2 If the stapler head is larger, a correspondingly larger portion of the wall is included, and this would result in perirectal tissues being within the firing stapling position. This involves a purse string that invaginates the wall of the anorectum into the shaft of the stapler. The crucial step in the MIPH is the stapler excision of the anal columns above the dentate line, resulting in repositioning of the hemorrhoids into a more proximal site. Thereafter, the patient had a smooth postoperative course, with no further complications. Immediate embolization was completed, with sealing of the contrast leak immediately demonstrated ( Figs. To this end, an angiogram of the internal iliac artery was obtained, which showed a pseudo aneurysm of the left superior haemorrhoidal artery, with active leak of contrast, signifying an ongoing bleed, known as the light bulb sign ( Fig. He was readmitted barely 12 h later, with a massive rebleed, and was hypotensive.Īfter aggressive resuscitation with intravenous fluids, packed cells, and fresh frozen plasma, a decision was taken to study the vascular anatomy locally in a more detailed manner. For the next 48 h he was stable, and consequently discharged. Deep sutures of 2/0 vicryl were again deployed. The staple line bleed was at the same spot, in the 3-o’clock position. After 48 h, he had one more bout of bright red blood issuing from the anus, and once more had transfusions and exploration. This was oversewn, along with the stapler line, using 2/0 polyglactin sutures (vicryl). Conservative management was adopted, but on the third post operative day, there was a massive bleed, and a drop of hemoglobin of 3 g, necessitating transfusion of three units of packed red cells, and an exploration of the staple line, which was found to have a brisk arterial spurter. On the second post-operative day, along with the stools, there was a large bleed per rectum. The procedure was straightforward, with a purse string up to the internal sphincter, but excluding it and the final staple line was 3 cm above the dentate line. Made in China, the gun looked identical to the standard guns from Ethicon, and functioned identically ex vivo. He underwent the procedure using a newer version of the MIPH gun, available in the Indian market. Case reportĪ 27-year old had MIPH for Grade 3 hemorrhoids, in a circumferential presentation. Emergency angioembolisation was therapeutic. This case report is one of a 27-year old male who underwent the MIPH and had severe postoperative bleeding, found to be pseudo aneurysmal in origin. ![]() This supradentate hemorrhoidopexy is of proven immediate postoperative benefit in the treatment of grade 4 hemorrhoids, 1 doughnut pattern of hemorrhoids, etc. The principle of this operation is to remove a doughnut of haemorrhoidal tissue from an area above the dentate line, and reposit the anal columns in such a way that the staple line is above the dentate line. The minimally invasive procedure for hemorrhoids or MIPH has made significant strides in the field of proctology. Este relato de caso documenta uma complicação rara e potencialmente fatal de um procedimento simples. O grampeador específico usado tinha um diâmetro 2 mm maior do que os grampeadores regulares da Medtronic e da Ethicon e possivelmente captou uma área maior da parede retal e a artéria hemorroidária superior. As dimensões do grampeador foram estudadas e descobriu-se a possível causa do evento. O exame revelou um pseudoaneurisma da artéria hemorroidária superior esquerda, que foi embolizada, interrompendo o sangramento. Um angiograma foi realizado quando a hemorragia foi considerada intensa. Este relato de caso descreve o desfecho de uma hemorragia após PMIH, refratária a duas tentativas locais de sobressutura. O diâmetro do tecido grampeado é crítico nessa operação um aumento nesse diâmetro poderia colocar mais tecido na bigorna do grampeador, com resultados desastrosos. O procedimento minimamente invasivo para as hemorroidas (PMIH) é uma das novas operações mais comuns para ao tratamento de hemorroidas prolapsadas.
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