A comparative study of conventional Milligan-Morgan hemorrhoidectomy versus harmonic scalpel hemorrhoidectomy

A comparative study of conventional Milligan-Morgan hemorrhoidectomy versus harmonic scalpel hemorrhoidectomy

Hesham M Hasan, MD

Department of General Surgery, Ain Shams University, Cairo, Egypt.

Abstract

Hemorrhoidal  disease is one of the most common anorectal disorders, affecting, in various forms, almost 50% of people over the age of fifty. Surgical treatment is considered the standard treatment for grade  III and IV hemorrhoids. However, although  it is considered a minor procedure, the post-operative course is protracted, and the post-operative complications  are not negligible. The resulting pain-related complications after conventional hemorrhoidectomy (CH) are often the major factors that prolong hospital stay and delayed  recovery.  Recently various new treatment modalities have been developed with the aim of overcoming post-operative pain, such as stapled hemorrhoidopexy, Ligasure, and harmonic scalpel, sealing devices. The aim of this study is to evaluate and compare the conventional Milligan- Morgan hemorrhoidectomy (CH) with harmonic scalpel hemorrhoidectomy (HSH) on eighty four patients with symptomatic grade III or IV hemorrhoids operated on at the Department  of General Surgery, AL-Jedaani hospital, Jeddah, Saudi Arabia, between May 2008 and January2011. The patients were randomly allocated to undergo either a CH (group]= 42 patients) or HSH (group 2=42 patients). After analyzing the data collected  from this study we can conclude  that; hemorrhoidectomy with harmonic scalpel can  provide a  safe,  fast,  low-morbidity alternative to  conventional hemorrhoidectomy.

Key words: Harmonic scalpel, Milligan- Morgan, hemorrhoidectomy.

Introduction:

Hemorrhoidal disease  is one of the most common  anorectal disorders, affecting, in various forms, almost 50% of people over the age of fifty and is one of the surgical problems which still there is a lot of debate regarding the best management for it.l Hemorrhoidectomy is superior to any proposed conservative procedure, including rubber band ligation, sclerotherapy, photocoagulation, and cryotherapy  for treating symptomatic grades III and N hemorrhoids.2 Unfortunately, it is usually associated with  significant post­ operative complications, including pain, bleeding, and anal stricture, which can result in  a protracted period  of convalescence.3

Throughout  the years, several modifications have been made to the original  operation  of excision of hemorrhoids using  scissors to improve outcomes, especially postoperative pain after the procedure.The Milligan-Morgan

open hemorrhoidectomy is the most widely practiced technique and is considered by many to be the  current standard for  surgical management ofhemorrhoids. 4 This traditional approach is effective; however,  it is often accompanied by  a high incidence of complications, such  as  urinary retention, hemorrhage, and  significant pain.5  Recent advances in instrumental technology, including the bipolar electrothermal device, ultrasonic scalpel, and circular stapler, are gaining popularity as  effective alternatives in hemorrhoidectomy.6 Surgical excision  using the harmonic scalpel is a more recent technique for use in symptomatic third- and fourth-degree hemorrhoids. Ithas been advocated in a number of other  surgical procedures to decrease bleeding and minimize operating room time.7

Harmonic scalpel works through the denaturation of proteins by breaking hydrogen bonds,  thereby  forming  a coagulum  to seal

vessels at lower temperatures and decreasing thermal damage to surrounding tissues.8 When used in hemorrhoidal surgery, the resulting mucosal defect created by  excising the hemorrhoid is then left open or sutured closed depending on surgeon preference.  It has been reported that harmonic  scalpel is superior to bipolar scissors because of less post-operative pain.9 The aim of this study is to evaluate and compare the  (CH)  with  (HSH)  in surgical management of third and  fourth degree hemorrhoids.The two different techniques will be compared as regards surgical outcome, post­ operative pain, hospital stay, post-operative bleeding, wound  infection, healing, fistula formation, stricture, and anal incontinence.

Patients and methods:

This  study  was  carried on eighty four patients with  symptomatic grade  III or IV hemorrhoids operated on at the Department of general Surgery, AL- Jedaani hospital, Jedclah, Saudi Arabia, between May  2008 and January2011. Written informed consent was obtained from all patients after full explanation of  the  procedure. The  exclusion criteria included patients on anticoagulants, patients with hematological disorder, concomitant anal disease, or a previous history of anorectal surgery.The patients were randomly allocated to undergo  either  a conventional Milligan­ Morgan hemorrhoidectomy (group I=  42 patients) or harmonic scalpel hemorrhoidectomy (UltraCision ® 10-mm Coagulating Shears, Ethicon  Endo-Surgery, Inc., Cincinnati, OH) (group 11=42 patients). The operation  was performed  under general

or spinal anesthesia at the discretion of the anesthetist. The  patients were  placed in lithotomy position. The internal and external components of each hemorrhoidal complex were first grasped and elevated using artery forceps, Figure(l)   a skin  incision at the junction of the hemorrhoid  and the flat peri­ anal skin was made by a scalpel, followed by the dissection  of the hemorrhoid  bundles off the underlying sphincter  using electrocautry in group I Figure(2) or harmonic  scalpel in group II Figures(3,4). The harmonic scalpel device was applied along the curvature of the artery forceps with its own curvature facing into the lumen of the anal canal to minimize potential injury to the  sphincter muscles. Finally, the hemorrhoidal pedicle was ligated by 2/0 silk suture  in group  I or sealed  and divided by harmonic scalpel in group II. The naked area was then inspected well to ensure complete hemostasis Figures(5,6). For post­ operative pain  relief, intramuscular non steroidal anti inflammatory Diclofenac sodium (75 mg) was prescribed twice a day for all patients.Additional parenteral analgesics would be administrated when patients complained of pain intolerance.The pain score was evaluated by means of the visual analog  score (0-10). The two groups were compared also for post­ operative bleeding, post-operative wound healing, post-operative hospital stay,  anal stenosis, wound infection, fistula formation, or incontinence. Follow-up was performed at one, two, four, six, eight, and twelve weeks to detect post-operative complications and time offwork in all84 patients.

Figure (1): The internal and external components of each hemo"hoid.

Figure  (2): Dissection of the hemorrhoid bundles using electrocautry.

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Figure  (3):  Dissection  of the hemorrhoid bundles using harmonic scalpel.

Figure (5): Inspection  to ensure complete hemostasis.

Results

Over a 32-months period, 84 patients were included in this study. 42 patients underwent hemorrhoidal excision via a conventional Milligan- Morgan hemorrhoidectomy (group I) another 42 patients underwent hemorrhoidal excision  via    the    harmonic  scalpel

Table (1): Demographic data.

Figure  (4):  Dissection of  the hemorrhoid bundles using harmonic scalpel.

Figure (6): Inspection to ensure complete hemostasis.

hemorrhoidectomy (group II). Mean follow­ up period was 12.5 (range, 9-21) months. The two groups were matched for age and gender distribution Table(l). There was no statistical difference in the duration of symptoms and the severity of hemorrhoids between the two groups.

NS=non significant

There was no significant difference between the two groups in number  of hemorrhoidal columns excised. The mean operating  time, was   significantly  longer  in   group  I (16.9±4.4min.)  than group II (14.4±2.5min.) (P< 0.01). Twenty patients (47.6%) of group

I needed opioid  analgesia in  addition to, intramuscular non steroidal anti inflammatory (Diclofenac sodium 75 mg) as they were not tolerating pain post operatively. While nine patients only in group II (21.4%) need opioid analgesia post operatively. Lower pain scores (2.37±0.85) were observed in the HSH group than in the CH group  (4.77±0.86). Pain  on postoperative day 1 was measured by the Visual Analogue Scale (VAS). A score ofO represents no pain, while a score  of 10 represents the worst pain. Significant postoperative bleeding occurred in three cases (7.1%) in group I after discharge from hospital  (around  the 5th-6th day). One  patient needed readmission in hospital with blood transfusion and reoperation to control bleeding.  Conservative  treatment

Table (2): Comparison of outcomes.

{compression and local ice) was sufficient to control bleeding in the other two patients. In group II no postoperative bleeding were observed. In group I only one patient (2.5%) developed infection which  occurred  at the surgical site. The patient was treated at home with oral antibiotic therapy (ciprofloxacin 1.0 g/day  + metronidazol 1.5  g/day, 7  days).

Four patients in group I and three patients in group II developed urinary retention; all 7 patients with  urinary  retention had  spinal anesthesia. There was no significant difference in length  of hospital stay  between the two groups (p>0.05).  Time to return to work or normal activity  was significantly shorter  in group II {5.79 days in the harmonic  scalpel groups and  9.56 days  in conventional hemorrhoidectomy group). Two patients (4.76 percent) developed subsequent  anal stenosis requiring anal  dilation at the  outpatient department in the CH group  whereas no symptomatic anal stenosis were found in the HSH during follow-up period.

NS=non significant     S=significant                HS=highly significant

Statistical methods:

ffiM SPSS statistics (V. 19.0, ffiM Corp., USA, 2010) was used for data analysis. Data were expressed as Mean±:SD for quantitative parametric  measures in addition  to Median Percentiles for quantitative non-parametric measures and both number and percentage for categorized data.

The following tests were done:

1.Comparison between two independent mean groups for parametric data using Student t test.

2. Chi-square test  to study  the association

between each 2 variables  or comparison between 2 independent groups as regards the categorized data.

3. Comparison between 2  proportions as regards univariant categorized data. The  probability of  error   at  0.05   was considered significant; while at 0.01 and 0.001

were highly significant.

Discussion:

There are  many options to  treat hemorrhoidal disease described in the literature, ranging from  simple clinical treatment (nutritional and hygienic informations) to more complex surgical techniques, like the use of circular staplers_lO,ll  Currently, surgical treatment is considered the standard treatment for grade III and IV hemorrhoids, although it is considered a minor  procedure, the post­ operative  course is protracted,  and the post­ operative complications are not negligible.The resulting pain-related complications after conventional hemorrhoidectomy are often the major factors that prolong hospital stay and delayed recovery. Recently various new treatment modalities have been developed with the aim of overcoming post-operative pain, such as stapled hemorrhoidectomy, Ligasure and harmonic scalpel, sealing devices.12 Much of the reported benefits of the harmonic scalpel in hemorrhoid surgery involve less desiccation, less eschar formation, improved wound healing, and decreased  postoperative pain.B Recent studies compared Milligan- Morgan hemorrhoidectomy with  harmonic scalpel method of dissection found harmonic scalpel hemorrhoidectomy prominently reduces post­ operative pain  and  numbers of parenteral

analgesic injections, which can be explained by the  minimal collateral thermal spread, limited tissue charring and absence of sutures might lead to less post-operative pain.6,14-16,25

Also in this study lower pain scores were observed in patients operated on by harmonic scalpel, and less opioid analgesia were needed for patients of HSH  group  than patients operated on by CH. Inthis study the operative time of HSH group was significantly  shorter when compared with CH group. Also in other study done by Chung et.al.,l4 they found that HSH was associated with shorter operative times (8.67 minutes shorter) and significantly less blood loss (23.08 mL less) compared with CH. The reduced  operative time associated with harmonic scalpel is likely related to better hemostatic  control and no need to ligate the hemorrhoidal pedicles.The incidence of urinary retention in the current  study  was 9.5%  in group I and 7.1% in group II which compares very favorably  with the previously reported rates of 2% to 36%.2,23,24 Spinal anesthesia, intraoperative intravenous fluid and postoperative pain  are  important factors contributing to increased rate of postoperative urinary retention.

The incidence of postoperative hemorrhage in the current study was (7.1%) in CH group and no postoperative hemorrhage was observed in HSH  group.  The  reported incidence of postoperative  hemorrhage in HSH in a large study done by David et.al. was 0.6 %17 while the recorded incidence in another study done by Nelson et al. was 2.8%.18 No patient needs reoperation in these  studies. The  reported incidence of postoperative hemorrhage in CH varied from 5% to 9 %.19-21 So from this study and other published studies we can conclude that HSH is associated with less postoperative hemorrhage than CH. This can be explained by the high vibration frequency produced by this device  which promotes  hemostasis and sealing of small and medium vessels, with the advantage of  producing minimal tissue injury.22,25 Infection at the surgical wound was a rare event after HSH.14,17 Also in this study no post operative infection occurred  at the surgical site in HSH group, while one patient developed  infection at the surgical wound in CH group and was treated at home with oral

antibiotic therapy. The incidence of anorectal incontinence is rarely mentioned  in most of the large hemorrhoidectomy studies, either because of its extreme rarity or because of difficulties in assessing its severity. In 1997, Lacerda-Filho and Cunha-Melo23 reported an incontinence rate of 4 percent in patients after hemorrhoidectomies.Theoretically, there is a wony that application of the harmonic scalpel clamp may risk incorporating internal anal sphincter beneath the haemorrhoidal  tissues. However, the very limited data available have not  shown  any  significant compromise of continence and no clinical sphincter  injury with any flatus or stool incontinence was noted in published studies. Also, in this study  no flatus  or stool  incontinence were  recorded during  the follow  up period in both groups. Two  patients in CH group in this study developed subsequent anal stenosis requiring anal dilation at the outpatient department whereas  no symptomatic anal stenosis were found in the HSH group during follow-up period. However, there  was  no  statically significant difference between the two groups as regards  symptomatic anal stenosis. The same was reported in other published studies comparing CH and HSH as regards post operative symptomatic anal stenosis.l7,18,26

Conclusion:

Hemorrhoidectomy with harmonic scalpel can provide a safe,  fast,  low-morbidity alternative to conventional hemorrhoidectomy. There  are  significant benefits  of harmonic scalpel  hemorrhoidectomy such as reduced postoperative pain, analgesic requirement, and time to return to work or normal activity. However, further prospective controlled studies are needed for  more  precise conclusions.

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