Curriculum Vitae

Dr. dr. Reno Rudiman, MSc., SpB-KBD, FCSI, FICS

1989 : Medical Doctor, Padjadjaran University
1993 : Master of Science in Research Methodology, University of Aberdeen UK
1998 : General Surgeon, Padjadjaran University
2000 : Digestive Surgeon, Padjadjaran University
2012 : Doctorale, Padjadjaran Univesrity

1991-now Staff of the Department of Surgery, Medical School Padjadjaran University

Endolaparoscopic Surgeons of Asia (ELSA) Member
Asean Society of Colorectal Surgeons (ASCS) Member
International College of Surgeons (ICS) Member
Puluhan publikasi di jurnal internasional (BMJ, Asian J Surg, Journal of nutrition and
metabolism, International Surgery, dll) dan jurnal dalam negeri

SIMPOSIUM 6 : PENCEGAHAN DAN PENATALAKSANAAN

KOMPLIKASI PADA OPERASI HEMOROID
SABTU 10 DESEMBER 2016 : 10.50 11.10
Reno Rudiman

COMPLICATIONS AND
ITS MANAGEMENT
IN HEMORRHOID SURGERY

Hasan Sadikin General Hospital, Bandung, Indonesia

History of PPH
Stapled transanal mucosectomy
Longo: treatment for hemorrhoids
PPH Procedure for Prolapsed Hemorrhoid
Low postoperative pain
Early return to work

1. Pescatori M, et al. Tech Coloproctol 1997:1;9698

2. Longo A. In: Proceedings of the Sixth World Congress of Endoscopic
Surgery. Monduzzi Editori, Rome, 1998: pp 777784
PPH
PPH
Complications following PPH
Complication rate is 20-36.4%
One report (ODS): 12,7% readmission
due to bleeding, pain and urinary
retention
Recurrence is high on 4th degree
hemorrhoidectomy
Equal to manual hemorrhoidectomy:
bleeding, strictures, fissures

Pescatori M, Gagliardi G. Tech Coloproctol 2008: 12:7; 7-19

Complications
Urinary retention
Bleeding (most common)
Urgency, fecal incontinence
Tenesmus
Pains (at the staple line)
Stricture
Perforation, Sepsis
Obstruction
Persistent, recurrent hemorhoids
Fissures, fistulas, thrombosis
PPH vs Morgan Milligan
Meta-analysis 16 RCT 1411 pts
PPH has
Shorter operating time
Shorter hospital stay
Shorter time to recover normal activity
Less postoperative pain
Higher ratio of wound healing in 2 weeks
Lower ratio of anal incontinence
Higher recurrence disease after 1 year

He P, Chen H. Zhounghua Wei Chang Wai Ke Za Zhi 2015; 18(12): 1224-30.

Long term Outcomes of PPH vs
Conventional Hemorrhoidectomy

Meta-analysis 15 articles, 1201 pts

Conv % PPH % p
Tenesmus 0 13.8 0.01
FI 2.6 1.1 NS
Anal Stenosis 3.0 1.9 NS
Pain at defecation 5.4 2.1 NS
Fecal urgency 5.6 8.1 NS
Skin tags 9.8 12.7 NS
Pruritus ani 12.4 11.7 NS
Anal fissure 2.3 2.8 NS
Anal fistula 1.8 0 NS

Giordano P, et al. Arch Surg 2009; 144(3): 266-72.

Rectal Bleeding
Rectal bleeding after PPH: 1-11%
Rectal bleeding after PPH required
readmission in 2 weeks: 5.6% (3000
cases in Singapore)
Only 1.8% required re-treatment
Most only required endoanal adrenaline inj
Bleeding mostly on 4th degree
hemorrhoid, anorectal varices,
thrombosed hemorrhoid
Pescatori M, Gagliardi G. Tech Coloproctol 2008: 12:7; 7-19
Rectal Bleeding
To minimize the risk of bleeding
Manual overstitching of the staple line
Use of PPH03 (smaller staple closure, more
hemostatic)
Tightening the gun to the absolute limit
Use of postoperative endoanal sponge

The bleeding rate decreased from 12.9% to

4.4% with increasing experience of surgeon
in performing PPH
Jongen JL, et al. Int J Colorectal Dis 2006;21:166171
Acute Pain
Early postoperative pain is lower after
PPH than conventional surgery
Pain may be induced by a low
anastomosis the level of the sensitive
epithelieum
Purse string is carried out too close to
the dentate line

Correa-Rovelo JM, et al. Dis Colon Rectum 2003;46:955962

Chronic Pain
Severe chronic proctalgia after PPH is
rarely reported.
Related to smooth muscle incorporation
in the doughnut.
Also related to persistent hemorrhoidal
disease, sphincter spasm, rectal spasm
or high anal resting pressures, suture
dehiscence, anal fissure, anorectal
sepsis, or retained staples.
Pescatori M, Gagliardi G. Tech Coloproctol 2008: 12:7; 7-19
Chronic Pain
Treatment
Agrapphectomy: excision of the staple
line and manual refashioning of the
anastomosis.
Conservative approach: transanal
electrostimulation, transanal injection of
steroids and local anesthetics

Wunderlich M, et al. J Urol Urogynakol 2004;11:3133

Mauillon J, et al. Dis Colon Rectum 1999; 42:186192

Rectovaginal Fistula
Rare after PPH (0.2%)
Due to local ischemia
Become evident days after operation
How to prevent
Careful vagina inspection during procedure
Inject saline at anterior rectum, below
mucosa increase distance between vagina
and rectum

Pescatori M. Dis Colon Rectum 2003;46:131 (letter)

Complete Rectal Obliteration
Very rare condition
May be to erroneous placement of a
purse string or firing the stapler outside
the purse string in a blind pocket
How to prevent:
Careful deep digital exploration of the rectum
after the procedure
May need subsequent dilatation or transanal
release of the strictured area
Cipriani S, Pescatori M. Colorectal Dis 2002;4:367370
Rectal Pocket
Partial slippage of the purse string may
cause pathological pocket in rectum,
resembling diverticle
Lead to intermittent fecalith collection,
local sepsis mimicking perirectal abcess
Treatment: lay-open of the pocket

Pescatori M, et al. Colorectal Dis 2006; 8:808811

Rectal dysplasia or Adeno Ca
Rare but possible event
May be due to misdiagnosis
May be prevented with a careful
selection of the patients
Send the specimen for histology

Watson AJM, et al. Colorectal Dis 2003; 5:270272

Tenesmus & Fecal Urgency
Tenesmus: 50% of 4th degree PPH operations
Rate dropped to 25% after 6 months
Fecal urgency in 14% after 87 months
Reduced rectal capacity
Treatment:
transanal electrostimulation
sensory biofeedback
transanal agrapphectomy

De Nardi P, et al. Dis Colon Rectum 2007;50:789 (abstract)

Fecal Incontinence
Incidence 3.2% after PPH 4th degree
Soiling up to 10% after 1 year,
decreased to 7% after 7 years
Fecal soiling after PPH, caused by:
Low placed staple line
Fragmentation of internal sphincter
due to large stapler diameter
However may happen in open op too

Johannsson HO, et al. Br J Surg 2006; 93: 1208-1214

Fecal Incontinence
Prevention:
Preop anal manometry

Therapy
Injection of silicone, micro-beads or
autologous fat
Sphincter repair is rarely needed

- Benardi C, et al. Plast Reconst Surg 1998; 102:1626-1628

- Chan MK, et al. Dis Col Rectum 2006; 49: 433-439
HAL-RAR
Doppler-guided haemorrhoidal artery ligation
(DG-HAL) was first described in 1995 by
Morinaga et al.

Recto-anal repair (RAR), a technique developed

by Scheyer

- Morinaga K, et al. Am J Gastroenterol. 1995;90:6103

- Scheyer M, et al. Am J Surg. 2006;191:8993
HAL-RAR
HAL-RAR
HAL-RAR complications
Post-operative complications were seen in 14
patients (8 %) out of 184 patients
2 patients (1 %) suffered from bleeding
which required operative revision
11 patients (7 %) had perianal thromboses
1 patient (1 %) was diagnosed with
unspecified proctitis.

Roka, S. et al. European Surgery 2013; 45(1): 2630.

Summary
Complications from hemorrhoid surgery
may happened up to 36%

Mostly minor, only some requires

revisional surgery

Knowledge of anatomy and mastery of

technique are the most important factors
to prevent unwanted complications