The Use of a Detachable Anvil in Stapled Hemorrhoidectomy

Rebekah Kim, MD, Ferrara Andrea, MD, Itriago Francisco, MD, Renee Mueller, MD, Joseph Gallagher, MD, Paul Williamson, MD, Samuel DeJesus, MD, Robert Stevens, MD, Heidi Bahna, MD, Mark Soliman, MD. Colon and Rectal Clinic of Orlando, Orlando Health

Stapled hemorrhoidopexy was first introduced in the 1990’s as an approach to treat prolapsing internal hemorrhoids. The procedure causes internal hemorrhoids to pull up and retract. It also severs the blood supply to the hemorrhoids which may encourage a reduction of size of the external hemorrhoidal component. In late 2008, Covidien introduced a hemorrhoidal stapler with a detachable anvil. This allows for visualization of the amount of tissue that will be incorporated into the stapler and may have further applications in the future in treatment of anorectal pathophysiology.
The steps of the procedure are outlined.

An anal block is performed for maximal relaxation of the anal canal.

The anal canal is dilated with the anoscope. 

A purse string suture is placed approximately 2-3 cm above the hemorrhoidal plexus. Only superficial mucosal bites are taken, and careful attention is made for a continuous suture line with no gaps between the mucosal bites.

A finger is inserted into the anal canal to feel for an uninterrupted suture line.

The pursestring suture is attached to the center rod and tied down.

The stapler is mated to the detachable anvil.

Stapler is closed and then fired.

The staple line is inspected and bleeding spots are oversewn with figure of eight sutures.

The tissue specimen is inspected for an intact circular hemorrhoidal plexus.

Conclusion:
The detachable anvil allows for inspection of the tissue captured by the pursestring suture before firing stapler. This innovative technology allows for precise capture of tissue and may have further implications in transanal or transoral removal of tissue.