Long-Term Outcomes of Sectorial Longitudinal Augmented Prolapsectomy for Asymmetric Muco-hemorrhoidal Prolapse: An Observational Study of 433 Consecutive Patients

Abstract

Purpose. Hemorrhoidal disease (HD) is a widespread condition severely influencing patients’ quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis. Methods. Patients affected by III–IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium–long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work. Results. We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2. Conclusions. The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.

Keywords

hemorrhoidal disease asymmetric prolapse muco-prolapsectomy hemorrhoidectomy hemorrhoidopexy

Introduction

Hemorrhoidal disease (HD) is a widespread anorectal condition determining a major medical and socioeconomic issue and detriment of patients’ quality of life.^1,2 Stapled hemorrhoidopexy was first described by Longo in 1998 and soon advocated as a valid alternative option to traditional hemorrhoidectomy for III-/IV-degree HD.³ It gained great popularity due to the presumed lower postoperative pain, resulting in shorter recovery and faster return to work than conventional hemorrhoidectomy. However, it has been burdened by a higher recurrence rate and few but serious reported complications when compared to conventional treatment.^4-6 Several hemorrhoidectomy variations were introduced during the last years (eg, ligasure and harmonic hemorrhoidectomy) and different alternative treatments.^7,8 Among them, the most diffused techniques are hemorrhoidal artery ligation and rubber band ligation.⁹

The unitary theory of prolapse proposed by Longo highlighted the attention of the surgical community about the differentiation among HD and the obstructive defecation syndrome (ODS), a primary aspect to indicate the adequate treatment.¹⁰

Therefore, over the past 2 decades, the widespread diffusion of stapled hemorrhoidopexy, performed upon placement of a circular anal dilator (CAD), has revealed a new unexpected pathological entity, named the asymmetric (ie, not circumferential) prolapse. Given the improved comprehension of the anatomy and pathophysiology of HD, the diffused and validated approaches (ie, traditional vs stapled) for a circumferential disease may not be fully suitable in these cases. Therefore, we described and characterized a technique, named sectorial longitudinal augmented prolapsectomy (SLAP), for asymmetric prolapse associated with HD. Probably someone might consider the description of SLAP useless or vain since every colorectal surgeon in his daily practice performs a SLAP, consisting in the resection of the redundant mucosa associated with a hemorrhoidal pile. Rather than introducing a new surgical technique, this study aims to describe and give dignity to the resection of the asymmetric mucosal prolapse, an intervention not assimilable to conventional Milligan-Morgan limited to the anal region, and to evaluate its long-term outcomes, focusing on the hemorrhoidal symptoms recurrence, the hemorrhoidal prolapse recurrence, and the anal and rectal stenosis onset.

Methods

This study is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cohort studies.¹¹ From a database of 1273 patients referred between February 2006 and February 2014 to the 2 referral centers of coloproctology, Division of General, Mini-Invasive and Obesity Surgery University of Campania “Luigi Vanvitelli” and Division of General Surgery of “Agostino Landolfi Hospital” of Solofra, 433 consecutive adult patients affected by III–IV-degree symptomatic HD associated to asymmetric mucosal prolapse were eligible for inclusion in this study, conducted according to the Declaration of Helsinki and approved by the local institutional ethical committee.

Inclusion criteria were HD grade III or IV (prolapsed hemorrhoids requiring manual reduction or non-reducible prolapsed hemorrhoids, respectively) according to Goligher’s classification, intraoperative evidence of asymmetric muco-hemorrhoidal prolapse involving <180° of anal canal circumference, and presence of symptoms for at least 1 month (hemorrhoidal syndrome without obstructed defecation) refractory to conservative measures (passing soft stool, ensuring a correct daily intake of fluids and fibers, and medical therapy).¹²

Exclusion criteria were prior acute thrombosed or strangulated hemorrhoids, concomitant anorectal disease independently from previous surgical treatment (eg, fistula, abscess, fissure, inflammatory bowel disease, polyps, and carcinoma), and active use of immunosuppressants or anticoagulants.

All patients were preoperatively assessed during a comprehensive evaluation including past proctological history, digital rectal examination, continence evaluation (Wexner’s continence score), obstructed defecation score (Agachan–Wexner score), and anoscopy; colonoscopy was performed in patients over 50 years or over 40 years if a familial history of colonic cancer was encountered.^13,14 The severity of hemorrhoidal symptoms was scored using Giordano’s specific questionnaire evaluating the presence of correlated symptoms (bleeding, prolapsed, manual reduction, and discomfort/pain) and their influence on patients’ daily quality of life.¹⁵ Anthropometrics and comorbidities of the patients were also recorded. SLAP was offered upon formal counseling with patients, explaining the potential advantages of this technique compared to other excisional or suspensive techniques. All patients received an enema for bowel preparation the night before surgery.

SLAP

Patients were placed in lithotomic position, and a spinal anesthesia was performed. Evaluation of the degree and geometry of muco-hemorrhoidal prolapse was obtained intraoperatively upon placement of the Eisenhammer retractor. In case of confirmed asymmetric prolapse, involving less than half of the anal circumference, a longitudinal resection of either 1 column (SLAP1) or 2 columns (SLAP2) was performed by radio frequency (LigaSure TM Small Jaw® Covidien®, Colorado, USA) or ultrasound (Focus® Ultracision® harmonic scalpel; Ethicon Endo-Surgery®, Inc., Cincinnati, Ohio). The anodermal wedge was incised, eventually removing external fibrosis and/or skin tags when present. Upward dissection started at this level with en bloc excision of mucosal and submucosal layers from the underlying internal anal sphincter. Anorectal ring was reached and contrarily to the traditional Milligan-Morgan technique, dissection continued proximally along the same plane while paying attention not to damage the longitudinal muscular fibers. This further dissection was carried out until no more redundant mucosa could be grasped downward, usually reaching 2–3 cm upward the anorectal ring [Figure 1(a)]. A re-absorbable running suture was packaged sewing the mucosal defect from the proximal margin of dissection to the anorectal ring, including any eventual mucosal edge and muscular rectal layers in order to increase the fixation of tissues and potentially reduce the risk of new descents [Figure 1(b)]. No further reconstruction was performed along the anal canal, with the intention to reduce any risk of collection and to improve drainage. Therefore, the SLAP technique consists in a Milligan-Morgan when considering the anal canal; the eventual resection of 1 or 2 rectal mucosal columns constitutes SLAP1 or SLAP2.

A compressive hemostatic sponge was left in place for 12-24 hours. A 24-hour elastomeric continuous intravenous analgesic infusion (ketorolac 30 mg/1 mL, tramadol 100 mg/2 mL, and ranitidine 300 mg) with a standardized therapy on demand (ketorolac 20 mg/1 mL, dose range 8–20 drops, max daily dose 60 drops) was indicated.

Management after discharge consisted of dietary modification (eg, stool softeners and fiber supplements with adequate fluid intake), sitz baths after every single defecation, and standard medical therapy. Wounds were treated by warm water wash 2–3 times per day, followed by oxide zinc powder placement. Postoperative pain after postoperative day 1 was controlled with ketorolac as needed. One month postoperatively, patients were invited to daily anal dilation for 4 weeks using a specific graduated mechanical dilator kit (Dilatan^©, Sapi Med spa, Italy). Patients were instructed to sit down on the toilet, bear down, and gradually insert the smallest dilator with ample lubrication.

Outcome Measures

Patient information was obtained during routine follow-up outpatient visits. Each patient was studied at baseline, 3, 6, 12, and 24 months and 5 years after surgery.

Perioperative outcomes were postoperative and defecation pain assessed by visual analog scale (VAS), length of hospitalization, time to return to work or normal activities (number of days), urinary retention, postoperative bleeding, early reoperation rate, and wound healing.¹⁶ Postoperative pain was evaluated longitudinally at 12 hours and 1, 2, 3, and 7 days after the operation. Fecal urgency (defined as the impossibility to defer defecation <2 minutes) and anal fissures were reported as number of cases.

Medium- and long-term postoperative outcome measures included the occurrence of anal stenosis, fecal incontinence, and recurrence of hemorrhoidal symptoms or prolapse.

Anal stenosis was classified according to its severity as mild (tight anal canal assessable by a well-lubricated index finger), moderate (requiring forceful dilatation to insert index finger), and severe (if a pinkie could not be inserted unless a forceful pressure).¹⁷ Moreover, for the presence of rectal scares (1 or 2 in SLAP1 and SLAP2, respectively), the occurrence of rectal stenosis was investigated.

Incontinence was defined as the experience of loss of flatus and/or stool, soiling, and/or difficulty with hygiene (>3 cleaning/day) and was defined as minor incontinence (loss of flatus or soiling) and major incontinence (loss of feces).¹⁶

Patients were considered to have recurrent hemorrhoidal symptoms when any of the following were recorded: bleeding, itching, pain, or discomfort affecting patient’s perception of quality of life, which could either be associated or not to prolapse recurrence. Postoperatively, Giordano’s specific score for severity of hemorrhoidal symptoms was reevaluated.

Statistics

Quantitative data were presented as mean and standard deviations (SD) or as median and interquartile range (25th–75th percentiles). Qualitative data are presented as absolute numbers and percentages. Differences between groups were evaluated using a parametric or nonparametric test as appropriate. Quantitative variables were analyzed using Student’s t test or the Mann–Whitney U test. Qualitative variables were analyzed using the chi-square test. The statistical analysis was performed using SPSS software (IBM SPSS-23®), and significance was set at a P-value of .05.

Results

Four-hundred and thirty-three patients (258 [60%] women) were enrolled in the current study. All patients had symptomatic grade III–IV HD with intraoperative evidence of an asymmetric muco-hemorrhoidal prolapse. Mean age was 48.2 ± 12.6 years (range, 21–68 years). Patients’ demographic and clinical characteristics and preoperative scoring system are detailed in Table 1. SLAP1 was performed in 156 (36%) cases and SLAP2 in 277 (64%). Mean total operative time was 25 ± 15 minutes for SLAP1 and 40 ± 12 minutes for SLAP2. No major intraoperative complications occurred. Median follow-up was 72 months (range 60–89 months). During hospitalization, the number of participants with acute urinary retention was 51 (12%) and 20 (13%) after SLAP1 and SLAP2, respectively. All were successfully treated with a temporary urinary catheter placed on the first postoperative night. Mean length of stay was 1.2 (range 1–2) days for the SLAP1 group and 1.5 (range 1–2) days for the SLAP2 group. Mean postoperative pain in patients undergone SLAP1 was 7.2 (range 5–9) in the early postoperative time (12 hours), and 6.5 (5–8), 5.8 (4–7), 5 (4–7), and 3.8 (3–5) at postoperative day 1, 2, 3, and 7, respectively. As for patients treated with SLAP2, considering the same postoperative times, mean postoperative pain was 7.9 (range 5–9), 6.7 (5–8), 6.1 (4–7), 5.3 (4–7), and 4.1 (3–5). An emergency reintervention for postoperative bleeding was deemed necessary in 13 (3%) cases of patients undergone SLAP1: 2 (.5%) of these within 24 hours from surgery and 11 (2.5%) between postoperative days 14th and 22nd, respectively. Postoperative bleeding causing an emergency reintervention affected 5 of the patients treated with SLAP2 (3%). A single attempt with surgical suture reinforcement was sufficient to treat all acute bleedings. The median time to return to work was 7 days in both SLAP variants; in heavy manual working participants, a cautious recovery was indicated with the aim of avoiding an excessive and acute increase of intra-abdominal pressure (range 6–9 days). Postoperative wound healing resolved in all patients in 60 days (median 28 days, range 21-60). Ten (3.7%) patients and 7 patients (4.5%), respectively, of SLAP1 and SLAP2 experienced fecal urgency, which spontaneously healed within 3 weeks. Among patients undergone SLAP1, an anal fissure was observed in 6 (2.3%) patients, all treated and successfully healed with nifedipine, except 1 (.2%) undergoing lateral internal sphincterotomy. For patients treated with SLAP2, such percentage increased to 3%; all 5 of them were treated conservatively [Table 2].

Table 1.

Patient demographics and clinical characteristics.

Patient Demographics (n = 433)
Male	175
Female	258
Mean age	48.2 ± 12.6 years*
BMI	26.4 (20.3–38)
Hemorrhoidal disease
Degree III sec Goligher	295
Degree IV sec Goligher	138
Preoperative symptoms
Hitching	267
Bleeding	374
Discomfort	401
Pain	230
Preoperative hemorrhoid symptom scoring system¹⁵	13.9 (9–20)
WS mean value	6.2* (4)°
AW mean value	11.3* (4)°

Abbreviations: SLAP1 = sectorial longitudinal augmented prolapsectomy of 1 hemorrhoidal column; SLAP2 = sectorial longitudinal augmented prolapsectomy of 2 hemorrhoidal columns. Values are expressed as number of cases, mean (*), or median (°).

Table 2.

Perioperative surgical outcomes after SLAP1 and SLAP2.

	SLAP1 (n = 277)	SLAP2 (n = 156)	P value
Perioperative outcome
Mean operative time	25 ± 15 minutes*	35 ± 12 minutes*	<.05
Urinary retention	33 (12%)	20 (13%)	NS
Mean hospitalization	1.2 (range 1–2) days*	1.5 (range 1–2) days*	NS
Mean postoperative pain (visual analog scale)	7.2 (range 5–8) at 12 hours *	7.9 (range 5–9) at 12 hours *	NS
	6.5 (range 5–8) at day 1*	6.7 (range 5–8) at day 1*	NS
	5.8 (range 4–7) at day 2*	6.1 (range 4–7) at day 2*	NS
	5 (range 4–7) at day 3*	5.3 (range 4–7) at day 3*	NS
	3.8 (range 3–5) at day 7*	4.1 (range 3–5) at day 7*	NS
Emergency reintervention	5 (2%)	5 (3%)	NS
Median time to return to work	7 (range 6–9) days°	7 (range 6–9) days°	NS
Fecal urgency	10 (3.7%)	7 (4.5%)	NS
Anal fissure	6 (2.3%)	5 (3%)	NS
Fecal incontinence	8 (3%)	4 (2.7%)	NS

Abbreviations: WS = Wexner’s Score for fecal incontinence; AW = Agachan–Wexner score for obstructed defecation syndrome. Values are expressed as the number of cases or mean (*). Interquartile range (°).

Within 8 months (median 6, range 4–8), 3 (1%) patients of the SLAP1 group developed anal stenosis, 2 of which classified as mild and 1 as moderate. In patients of the SLAP2 group, anal stenosis occurred in 3 patients (1.9%). All these patients were treated by exploration under anesthesia (EUA) with Egar probe. Fecal incontinence occurred in 8 (3%) cases and 4 (2.7%) cases of patients treated with SLAP1 and SLAP2. All patients were resolved by pelviperineal rehabilitation treatment.^18,19

No case of rectal stenosis occurred neither in SLAP1 nor SLAP2. Hemorrhoidal symptoms recurrence was reported in 9 (3.2%) patients of the SLAP1 group and in 4 (2.5%) patients undergone SLAP2 (overall rate on 433 patients of 3%) [Table 3], while prolapse recurrence occurred, respectively, in 4 (1.4%) and 2 (1.2%) patients (overall rate 1.4% in the entire cohort). Postoperative hemorrhoid symptoms scoring system become 1.2 (range 0–3) in the SLAP1 group and .9 (range 0–3) in the SLAP2 group. Giordano’s specific score for severity of hemorrhoidal symptoms was 1.2 (range 0–3) in SLAP1 patients and .9 (range 0–3) in SLAP2 patients [Table 3].

Table 3.

Medium–long-term surgical outcomes after SLAP1 and SLAP2.

Medium–Long-Term Postoperative Outcomes (Mean follow-up = 72 months*)	SLAP1 (n = 277)	SLAP2 (n = 156)	P value
Anal stenosis	3 (1%)	3 (1.9%)	NS
Rectal stenosis	0	0	NS
Hemorrhoidal symptoms recurrence	9 (3.2%)	4 (2.5%)	NS
Hemorrhoidal prolapse recurrence	4 (1.4%)	2 (1.2%)	NS
Postoperative hemorrhoid symptom scoring system¹⁵	1.2 (range 0–3)	.9 (range 0–3)	NS

There were no statistical differences among intraoperative, perioperative, and medium- and long-term postoperative outcomes in patients undergone SLAP1 or SLAP2 besides for the mean operative time (25 ± 15 minutes vs 35 ± 12 minutes).

Discussion

According to Thomson’s hypothesis, the etiology of HD is attributable to the sliding down effect of the whole anal canal mucosa or portions of it.²⁰ Therefore, in case of mucosal prolapse, an outward displacement of the mucosa of either the anal canal or rectum can be detected. This innovative concept was resumed and put into surgical practice by Longo, who considered the mucosal prolapse as the physiopathologic expression of HD, suggesting its reduction as the main surgical goal to resolve symptoms. Hence, a new technique, known as hemorrhoidopexy, was proposed and popularized as an alternative treatment to conventional hemorrhoidectomy.^10,21 The latter led to the study and theorization of the unitary theory of rectal prolapse, considered the cornerstone of the modern coloproctology and highlighted the attention of the surgical community about differentiation among HD and ODS.¹⁰

Differentiating between patients affected by HD, usually complaining of pain, bleeding, hitching and hemorrhoidal prolapse and those with symptoms related to ODS (eg, straining, digitation, and incomplete and fragmented evacuation) is in fact of paramount importance.²² Although the abovementioned conditions may coexist in the same subject, a complete and meticulous preoperative evaluation drives the surgeon in the choice of preferring either the “simple” treatment of hemorrhoidal tissue in isolated HD vs rectal resection/suspension in case of ODS.^23-25 Moreover, this dichotomy could alter surgical outcomes, especially the recurrence. In fact, a patient affected by HD, who also complains of severe straining, may not find symptom resolution after a mere hemorrhoidal resection that would also be burdened by a high risk of recurrence.

It is worth to comment that in case of HD either excisional (eg, Milligan-Morgan, Whitehead, and Ferguson) or suspensive techniques (stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization (THD)) have been proven as effective.^26,27 In particular, the intraoperative positioning of the CAD during stapled hemorrhoidopexy has determined the emersion of an underestimated and unrecognized pathological entity, known as the asymmetric prolapse. Technically, in fact, during anesthesia, a surgeon may face an asymmetric rather than circumferential prolapse (eg, involving only 1 or 2 hemorrhoidal piles with the rectal mucosa above), challenging the use of a conventional circular stapler. It is noteworthy that the contemporary presence of 3 hemorrhoidal prolapsed nodes assumes the shape of a complete circumferential prolapse; the latter was not the object of the current study.

Despite it is more easily recognizable during stapled hemorrhoidopexy, the asymmetric prolapse can be found even in course of a conventional hemorrhoidectomy. In detail, once the dissection of the hemorrhoidal pedicle until the anorectal ring is completed, the presence of asymmetric redundant mucosa, potentially representing a risk factor for recurrence, can be revealed.

The mainly accepted pathophysiological mechanism should be found in the irregular and asymmetric mucosal fragmentation of the suspensory ligament of Parks, determining the drop of sectorial areas of mucosa and leading to an asymmetric and not circumferential prolapse.²⁸

In our large clinical series, SLAP allowed the en bloc resection of hemorrhoids and the whole mucosal prolapse with the eventual perianal fibrosis. Asymmetric prolapse involving 2 hemorrhoidal columns was more prevalent than that involving 1 column (64% vs 36%). The long follow-up time (72 months) allowed to not underestimate the rate of possible long-term complications or recurrence. Indeed, we reported a hemorrhoidal symptoms recurrence in only 13 patients (9 in SLAP1 and 4 in SLAP2), while hemorrhoidal prolapse recurrence occurred in 6 patients (4 in SLAP1 and 2 in SLAP2). Probably, the low recurrence in our study, particularly considering the overall rate of 3% and 1.4% of hemorrhoidal symptoms recurrence and hemorrhoidal prolapse recurrence, respectively, is mainly due to the complete resection of the prolapse and to the fixing of the rectal mucosa to the circular muscular layer below. In one of the largest series on conventional hemorrhoidectomy by Chen et al²⁹ on 666 patients, the hemorrhoidal prolapse recurrence was estimated to be 3.1%, a double rate compared to our series. The recurrence rate is even considerably higher in many other series.^29-31 Despite the larger rectal mucosal resection, we did not experience any case of rectal stenosis (0%), but we reported 6 cases (3 in SLAP1 and 3 in SLAP2) of anal stenosis, similar to that reported in literature after conventional hemorrhoidectomy. Regarding the perioperative outcomes, the sectorial prolapsectomy performed by radio frequency or ultrasound guaranteed a low postoperative bleeding risk in line with that observed in other experiences.^32,33 The advanced hemostasis devices, in fact, allow sealing of blood vessels up to 7 mm diameter with minimal collateral damage to the surrounding tissues and tissue charring as the thermal spread is confined within 2 mm of the adjacent tissues.^29-32 These particular properties are both capable of reducing the anal spasm and permitting a bloodless hemorrhoidectomy. We would emphasize that the postoperative anatomical condition after the SLAP technique is identical to Milligan-Morgan resection in the anal region; it only differs for the longitudinal mucosa resection in the rectal region. For this reason, the resection in the above area of the rectum distinguished a different technique that is not possible to identify as a conventional Milligan-Morgan.

In our experience with sectorial resection, we did not register any intraoperative complications. The operative time, postoperative bleeding, time to return to work, and postoperative wound healing after SLAP (1 and 2) resulted within the literature benchmark cutoffs in patients undergoing conventional hemorrhoidectomy.^30-35 An emergency reoperation for postoperative bleeding was necessary in only 10 cases (5 in SLAP1 and 5 in SLAP2). We found an overall rate of 3.9% of fecal urgency (8 in SLAP1 and 4 in SLAP2). Despite it is strongly associated with hemorrhoidopexy, several articles reported cases of fecal urgency after Milligan-Morgan hemorrhoidectomy.³⁶ The pathophysiologic mechanism is still unclear and debated, but it is probably the result of postoperative anatomic remodeling of the anal canal and the postsurgical rectal irritability; it generally improves within 12 months.^36,37 We found no statistical differences among perioperative and medium-term postoperative outcomes when comparing the 2 groups of patients treated, respectively, with SLAP1 or SLAP2. We chose to divide patients in the 2 groups, SLAP1 and SLAP2, rather to evaluate the possible onset of rectal stenosis after a more extensive surgery than to investigate the efficacy of the technique that it was expected to be similar. In our series, even with a multiple rectal resection as in SLAP2, we did not experience cases of rectal stenosis.

We would highlight that for an experienced colorectal surgeon, the description of SLAP may seem unnecessary and vain. In fact, during a hemorrhoidectomy, all surgeons are able to resect the redundant mucosa associated to a hemorrhoidal pile and probably perform a SLAP every day. Therefore, our efforts were not addressed to introduce a new surgical treatment for the HD, but they were spent in the attempt of describing and giving dignity to the resection of the asymmetric mucosal prolapse, an intervention not assimilable to conventional hemorrhoidectomy limited to the anal region. We recognized and detailed this surgical act and we named it as SLAP.

The current study has several limitations to address, mainly its retrospective design and the absence of a control group of patients undergoing conventional Milligan-Morgan hemorrhoidectomy.

Conclusions

Considering the multitude of surgical techniques for the HD treatment, the question to be answered is do we really need another new surgical procedure for hemorrhoids? Certainly yes! Indeed, we did not introduce a new surgical technique; we would like to name and popularize a technique, surely already performed, that extends and combines a simple hemorrhoidectomy, regarding only the anal canal, to a mucosal prolapsectomy interesting the rectal area. It should be part of any coloproctologist background as an asymmetric mucosal prolapse in patients with HD is very often encountered intraoperatively. Future comparative studies are needed to assess the superiority of SLAP over conventional Milligan-Morgan hemorrhoidectomy, especially in terms of lower recurrence rate. At present, it seems reasonable to assert that SLAP is a safe, reliable, and feasible procedure in patients with asymmetric mucosal prolapse.

Footnotes

Author Contributions

Study concept and design:

Acquisition of data: Claudio Gambardella, Luigi Brusciano, and Vincenzo Landolfi

Analysis and interpretation: Claudio Gambardella, Luigi Brusciano, and Ludovico Docimo

Study supervision: Claudio Gambardella, Luigi Brusciano, Salvatore Tolone, Gianmattia del Genio, Ugo Grossi, Giorgia Gualtieri, and Francesco Saverio Lucido

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

The study was conducted according to the Declaration of Helsinki and approved by the local institutional ethical committee.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the Division of General, Mini-invasive and Obesity Surgery University of Study of Campania “Luigi Vanvitelli” Naples, on reasonable request.

ORCID iDs

Luigi Brusciano

Claudio Gambardella

Salvatore Tolone

Ugo Grossi

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