapsing hemorrhoids in the elderly. Surg Endosc 2003; 17:1990-1995

2. Ravo B, Amato A, and Bianco V et al Complications after stapled hemorrhoidectomy: can they be prevented? Tech Coloproctol 2003; 6:83-88

3. Altomare DF, Rinaldi M, Sallustio PL et al Long -term effects of stapled haemmorrhoidectomy on internal anal function and sensitivity. Br J Surg 2000; 88:1487-1491

4. Row sells M , Bello M, Hemingway DM Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy; randomised controlled trial. Lancet 2000; 355:779-781

5. Mehigan BJ, Monson JR, Hartley JE Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial. Lancet 2000; 355:782-785

6. Racalbuto A, Aliotta I, Corsaro G et al Hemorrhoidal stapler prolapsectomy vs. Milligan-Morgan hemorrhoidectomy: a long-term randomized trial. Int J Colorectal Dis 2004; 19:239-244

7. Ortiz H, Marzo J, Armendariz P Randomized clinical trial of stapled hemorrhoidopexy versus conventional diathermy haemorrhoidectomy. Br J Surg 2002; 89:1376-1381

8. Ganio E, Altomare DF, Gabrielli F et al Prospective randomizd multicentre trial compared stapled haemorrhoidectomy. Br J Surg 2001;88;669-674

9. Ho YH Tsang C, Tang CL et al Anal sphincter injuries form stapling instruments introduced transanally: randomized, controlled study with endoanal ultrasound and anorectal manometry. Dis Colon rectum 2000; 43:169173

10. Au-Yong I, Rowsell M, Hemingway DM Randomised controlled clinical trial of stapled haemmorrhoidectomy vs conventional haemorrhoidectomy: a three and a half year follows up. Colorectal Dis 2004; 6:37-38

11. Fazio V W Early promise of stapling technique for haemorrhoidectomy. Lancet 2000; 355:768-769

12. Cheetham MJ, Mortensen NJ , Nystrom PO et al Persistent pain and faecal urgency after stapled hemorrhoidectomy. Lancet 2000; 356:730-733

13. Kolbert GW, Raulf F Evaluation of the results of hemorrhoidectomy with Longos technique by Doppler ultrasound of the arteria rectalis superior artery. Zentrable Chir 2002; 127:19-21

14. Wilson MS, Pope V, Doran HE et al Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized controlled trial. Dis Colon Rectum 2002; 45;1437-1344

15. Symth EF, Baker RP, Wiliken BJ et al stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial. Lancet 2003; 361:1437-1438

16. Hetzer FH, Demartines N, Handschin AE et al stapled vs excision hemorrhoidectomy: long-term results of a prospective randomized trial. Arch Surg 2002; 137:337-340

17. Corman ML, Gravie JF, Hager T et al Stapled hemorrhoidopexy: a consensus position by an international working party-indications, contra-indications and technique. Colorectal Dis 2003; 5:304-310

18. Mathai V,Ong BC , Ho YH Randomized controlled trail of lateral internal sphincterotomy with haemorrhoidectomy. Br J Surg 1996; 83:380-382

19. Mlakar B , Kosorok P Complications and results after stapled hemorrhoidopexy as a day surgical procedure. Tech Coloproctol 2003; 7:164-168

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The American Society of Abdominal Surgeons, Inc.
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Louis F. Alfano, Jr., M.D., Editor-in-Chief
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Table 1: Patient Sex and clinical presentations

Table 2: Operative data and VAS scores on postoperative days 1 and 7

Table 3: Clinical outcome of the patients

Table 4: Patient satisfaction at the time of the study