1. Stapled Hemorrhoidopexy : How to Avoid Complications
굿모닝대홍병원 이선칠

2. Complications after S.H
Improper use of SH can lead to complications which
include bleeding, urinary retention, stenosis, and thrombosis.

3. Tech Coloproctol (2012)
Immediated (within 1 week) complications of stapled hemorrhoidectomy reported for 1107 patients treated in a 2-year period

4. Tech Coloproctol (2012)
Late complications of stapled hemorrhoidectomy reported for patients treated in a 2-year period

5. Major Septic Complications
Pelvic sepsis
Intra-abdominal sepsis
Fournier gangrene
Rectovaginal fistula
Rectal perforation
: Related to technical errors
inappropriate placement of purse-string
(too deep or to cephalad in the rectum)
Full thickness rectal anastomosis
Dis Colon Rectum (2007)

6. Complications after S.H
Literature review of complications after S.H in Korea

7. Post-operative pain Causes
Staple line level(too close to the dentate line)
Inclusion of muscle fibers
그 외, narrow anal canal ,
excessive sphincter tone,
staple dehiscence,
mucosal injury,
thrombosis.

8. Smooth Muscle Including

9. Smooth Muscle Including

10. Early post operative bleeding (within 24hr)
* Causes
Staples did not achieve proper hemostasis
Too much folded mucosa in the staple
Taking larger bites of the mucosa in to the purse-string

11. Late post operative bleeding (after 24hr)
Causes
Suture line
dehiscence,
infection,
necrosis.

12. Treatment of postoperative bleeding
① . Bed rest and supportive treatment ② . Anal packing ( Foley catheter, Gauze) ③ . Injection of Epinephrine ④ . Suture ligation

13. 술 후 출혈을 예방하기 위한 Tips Pre Operative 1. 혈전용해제 복용유무 확인 2. 출혈에 영향을 주는 질환들
: Hemophila, DM, Hypertension, Liver cirrhosis, Leukemia
3. Prophylatic antibiotics

14. 술 후 출혈을 예방하기 위한 Tips Intra operative
1. Purse-string suture시 mucosa and submucosa layer만 균일하게 6~8 stitches
2. SH firing 하기 전, 후 적어도 15초 이상 기다린다.
3. 수술시 Electrocautery 사용은 조심스럽게.
: 나중 delayed local tissue necrosis 야기, 심하면 retroperitoneal sepsis
4. Pumping artery : Suture ligation
Oozing : Compression or Electrocautery
5. 지혈제 사용. (Spongostan, Gelform, FloSeal, etc.)

15. 술 후 출혈을 예방하기 위한 Tips Post operative
1. Antibiotics (Metronidazole, Cefa.)
2. Stool softening,
과도한 strain 금지.

16. Urinary Retention Etiology - higher spinal anesthesia level of C.H.
- BPH in male, urinary bladder disorder in old female
Incidence
- In Korea : 9.4%(4 – 20%)
urinary retention + catheterization

17. Rectal Stenosis / stricture
Causes : residual sphincter hypertonia
scar tissue retration
In Korea 0.9% (0 – 3.2%)
Management: Finger & Hega dilatation in OPD
Surgical intervention
Prevention
Post-op. 3-4weeks : distal rectal exam
if, ring-like diaphragm : finger fracture & dilatation
수술 시 staple line이 anal verge에서 항상 4cm 정도 되도록 한다

18. Postoperative Anal incontinence
No complete anal incontinence after S.H
Self-limiting
Causes : Temporary sphincter dysfunction
Dilation with anoscope
Post-operative tissue edema
Reduction in anal sensation
Prevention
Avoidance of over-stretching of internal sphincter

19. Recurrence Two major technical concerns
Misapplication of purse-string suture
(either too higher, too deep, or too superficial)
2. Inadequate control of the amount of rectal mucosa and submucosa to be excised
double or spiral purse-string suture
Higher recurrence of prolapsing hemorrhoids
incomplete mucosal resection in grade Ⅳ
volume of prolapsed tissue exceeds the volume of the stapler casing

20. Chang Gung Med J (2010)

21. * Complication (출혈, 협착으로 수술한 경우)
In my clinic
* Complication (출혈, 협착으로 수술한 경우)