haemorrhoidal disease is common . when the supporting submucosal fibres fragment due to prolonged straining during defaecation of hard stools , the anal cushions are no longer restrained from engorging excessively with blood and this results in bleeding and prolapse [ 1 , 2 ] . after other life - threatening diseases have been excluded , in the past , severe circumferential prolapse with massive engorgement of both external and internal haemorrhoidal plexuses required extensive ablation to ensure adequate treatment with subsequent mucocutaneous reconstitution . a 75-year - old man was admitted electively to the hospital for assessment and management of persistent prolapsed haemorrhoids ( fig .  1 ) , despite recurrent surgery , thrice in the past 3 years . he had no loss of appetite nor weight loss . on examination , he was pale and tired - looking . a rectal examination revealed massive , irreducible , prolapsed , circumferential haemorrhoids that were ulcerating , bleeding and occluding the anal orifice . the external components showed squamous hyperplasia with keratinization and a frond - like , friable appearance . proctoscopy revealed solid palpable internal haemorhoidal components with a similar pigmentation ( acanthosis ) as the external components at their classic anatomical positions the left lateral , right posterior and right anterior positions  but no definite rectal mucosal lesion was seen . he was found to be anaemic with a haemoglobin level of 7 gm / dl . the differential diagnosis included an extensive locally advanced anal carcinoma , an extensive fungating perianal condylomata acuminata ( buschke - lowenstein 's disease ) , chronically prolapsed ( fourth degree ) haemorrhoids with external components or a chronic rectal prolapse . his iron - deficiency anaemia was corrected by blood transfusion prior to an examination under anaesthesia . prolapsed thrombosed fourth degree haemorrhoids ( with permission ) . in the lithotomy position , an extensive milligan morgan haemorrhoidectomy with mucocutaneus skin bridges and high ligation was performed ( fig .  2 ) . the external component of the haemorrhoidal tissue disintegrated into black clots on dissection ( fig .  3 ) . an intussucepting rectal prolapse with a sulcus between the prolapse and the edge of the anal canal became evident . a modified delorme 's procedure was done by excising the redundant mucosal sleeve , reducing the prolapse and plicating the prolapsed muscle wall to the proximal rectal mucosa cuff ( fig .  2 ) . however , as most of the anal canal skin at the level of the dentate line was incorporated in the extensive internal and external haemorrhoidal engorgement and thus been excised en - bloc , the distal component of the plication was sutured but to the fascia ( epimysium ) overlying the internal anal sphincter . pouting of the rectal mucosa at the anal orifice causing a mucoid leak was prevented by not stitching to the perianal skin . the wide perianal skin defects were approximated to facilitate healing and reduce pain ( fig . he was discharged on the eighth postoperative day on iron supplements and advised a high - fibre diet and regular follow - up . this case illustrates the importance of excluding an underlying rectal prolapse in a patient with recurrent haemorrhoids despite conventional haemorrhoidectomy . the introduction of less invasive surgical modalities , which offer good symptomatic control and less postoperative pain , has reduced the number of patients requiring conventional haemorrhoidectomy . conventional haemorrhoidectomy deals with the symptoms alone without due regard to restoration of the normal physiology by fixation of the congested anal cushions . on the other hand , stapled haemorhoidopexy tries to correct the primary pathology , by after reducing the prolapsed haemorrhoidal tissue , the redundant lower rectal mucosa is excised and the prolapse fixed back into its proper place on the wall of the anal canal [ 4 , 5 ] . there is less postoperative pain as the procedure avoids the sensitive anoderm below the dentate line , which is usually incorporated in conventional haemorrhoidectomy . in this case , the true nature of the rectal prolapse was not diagnosed till the milligan > 34 cm outside the anal verge , there is not enough space with the staple housing to contain it , and thus a circular pph ( proximate ethicon ) stapler may be found to be effective . in this patient with such a wide extension of the external component outside the anal verge , a more expensive alternative might be to use two staplers simultaneously . in areas with limited health resources , an alternative surgical method for the irreducible massive circumferential prolapsed ( fourth degree ) haemorrhoids is an excision followed by a modified  delorme's correction approach , if there is associated rectal prolapse as in this case , so as to reduce rectal mobility and prevent recurrence [ 9 , 10 ] . this research received no specific grant from any funding agency in the public , commercial or not - for - profit sectors .
more recently some patients with rectal mucosal prolapse and obstructive defaecation have been treated with the procedure for prolapse and haemorrhoids . 
 we report a case of symptomatic chronic circumferentially prolapsed haemorrhoids that had several failed attempts at surgical repair . 
 this was finally managed by ablation and correction of the associated rectal mucosal prolapse by a modified 
 delorme 's procedure akin to a stapled anopexy .