European Journal of Cardiovascular Medicine

Haemorrhoids are one of the most common anorectal conditions worldwide, particularly among adults over 45 years of age. In advanced cases—Grades III and IV—patients often present with bleeding, prolapse, and discomfort, necessitating surgical intervention. While conventional haemorrhoidectomy techniques such as the Milligan-Morgan procedure have long been the standard, the introduction of stapled hemorrhoidopexy by Longo in 1998 significantly altered surgical management strategies for prolapsing haemorrhoids [1].

Stapled hemorrhoidopexy, also known as the Procedure for Prolapse and Haemorrhoids (PPH), involves resection of a circumferential strip of rectal mucosa and submucosa above the dentate line. This reduces the vascular supply to hemorrhoidal cushions while simultaneously repositioning the prolapsing tissue [2]. Compared to traditional excisional methods, the stapled approach has been associated with reduced postoperative pain, shorter hospital stay, and faster return to normal activity [3,4].

Despite these advantages, multiple studies have reported varying recurrence rates following stapled hemorrhoidopexy, particularly in higher-grade haemorrhoids [5,6]. These failures are often linked to technical limitations such as incomplete tissue capture or shallow mucosal resection, resulting in residual or recurrent prolapse [7,8]. As a result, increasing attention has been paid to the adequacy and symmetry of mucosal resection.

An insufficient mucosectomy, especially at key anatomical positions, may leave behind redundant mucosa that fails to retract adequately, contributing to persistent prolapse or early recurrence. Although some authors have advocated for deeper or more circumferential resection to mitigate this risk, there is currently no consensus on the optimal mucosectomy length [9,10].

This study was conducted to evaluate the circumferential rectal mucosectomy length at three specific anatomical positions—3 o’clock, 7 o’clock, and 11 o’clock—in patients undergoing stapled hemorrhoidopexy for Grade III and IV haemorrhoids. The primary aim was to assess the correlation between mucosectomy length and recurrence, with the goal of identifying technical factors predictive of clinical failure.

Study Design and Setting

This prospective observational study was conducted in the Department of Surgery at Gandhi Medical College & Hamidia Hospital, Bhopal, over a period of one year from May 2014 to April 2015. The study was approved by the institutional ethics committee, and written informed consent was obtained from all participants.

Patient Selection

A total of 28 patients diagnosed with Grade III or Grade IV internal haemorrhoids, based on clinical and proctoscopic evaluation, were included. All patients were planned for stapled hemorrhoidopexy. Exclusion criteria included patients with external haemorrhoids alone, prior anorectal surgery, inflammatory bowel disease, bleeding disorders, or those who declined participation.

Surgical Procedure

All patients underwent stapled hemorrhoidopexy using a circular stapling device under regional or general anaesthesia. After appropriate positioning and dilation, a circumferential purse-string suture was placed approximately 2–3 cm above the dentate line. The stapling gun was then introduced and fired to resect a circumferential strip of rectal mucosa and submucosa. Haemostasis was confirmed, and no anal canal packing was routinely used.

Mucosectomy Length Measurement

Following resection, the excised mucosal ring was immediately examined. The length of mucosectomy was measured in the relaxed state at three standard positions on the excised specimen: 3 o’clock, 7 o’clock, and 11 o’clock. These positions were selected based on conventional anatomical reference points used in proctologic surgery.

Follow-up and Outcome Assessment

Patients were monitored postoperatively during hospital stay and followed up at 3, 6, and 12 months. At each visit, the presence of symptoms such as pain, bleeding, and prolapse was recorded. Recurrence was defined as the reappearance of prolapse or bleeding requiring medical or surgical management during follow-up.

Statistical Analysis

Data were compiled using Microsoft Excel and analyzed with SPSS software (version 20). Descriptive statistics (mean, standard deviation, percentages) were used for baseline variables. Mann–Whitney U test was used to compare mucosectomy length between patients with and without recurrence. The association between inadequate mucosectomy and recurrence was tested using the chi-square test. A p-value less than 0.05 was considered statistically significant.

1. Patient Profile and Baseline Characteristics

A total of 28 patients diagnosed with Grade III or Grade IV internal haemorrhoids were enrolled and underwent stapled hemorrhoidopexy. The majority of patients had Grade III haemorrhoids (64.3%), while the remaining 35.7% presented with Grade IV disease. Although demographic variables such as age and sex were not explicitly documented, the cohort was representative of typical patients undergoing operative treatment for prolapsing haemorrhoids in a tertiary care setting.

The distribution of haemorrhoid grades is summarized in Table 1.

Table 1. Baseline Characteristics of the Study Population (N = 28)

2. Postoperative Symptom Resolution over Time

Stapled hemorrhoidopexy resulted in progressive resolution of hemorrhoidal symptoms across the follow-up period. At the time of admission, 46.5% of patients reported pain, 67.8% reported bleeding, and all patients (100%) had prolapsed. Immediately following surgery, pain was present in 28.5% of patients, while bleeding and prolapse persisted in 32.2% and 25%, respectively.

At the 3-month follow-up, pain persisted in only 10.7% of patients and bleeding had resolved completely. Prolapse remained unchanged at 25% during this period. By 6 and 12 months, no patients reported pain or bleeding; however, prolapse continued in 21.4% of the cohort, suggesting partial persistence or recurrence in a subset despite symptomatic relief. The progression of symptom resolution is detailed in Table 2.

Table 2. Postoperative Symptom Resolution Over Time (N = 28)

3. Mucosectomy Length by Position

The mean circumferential mucosectomy length was measured in the relaxed state at three anatomical positions: 3 o’clock, 7 o’clock, and 11 o’clock. The shortest mucosectomy length was observed at 3 o’clock (mean: 2.76 ± 0.59 cm), while the longest was at 11 o’clock (3.34 ± 0.29 cm). The 7 o’clock position showed an intermediate mean length of 3.30 ± 0.32 cm. This mild asymmetry suggests variability in tissue capture during stapled hemorrhoidopexy.

A summary of mucosectomy lengths is shown in Table 3 and illustrated in Figure 2.

Table 3. Mean Mucosectomy Length by Clock Position (N = 28)

4. Association between Mucosectomy Length and Recurrence

To explore whether mucosectomy length influenced recurrence after stapled hemorrhoidopexy, a Mann–Whitney U test was performed comparing the mean rank of mucosectomy lengths at three anatomical positions between patients who developed recurrence and those who did not.

At the 3 o’clock position, patients without recurrence had a higher mean rank mucosectomy length (15.5) compared to those with recurrence (10.8); however, this difference was not statistically significant (p = 0.23). At the 7 o’clock and 11 o’clock positions, the differences were even smaller and also non-significant (p = 0.71 and p = 0.95, respectively). These results suggest that while shorter resections may be more frequent in cases of recurrence, mucosectomy length alone did not consistently predict recurrence when assessed as a continuous variable.

Table 4. Mann–Whitney U Test Comparing Mucosectomy Lengths in Recurrence vs Non-Recurrence

5. Inadequate Mucosectomy and Recurrence

To further explore the relationship between mucosectomy adequacy and recurrence, mucosectomy lengths were categorized as “adequate” or “inadequate” based on a predefined threshold (as specified in the operative protocol). A chi-square test was used to determine whether inadequate resection at each clock position was associated with a higher recurrence rate.

At the 3 o’clock position, a statistically significant association was observed: 83.3% of patients with inadequate mucosectomy at this site experienced recurrence (p = 0.04). This finding supports the hypothesis that insufficient resection at certain anatomical points—particularly anteriorly at 3 o’clock—may contribute to surgical failure.

At the 7 o’clock and 11 o’clock positions, no significant association was found between mucosectomy adequacy and recurrence, suggesting that tissue capture at these positions may be less critical to long-term prolapse control.

Table 5. Inadequate Mucosectomy and Recurrence by Position (Chi-square Analysis)

This prospective study evaluated the relationship between circumferential rectal mucosectomy length and recurrence following stapled hemorrhoidopexy in patients with Grade III and IV hemorrhoids. While the stapled approach offered substantial relief from symptoms such as pain and bleeding, persistent prolapse in over 20% of patients at one year highlights a clinically relevant recurrence rate.

The resolution of pain and bleeding in nearly all patients by 3 to 6 months aligns with previous findings that stapled hemorrhoidopexy is associated with reduced postoperative discomfort and faster recovery compared to conventional excisional hemorrhoidectomy [11,12]. However, the persistence of prolapse in 21.4% of patients at one year mirrors concerns raised in several prior studies regarding the durability of symptom control with this technique [13–15]. The mucosectomy length analysis revealed that resections were generally shortest at the 3 o’clock position. Although no statistically significant difference in mucosectomy length between recurrence and non-recurrence groups was found using continuous data (via Mann–Whitney U test), the categorical chi-square analysis provided stronger insight. A significant association between inadequate mucosectomy at 3 o’clock and recurrence (p = 0.04) suggests that insufficient tissue resection at anterior locations may predispose to treatment failure. Similar concerns have been raised by Ho et al. and Dodi et al., who reported that incomplete or asymmetrical tissue capture can lead to recurrence or persistent prolapse [16,17].

The findings reinforce the importance of achieving symmetrical, adequate mucosectomy. Renzi et al. and Gallo et al. emphasized that tissue bridges, especially anteriorly, are common sites of incomplete resection and should be addressed surgically to avoid relapse [18,19]. Our results support this anatomical vulnerability and highlight the need for careful purse-string placement and intraoperative assessment of tissue capture. Interestingly, mucosectomy length at 7 o’clock and 11 o’clock did not correlate significantly with recurrence. This suggests that while circumferential resection is essential, the anterior position (3 o’clock) may be disproportionately important in maintaining rectal support and preventing prolapse, likely due to the biomechanics of rectal wall redundancy and pressure vectors during defecation.

This study's strengths include its prospective design, standardized measurement of mucosectomy lengths, and structured follow-up. However, limitations include the small sample size (N = 28), lack of demographic diversity, and absence of long-term functional outcomes such as continence or quality of life scores. Additionally, mucosectomy adequacy was assessed post hoc based on thresholds not validated across studies. Despite these limitations, this study provides practical evidence for the role of anatomical precision in surgical technique and offers a measurable parameter—anterior mucosectomy length—that may serve as a quality control marker during stapled hemorrhoidopexy.

Stapled hemorrhoidopexy was effective in resolving pain and bleeding in most patients with advanced hemorrhoidal disease. However, recurrence of prolapse in over 20% of cases at one year raises concern about the durability of this technique, particularly when mucosectomy is inadequate. This study identifies the 3 o’clock position as a critical site for tissue resection, with inadequate mucosectomy at this point being significantly associated with recurrence. These findings underscore the importance of symmetrical and complete circumferential resection during stapled hemorrhoidopexy, especially anteriorly. Intraoperative assessment of mucosectomy adequacy, particularly at vulnerable positions, may improve long-term outcomes and reduce recurrence. Further studies with larger cohorts and standardized thresholds for mucosectomy adequacy are needed to refine surgical technique and optimize patient outcomes

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