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Invited Critique
December 2002

A Systematic Review of Stapled Hemorrhoidectomy—Invited Critique

Arch Surg. 2002;137(12):1407. doi:10.1001/archsurg.137.12.1407

Dr Sutherland and colleagues have undertaken a difficult task, that of analyzing results of RCTs, evaluating stapled and conventional hemorrhoidectomies. Stapled hemorrhoidectomy seems to be superior with respect to bleeding at 2 weeks and length of hospital stay. There is also a trend toward less postoperative pain and fewer problems with wound healing.

There are several important points that need to be taken into account when comparing stapled with conventional hemorrhoidectomy. Stapled hemorrhoidectomy is not hemorrhoidectomy in the true sense, but rather an excision of redundant rectal mucosa. Stapled hemorrhoidectomy is suitable for those patients who do not have a significant external hemorrhoidal component and those without a significant amount of hemorrhoidal prolapse. This procedure is probably suitable for most patients with grade 1 and 2 hemorrhoids, who are exactly those patients that respond most frequently to conservative treatment using fiber products, topical medication, rubber band ligation, or infrared therapy. Conventional hemorrhoidectomy is typically reserved for those patients with a significant external hemorrhoidal component and for those with large prolapsing internal hemorrhoids. The types of patients who are ideally treated by each procedure, therefore, tend to be different. Conventional hemorrhoidectomy is a rapid and inexpensive procedure that is typically performed using some type of absorbable suture; in the case of open hemorrhoidectomy, the wounds are left open to granulate and heal by secondary intention. Hospital stays associated with this procedure vary greatly. In Europe and in some areas in North America, this is an inpatient procedure with an inpatient hospital stay; however, in much of the United States, this is an outpatient procedure. Data from RCTs performed in different countries can, therefore, not really be compared for length of stay. Stapled hemorrhoidectomy is an outpatient procedure. It does, however, involve the use of a circular stapler at a cost of several hundred dollars. Because there is no external excision, there is, not surprisingly, less pain than with conventional hemorrhoidectomy, and because there is less pain, the rates of urinary retention will be lower.

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