A Comparison between the Outcome of LigaSure Hemorrhoidectomy Versus Conventional Milligan Morgan’s Technique

INTRODUCTION

Anorectal piles are characterized by distal displacement or expansion of the anal cushion ^1-3. Various publications have reported the main pathological finding as abnormal degenerative changes and dilated vascular channels of the anal cushion ^4-5. The prevalence of piles is estimated at 5%, in the general population ⁶.  According to Goligher’s classification, piles can be classified in four degrees according to the degree of prolapse and appearance of piles ⁷. In the 1^st degree piles, there is only anal without any protrusion of anal cushions. In the 2^nd degree piles, there is a protrusion of anal cushions outside on straining with spontaneous reduction. In the 3^rd degree piles, there is a protrusion of anal cushions outside on straining but need to be reduced manually. In the 4^th degree piles, there is a permanent, irreducible protrusion of anal cushions outside through the anus. Most of the complications occur in the 4th degree and include incarceration internal piles, thrombosis, inflammation, and mucosal prolapse ⁸. The appropriate surgical modality depends on the degree of piles, the patient’s age, and the complications ^9-11. Hemorrhoidectomy is the chief technique for the

treatment of 3^rd and 4^th grades piles ¹². Milligan Morgan technique is the most frequently practiced open surgical procedure using a combination of electrocautery and suture ligation of the pile pedicle. This technique may be complicated by postoperative pain, hemorrhage, and wound infection ¹³. Many surgeons advocate that vascular pedicle ligation itself may raise the chance of secondary hemorrhage as it may result in ischemia and necrosis ^9-13.  Ligasure vessel sealing system is a bipolar electro-thermal device that uses a calculated arrangement of pressure and radiofrequency to seal blood vessels. By using Ligasure, there is no need to suture the vascular pedicle and avoid its drawbacks. The goal of this study is to compare traditional Milligan-Morgan hemorrhoidectomy versus ligasure hemorrhoidectomy in the treatment of individuals with 3^rd and 4^th degree piles ¹³.

PATIENTS AND METHODS

The current studywas achieved from January 2018 to January 2020. A total of 50 Patients suffering symptomatic hemorrhoids of 3^rd and 4^th degrees were involved.

After randomization, the cases were subsequently separated into 2 comparable groups after a thorough explanation of either technique.  Group A: 25 patients were scheduled for Ligasure Hemorrhoidectomy. Group B: 25 patients were scheduled for hemorrhoidectomy by Milligan Morgan’s technique. All patients provided written consent and accepted to participate in our study.

Inclusion criteria:

All patients who presented with symptomatic hemorrhoids of 3^rd and 4^th degrees in all age groups and both sexes were involved in this study.

Exclusion criteria:

Patients with acute episodes of thrombosed hemorrhoids, co-existing anal diseases, inflammatory bowel diseases, patients with previous anal surgery, anticoagulant therapy, immunosuppressed patients were excluded from the study.

Methods:

Preoperative prophylactic antibiotic (cefazolin 1g IV) was given to all patients in addition to preoperative rectal enema.

Operative Technique

Group A: LigaSure hemorrhoidectomy

After digital anal dilatation and examination, the pile mass is grasped by Allis clamp distally and artery forceps proximally (Fig.1). The ligasure apparatus (Fig.2) was used to divide the hemorrhoidal cushion starting from mucocutaneous junction to the hemorrhoidal pedicle, with preservation of the anal sphincters till the pedicle of hemorrhoid appears (Fig.3). The pile pedicle can be sealed twice to ensure good hemostasis and reduced postoperative bleeding (Fig.4). A similar procedure was done for 2nd and 3rd hemorrhoids with skin bridges between them. The anal pack was used if needed.

Fig. 1: Pile was grasped by Allis clamp distally and artery forceps.

Fig. 2: LigaSure device handle.

Fig. 3: Dissection of the pile mass.

Fig. 4: Sealing of the pile pedicle.

Group B: Conventional (Milligan-Morgan) hemorrhoidectomy

Digital anal dilatation and anal examination were done to evaluate the piles' position and to exclude other anal pathology. The hemorrhoidal cushion is grasped by Allis clamp distally and artery forceps proximally, then a V-shaped incision is made in the mucocutaneous skin junction, and hemorrhoids are dissected using electrocautery (Fig.5) and its pedicle transfixed and ligated using Vicryl 2-0 (Fig.6). The steps were repeated to other hemorrhoids, and the wound was left open with a raw surface. The anal pack was inserted using one gauze rolled inside Sofra-Tulle gauze.

Fig. 5: Dissected using electrocautery.

Fig. 6: Pedicle was transfixed and ligated using Vicryl 2-0.

Assessment

The duration of surgery was noted from the beginning of skin preparation to the placement of the pack after surgery completion. Per-operative bleeding was noted by counting the sum of gauze pieces (4*4). Each blood-soaked gauze accounted for 5 ml of lost blood. Post-operative pain was evaluated using a visual analogue scale (VAS) provided to the patient and they were asked to grade the severity of pain on 0–10. Early postoperative complications like secondary hemorrhage, urinary retention, and wound infection were recorded.

Follow Up: Examination was conducted at 1 month, 3 months, and 6 months after complete wound healing. Late postoperative complications such as recurrence and anal stenosis had not been recorded.

Statistical Analysis

The statistics were represented as a mean and standard error. Data analysis was performed by one-way analysis of variance (ANOVA).

RESULTS

Out of fifty cases, in group A there were 14 males and 11 females, while in group B there were 18 males and 7 females. The mean age of all patients for group A was 43 years (range 22–63 years), and for group B was 47 years (range 27–64 years). (Table 1).

Table 1: Showing Preoperative data in the study groups (gender and age).

The average procedure time in group A and B was 12.5±3 min and 23.3±5.2 min respectively (P-value <0.001). The VAS pain scores on the 1^st day and 7^th day in group A were 4.1±0.8, and 1.2±0.2 respectively, and in group B were 6.8±1.8, and 2.1±0.7 respectively (<0.001), The average postoperative stay in group A was 1.4 days, and in group B was 3.2 days.  (Table 2.)

Table 2: The results of each technique.

The average volume of blood loss was 14.50±6.66 ml with Ligasure and 25.17±2.52 ml with conventional hemorrhoidectomy (<0.001).  

Table 3: Average of blood lost during operation.

In group A, one developed urinary retention, and in group B one patient had a secondary hemorrhage, two patients developed urinary retention during the postoperative period. None of our patients developed delayed complications such as recurrence, anal incontinence, or anal stenosis.

Table 4: Postoperative complications.