Minimally Invasive Procedures Transform Proctology

Surgical approaches advance for hemorrhoids and fecal incontinence.

Minimally invasive surgical techniques are becoming more important in proctology, according to experts at the National Academy of Surgery. These procedures offer less pain and quicker recovery times for patients suffering from hemorrhoids and fecal incontinence.

Hemorrhoid Treatment Evolves

Treatment for hemorrhoids is shifting away from traditional hemorrhoidectomy toward less invasive, technology-driven options, according to Béatrice Vinson-Bonnet, MD, a visceral and digestive surgeon. Before surgery, doctors focus on medical treatments, such as resolving intestinal transit issues and educating patients on proper bowel habits.

Vinson-Bonnet stated that all surgical methods now aim to be minimally invasive due to technological progress. Alternatives like nerve blocks and stapling have appeared since the 2000s, avoiding external incisions.

Pudendal nerve blocks can offer 12–24 hours of pain relief after hemorrhoid surgery. Even so, Vinson-Bonnet pointed out that stool passage might still be uncomfortable between days 3 and 10, and it could take six weeks to heal completely.

In 1998, Antonio Longo, MD, introduced stapled hemorrhoidopexy, which uses a circular stapler to remove a ring of rectal mucosa, repositioning prolapsed internal hemorrhoids. Longo is a colorectal surgeon and director of the European Centre for Coloproctology and Pelvic Diseases.

According to Vinson-Bonnet, the stapled hemorrhoidopexy, while innovative, has been linked to serious complications and is now often replaced by a simpler technique that uses an anoscope to locate and ligate small rectal arteries.

Vinson-Bonnet also noted that these methods are not suitable for large external hemorrhoids or those caused by thrombosis, and recurrence can occur in up to 20% of patients within two years.

Thermofusion, using microwave energy to dry out internal bleeding, is an emerging technique now used in clinical practice while still under evaluation. Radiofrequency and laser methods are also employed, said Vinson-Bonnet.

New Fecal Incontinence Treatments

Professor Émilie Duchalais, MD, PhD, a digestive surgeon, presented recent advances in minimally invasive fecal incontinence treatment. She leads clinical studies on the condition. The prevalence of fecal incontinence increases with age, affecting about 8% of adults over 80 (National Institutes of Health).

According to Duchalais, sacral neuromodulation and Botox are mainly reserved for fecal incontinence patients when medical treatment or rehabilitation has failed. Duchalais explained that sacral neuromodulation involves stimulating nerve roots near the sacrum that affect sphincter control and rectal sensitivity.

Duchalais said long-term improvement is seen in 50%-70% of patients five to 10 years after implantation. A temporary trial phase allows patients to assess the treatment’s effectiveness before permanent implantation. The system, similar to a pacemaker, typically remains in place for at least five years, depending on battery life.

“If the patient experiences at least a 50% reduction in incontinence episodes during this period, the device is permanently implanted. The system, similar to a pacemaker but placed in the buttocks, typically remains in place for at least 5 years, depending on the battery life,” she said.

Botox, commonly used by urologists for overactive bladder, blocks acetylcholine, preventing muscle contractions and reducing urinary leakage. In the rectum, Botox blocks muscle activity and nerve signals to improve control in patients with fecal incontinence, Duchalais noted.

Botox provides temporary relief, typically lasting 6-9 months. Duchalais added that a recent study showed patients needed injections only once every three years after five years.

Researchers are also studying autologous fat injection into the anal sphincter to restore sphincter tone through stem cells. A clinical trial is evaluating this method, with promising early results; however, it remains experimental, said Duchalais.