A comparison between conventional milligan morgan hemorrhoidectomy and stapled hemorrhoidopexy in a tertiary care center
BP Ranjan NG, Sneha Daniel
Introduction: Hemorrhoids are known to man since ancient days due to high prevalence, easy observability and symptoms are well appreciated by patients. Oldest literature dates back to 1500 BC from Mesopotamia. Even today, the search for the exact origin and most appropriate treatment continues. Initially it was thought to be due to, varicose veins in anal cushions, but recently sliding of anal canal lining is gaining popularity. Treatment modalities ranging from dietary changes, defecation habit (life style and behavioral changes), medications, injection sclerotherapy and banding (office procedures), various operative procedures. While excisional hemorrhoidectomy remains the gold standard modality of treatment, patient acceptance for the procedure is limited by the very high postoperative pain. Thus, newer modalities are still being developed with the aim to reduce post-operative pain and early recovery. The most researched among the recent operative modalities is stapled hemorrhoidopexy. In this present study we compared conventional Milligan Morgan hemorrhoidectomy and stapled hemorrhoidopexy in grade III and IV hemorrhoid patients. Material and Methods: After approval from institutional ethical committee and informed consent from each patient, we conducted a prospective study in the Department of General surgery of Silchar Medical College and Hospital, Silchar. It included 67 (n) patients symptomatic for grade III/IV selected randomly for each procedure. Of these 33 (n1) underwent conventional Milligan Morgan hemorrhoidectomy and 34 (n2) underwent stapled hemorrhoidopexy. Patients were followed up for a period of 24 weeks Follow up was done at 2nd, 8th, and 24th weeks routinely and in between if required. Parameter observed were degree of disease, sex ratio, mean age operating time, intraoperative blood loss, postoperative pain, postoperative blood loss, hospital stay, anal incontinence (fecal/flatus), anal stenosis/stricture. Observations and Results: Of the 67 patients, 40 were male and 27 females. Sex ratio (M: F) was 21: 12 in MMH and 19: 15 in SH. Overall mean age was 49.13±11.08. For MMH it was 46.03±13.45 and for SH it was 52.15 ±7.92. Total 41 patients had grade III and 26 patients had grade IV hemorrhoids. 19 grade III patients underwent MMH and 22 patients underwent SH. 14 grade IV patients underwent MMH, and 12 under SH. Bleeding was the most common symptom in 61 patients followed by prolapse in 47 patients and 11 patients complained of pruritis discharge and constipation. Operating time was slightly less with SH. (24.12±2.18 min vs 18.82±3.7 min) Intraoperative blood loss was much more in MMH in comparison to SH (38.48±5.13ml vs 13.65±3.07ml). Length of hospital stay was more in the MMH group (4.18±0.46 Days vs 1.85±0.5 days). The need for injectable analgesics and duration of hospital stay was thus considered to be an indirect measure of pain. The complications encountered in our study were bleeding (8.9%), urinary retention (7.46%), fecal impaction (2.98%), surgical site Infection (7.46%), delayed wound healing (10.44%), and residual prolapse (14.92%) and anal stenosis (1.49%). All complications were more in MMH group, but residual prolapse and anal stenosis were noted only in the SH Group. Conclusion: To conclude, while SH is relatively less painful and equally efficacious in smaller grade III disease, better results are obtained with MMH when dealing with larger grade III and IV hemorrhoids. Also, SH has a longer learning curve and is relatively costlier.