LigaSure versus Milligan-Morgan hemorrhoidectomy: a prospective randomized clinical trial

A Retrospective Study of Milligan-Morgan Versus LigaSure Hemorrhoidectomy in the Treatment of Symptomatic Hemorrhoids at an Institute in North India

Objective The present study aimed to assess and compare the surgical outcomes of hemorrhoidectomies performed using two different techniques: conventional Milligan-Morgan and another popular vessel sealing approach of LigaSure hemorrhoidectomy. Methods This retrospective study was conducted at our tertiary care hospital and involved patients who underwent either of the surgical procedures from June 2016 to March 2022. The patient demographics and data on the duration of operation, hospital stay, and postoperative recovery were collected and evaluated. Results Of the 91 cases reviewed, a total of 44 patients underwent Milligan-Morgan open hemorrhoidectomy and 47 had LigaSure hemorrhoidectomy. The mean operative time was significantly shorter for LigaSure hemorrhoidectomy (33.84 ±9.18 vs. 23.15 ±3.36 minutes for Milligan-Morgan and LigaSure, respectively, p<0.0001). Additionally, in comparison to Milligan-Morgan open hemorrhoidectomy, the LigaSure hemorrhoidectomy group exhibited a significant reduction in hospital stay (2.20 ±0.79 vs. 1.47 ±0.50 days), lower pain score [6.55 ±1.19 vs. 5.30 ±1.10 on the visual analog scale (VAS) on day one and 2.25 ±1.26 vs. 1.47 ±0.78 VAS on day seven], and faster return to normal activities (18.18 ±4.30 vs. 14.85 ±3.15 days). Conclusions When pitted against the traditional Milligan-Morgan method, the LigaSure approach to performing a hemorrhoidectomy is superior, owing to the shorter duration of operation, shorter hospital stays, lesser pain, and earlier return to normal activities. In light of these findings, surgeons may consider choosing this procedure to improve surgical outcomes and efficiency.

Laser Hemorrhoidoplasty Versus Ligasure Hemorrhoidectomy: A Comparative Analysis

Background and objective Minimally invasive techniques in the surgical treatment of hemorrhoids have been gaining in popularity. Laser hemorrhoidoplasty (LHP) and LigaSure™ (LigH; Medtronic, Dublin, Ireland) hemorrhoidectomy methods are the most recent innovative methods that are increasingly used. In this study, we aimed to compare the effectiveness of these two innovative techniques. Methods The data of patients who underwent LHP or LigH for grade III hemorrhoidal disease at our clinic between January 2022 and June 2023 were retrospectively analyzed. Postoperative pain levels, time to return to work or daily activities, complication rates, and recurrence rates of the treated patients were recorded. Results A total of 100 patients were included in the study. Of these, 48 patients had LHP surgery and 52 had LigH surgery. The demographic characteristics of both groups were similar. The mean operation time was statistically significantly shorter in the LHP group (p<0.001). The visual analog scale (VAS) scores on postoperative days one and seven were lower in favor of the LHP (2.4 ± 0.7 and 1.2 ± 0.9 vs. 6.2 ± 1.5 and 3.8 ± 1.3, respectively; p< 0.001). The median time to return to daily activity was 2.3 (range: one to three) days in the LHP group and 4.6 (range: 3-11) days in the LigH group (p<0.001). Recurrence was observed in 11 (22%) patients in the LHP group and in three (6%) patients in the LigH group (p<0.001). Conclusion Based on our findings, LHP is an effective procedure for the surgical treatment of hemorrhoidal disease as it is associated with less morbidity, less pain, early return to work, and acceptable recurrence rates.

High-energy devices in different surgical settings: lessons learnt from a full health technology assessment report developed by SICE (Società Italiana di Chirurgia Endoscopica)

BACKGROUND

The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices.

METHODS

A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings.

RESULTS

The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged.

CONCLUSIONS

The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.

Ten-year multicentric retrospective analysis regarding postoperative complications and impact of comorbidities in hemorrhoidal surgery with literature review

BACKGROUND

Hemorrhoidal disease (HD) is considered a low-severity pathology by both general population and physicians, but the lengthy conservative therapy and postoperative complications suggest otherwise.

AIM

To assess the effectiveness of different treatment options, both conservative and surgical, in contrast with some preexisting comorbidities.

METHODS

We conducted a retrospective, 10-yearlong study between January 2011 and December 2021 in two surgical centers, a private and a state-owned hospital. We compared the efficacy and safety of several treatment options, such as open hemorrhoidectomy, stapled hemorrhoidopexy, rubber band ligation and infrared coagulation in terms of complication rates and types and their correlation with different preexisting comorbidities such as inflammatory bowel disease (IBD), use of anticoagulant medication (AM) and liver cirrhosis. We also conducted a 20-years long PubMed research (1.263 articles) for relevant comparisons.

RESULTS

Our study recorded 10940 patients with HD, 10241 with conservative and 699 with surgical treatment. Out of these, the male-to-female ratio of 1.3, and a peak in age distribution between 59 and 68 years old (32% of patients). For the entire study, we recorded a 90% incidence of immediate pain, immediate bleeding in 1.5% (11 cases), delayed bleeding in 1.0% (7 cases), and 0.6% surgical site infections. Urinary retention was also present, with 0.2% of patients, anal stricture in 1% and fecal incontinence for 0.5% of patients (4 cases). We recorded no severe complications such as Fournier`s gangrene or rectovaginal perforations. IBD accounted for 6% of the patients, with ulcerative colitis in 12% and Chron`s disease in 10.5%. 6.6% of the patients had AM, determining 4% immediate and 2% delayed bleeding, in surgically treated patients.

CONCLUSION

Our study determined that most common complications (pain, urinary retention, bleeding, and stricture) are correlated with each surgical technique and pre-existing comorbidities.

Outcome of a modified Park's submucosal hemorrhoidectomy versus Milligan-Morgan for grade III-IV circumferential prolapsed hemorrhoids

BACKGROUND

This prospective randomized controlled study compared the short- and long-term efficacy and advantages of modified Park's submucosal over Milligan-Morgan hemorrhoidectomy (MMH) in the treatment of grade III and IV circumferential prolapsed hemorrhoids (CPH).

METHODS

A total of 186 consecutive patients with grade III or IV CPH were enrolled. The patients were randomized to MPSH (n = 93) or MMH (n = 93) treatment groups. Patient data included demographics, clinical characteristics, surgical parameters, underlying or arising complications, and CPH recurrence. The patients were closely followed up for at least 24 months.

RESULTS

The patient demographic data and clinical parameters were comparable in the two groups (P > 0.05). MPSH took significantly longer operative time (P < 0.05). Although there was no significant difference in mean postoperative pain between the two groups at days 3 and 14, pain at day 7 was significantly more frequent and severe in the MMH group (P < 0.05). There were no significant group differences in postoperative bleeding, intraoperative blood loss, or development of anal stenosis (P > 0.05). However, the cumulative relapse-free rate was substantially higher in the MPSH group (P < 0.05).

CONCLUSION

MPSH and MMH are both practical and safe techniques for treating grade III and IV CPH disease. However, MPSH is safer, easier, and faster to perform and is associated with fewer recurrences within 24 months of surgery. Additional clinical studies are needed to validate these conclusions.

Doppler-guided hemorrhoidal artery ligation with suture mucopexy compared with LigaSure™-assisted pile excision for the treatment of grade III hemorrhoids: a prospective randomized controlled trial

BACKGROUND

Doppler-guided hemorrhoid artery ligation and stapled hemorrhoidopexy have been used in surgical practices to avoid post-hemorrhoidectomy pain. Our study compared Doppler-guided hemorrhoid artery ligation with suture mucopexy (DGHAL-SM) and ligature-assisted pile excision (LAP) for greater than three grades of internal hemorrhoids.

METHODS

Eighty patients with greater than 3 grades of internal hemorrhoids were selected (age range: 20-28 years; average age: 23 years) between January and June 2015. The patients were randomly divided into group A (DGHAL-SM) and group B (LAP); each group had 40 patients.

RESULTS

With respect to the postoperative cure rate and anal skin tags, group A was inferior to group B, but the postoperative pain assessment and satisfaction were better than group B (P<0.001).

CONCLUSIONS

The DGHAL-SM cure rate was high; the postoperative pain was mild; 97.5% of the patients did not return to hospital because of pain. LAP has a higher cure rate than DGHAL-SM, but the postoperative pain and return rate within 6 h was as high as 65%, and the postoperative satisfaction assessment was lower than DGHAL-SM. Therefore, we recommend that DGHAL-SM for outpatient surgery in patients with greater than three grades of internal hemorrhoids.

Long-Term Outcomes of Sectorial Longitudinal Augmented Prolapsectomy for Asymmetric Muco-hemorrhoidal Prolapse: An Observational Study of 433 Consecutive Patients

PURPOSE

Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis.

METHODS

Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work.

RESULTS

We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2.

CONCLUSIONS

The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.

Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids

The pathogenesis of hemorrhoids is a weakening of the anal cushion and spasm of the internal sphincter. Bowel habits and lifestyles can be risk factors for hemorrhoids. The prevalence of hemorrhoids can encompass 4 to 55% of the population. Symptoms include bleeding, pain, prolapsing, swelling, itching, and mucus soiling. The diagnosis of hemorrhoids requires taking a thorough history and conducting an anorectal examination. Goligher's classification, which indicates the degree of prolapsing with internal hemorrhoids, is useful for choosing treatment. Drug therapy for hemorrhoids is typically utilized for bleeding, pain, and swelling. Ligation and excision (LE) is considered for Grade III and IV internal and external hemorrhoids. Rubber band ligation is used to treat up to Grade III internal hemorrhoids. Phenol almond oil is effective for internal hemorrhoids up to Grade III, while aluminum potassium sulfate and tannic acid have shown efficacy in treating prolapsing in internal hemorrhoids at Grades II, III, and IV. Procedure for prolapse and hemorrhoids (PPH) is surgically effective for Grade III internal hemorrhoids; however, the long-term prognosis is not favorable, with high recurrence rates. Separating ligation is effective surgical treatment for internal/external hemorrhoids Grade III and Grade IV. The basic approach to thrombosed external hemorrhoids and incarcerated hemorrhoids is conservative treatment; however, in some acute or severe cases, surgical resection is considered. Comparing the different instruments used for hemorrhoid surgery, all reduce operating time, blood loss, post-operative pain, and length of time until the return to normal activity. They do, of course, increase the cost of the procedure.

Efficacy of Mesoglycan in Pain Control after Excisional Hemorrhoidectomy: A Pilot Comparative Prospective Multicenter Study

INTRODUCTION

Various pain management strategies for patients undergoing open excisional hemorrhoidectomy have been proposed, yet postoperative pain remains a frequent complaint.

OBJECTIVE

To determine whether mesoglycan (30 mg two vials i.m. once/day for the first 5 days postoperative, followed by 50 mg 1 oral tablet twice/day for 30 days) would reduce the edema of the mucocutaneous bridges and thus improve postoperative pain symptoms.

PATIENTS AND METHODS

For this prospective observational multicenter study, 101 patients undergoing excisional diathermy hemorrhoidectomy for III-IV degree hemorrhoidal disease were enrolled at 5 colorectal referral centers. Patients were assigned to receive either mesoglycan (study group SG) or a recommended oral dose of ketorolac tromethamine of 10 mg every 4-6 hours, not exceeding 40 mg per day and not exceeding 5 postoperative days according to the indications for short-term management of moderate/severe acute postoperative pain, plus stool softeners (control group CG).

RESULTS

Postoperative thrombosis (SG 1/48 versus CG 5/45) (p < 0.001) and pain after rectal examination (p < 0.001) were significantly reduced at 7-10 days after surgery in the mesoglycan-treated group, permitting a faster return to work (p < 0.001); however, in the same group, the incidence of postoperative bleeding, considered relevant when needing a readmission or an unexpected outpatient visit, was higher, possibly owing to the drug's antithrombotic properties.

CONCLUSIONS

The administration of mesoglycan after an open diathermy excisional hemorrhoidectomy can reduce postoperative thrombosis and pain at 7-10 days after surgery, permitting a faster return to normal activities.

Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement

Hemorrhoids are one of the most common medical and surgical diseases and the main reason for a visit to a coloproctologist. This consensus statement was drawn up by the Italian society of colorectal surgery in order to provide practice parameters for an accurate assessment of the disease and consequent appropriate treatment. The authors made a careful search in the main databases (MEDLINE, PubMed, Embase and Cochrane), and all results were classified on the basis of the grade of recommendation (A-C) of the American College of Chest Physicians.

Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids

BACKGROUND

The aim was to compare the clinical outcomes and effectiveness of surgical treatments for haemorrhoids.

METHODS

Randomized clinical trials were identified by means of a systematic review. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS.

RESULTS

Ninety-eight trials were included with 7827 participants and 11 surgical treatments for grade III and IV haemorrhoids. Open, closed and radiofrequency haemorrhoidectomies resulted in significantly more postoperative complications than transanal haemorrhoidal dearterialization (THD), LigaSure™ and Harmonic® haemorrhoidectomies. THD had significantly less postoperative bleeding than open and stapled procedures, and resulted in significantly fewer emergency reoperations than open, closed, stapled and LigaSure™ haemorrhoidectomies. Open and closed haemorrhoidectomies resulted in more pain on postoperative day 1 than stapled, THD, LigaSure™ and Harmonic® procedures. After stapled, LigaSure™ and Harmonic® haemorrhoidectomies patients resumed normal daily activities earlier than after open and closed procedures. THD provided the earliest time to first bowel movement. The stapled and THD groups had significantly higher haemorrhoid recurrence rates than the open, closed and LigaSure™ groups. Recurrence of haemorrhoidal symptoms was more common after stapled haemorrhoidectomy than after open and LigaSure™ operations. No significant difference was identified between treatments for anal stenosis, incontinence and perianal skin tags.

CONCLUSION

Open and closed haemorrhoidectomies resulted in more postoperative complications and slower recovery, but fewer haemorrhoid recurrences. THD and stapled haemorrhoidectomies were associated with decreased postoperative pain and faster recovery, but higher recurrence rates. The advantages and disadvantages of each surgical treatment should be discussed with the patient before surgery to allow an informed decision to be made.

Tailored excisional treatment for high-grade haemorrhoidal disease

Patients affected by high-grade haemorrhoid with a fibrous internal pile or an important external component are suitable for an excisional procedure. The aim of this study is to evaluate the outcome of different excisional treatments such as Milligan and Morgan haemorrhoidectomy, Ferguson haemorrhoidectomy and Pexy-excision carried out according to a tailored treatment on each pathological pile. All the consecutive patients that underwent an excisional procedure for high-grade haemorrhoids in two different centres were considered for the present study. From January 2010 to December 2012, 135 patients affected by high-grade haemorrhoidal disease were treated with excisional procedures. No statistically significant differences were noted regarding age, sex distribution, symptoms, Goligher grade, length of surgery, number of pathological piles treated and number of pathological piles excised for each patient between groups. The Ferguson and Pexy-excision procedures yield better results in terms of pain and healing than open haemorrhoidectomy, whereas recurrence and complications are similar after 1 year. Excisional procedures are safe and effective for the treatment of high-grade haemorrhoids mostly if performed according to a tailored project. An increase in the number of pathological piles treated corresponded to an increase in the need of analgesics regardless of the procedure performed.

Recent advances in the management of hemorrhoids

Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a prolapsed lump, painless bleeding, discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease; however, it is also associated with hyper-vascularity, and, recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. A comprehensive search in published English-language literature till 2013 involving hemorrhoids was performed to construct this review article, which discusses advances in the management of hemorrhoids. This includes conservative treatment (life style modification, oral medications, and topical treatment), office procedures (rubber band ligation, injection sclerotherapy, infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy, cryosurgery, and laser therapy), as well as surgical procedures including diathermy hemorrhoidectomy, LigaSure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy (SH), and double SH. Results, merits and demerits of the different modalities of treatment of hemorrhoids are presented, in addition to the cost of the recent innovations.

Development and validation of a practical score to predict pain after excisional hemorrhoidectomy

PURPOSE

Excisional hemorrhoidectomy (EH) can be complicated by high early (EP) and prolonged pain (PP). This study aimed to determine predictors of high postoperative pain and to develop a risk score suitable to identify patient candidates to a more active analgesic treatment.

METHODS

We collected data of patients undergoing EH between January 2005 and September 2012 (development group). Patient-, disease-, surgery-, and surgeon-related characteristics were gathered. Anxiety was evaluated by means of STAI-Y. EP was assessed at 1-day, while PP at 15-day follow-up by means of a 10-cm VAS (cutoff, EP ≥ 5; PP ≥ 3 cm). On the basis of the odds ratio from a logistic regression, independent risk factors were assigned a weighted integer. The sum comprised the risk score, which was validated on a prospective cohort of patients undergoing EH between September 2012 and January 2014.

RESULTS

Five hundred fourteen patients were included in development group. Incidence of EP was 18.3 %, with 40.4 % developing PP. Younger age, male gender, advanced education, constipation, external component, anxious state and trait, and high anal resting tone were independent predictors of EP. Previous pain exerted a protective effect. Incomplete postoperative evacuation, advanced education level, high anal resting tone, and anxious trait were predictors of PP. In the development group, the risk of EP ranged between 1 % (low risk) and 21 % (high risk). Receiver operating curve (ROC) analysis of validation group (n = 130) confirmed the discriminatory power of this model (area under the ROC = 0.69).

CONCLUSION

The score can stratify the risk of EP following EH, identifying high-risk patient candidates to active analgesic administration or alternative surgical procedures.

Classical treatment of hemorrhoids

Radical and definitive surgical treatment is indicated in approximately one out of ten patients with hemorrhoidal disease. The Milligan and Morgan hemorrhoidectomy technique is the most widely performed in France: the technique is well-codified and results are satisfactory and durable if the indications and the post-operative follow-up are appropriately respected. Post-operative pain can be adequately controlled.

Results of 666 consecutive patients treated with LigaSure hemorrhoidectomy for symptomatic prolapsed hemorrhoids with a minimum follow-up of 2 years

BACKGROUND

Our aim is to report the outcomes of hemorrhoidectomy performed via LigaSure™ with a minimum follow-up of 2 years.

METHODS

A total of 666 patients underwent hemorrhoidectomy for symptomatic prolapsed hemorrhoids (grade III and IV) via LigaSure between June 2006 and June 2008. Patient demographic and operative data were collected and analyzed.

RESULTS

The mean patient age was 45.4 ± 11.1 years (x ± SD; range, 22-77), and approximately 72% had grade III hemorrhoids. All procedures were performed without complications. The operative time was 18.7 ± 4.1 minutes (range, 9-43), and hospital stay was 1.5 ± 0.6 days (range, 1-4). There was no immediate postoperative bleeding or other procedure-related complications. Twelve (1.8%) patients required urinary catheterization for a maximum of 1 day, and 21 (3.2%) patients had delayed postoperative bleeding. Most cases of bleeding resolved spontaneously; 3 patients (0.4%) required reoperation. A total of 645 patients (96.6%) responded to a follow-up telephone interview at a mean of 36 months (range, 24-49) after hemorrhoidectomy. After 1 year postoperatively, 2 patients received additional excisions for residual skin tags, 1 was treated for an anal stricture, 1 was treated for an anal fistula, and 3 were treated for anal fissures. Minor incontinence (flatus) was present in 11 (1.7%) patients, and 13 (2.0%) experienced mild bleeding caused by residual hemorrhoids; 1 patient underwent rubber-band ligation, and the others were successfully treated medically. No recurrent prolapse or persistent anal pain occurred during the follow-up period. The overall recurrence rate at 2-years follow-up was 3.1%.

CONCLUSION

The long-term recurrence rate after hemorrhoidectomy with LigaSure is low and comparable with conventional hemorrhoidectomy.

Perioperative outcomes using LigaSure™ compared to conventional bipolar instruments in laparoscopic salpingo-oophorectomy: a randomized controlled trial

BACKGROUND

The aim of this study was to compare the effects of LigaSure™ versus conventional bipolar techniques on operating time and blood loss during laparoscopic salpingo-oophorectomy in a randomized controlled trial.

METHODS

In three teaching hospitals, 100 women undergoing a laparoscopic salpingo-oophorectomy were randomized for LigaSure or conventional bipolar instruments. Primary outcome was operating time (from initial skin incision to removal of the specimen). Secondary outcome measures were total operating time (from initial skin incision to skin closure), time to dissect the ovarian and infundibulopelvic ligaments, intraoperative blood loss, and subjective judgment of the instrument used.

RESULTS

There were no differences in operating time and total operating time using LigaSure versus conventional bipolar instruments: 41.0 vs. 39.2 min (p = 0.78; 95 % CI = -10.9 to 14.5) and 54.6 vs. 58.6 min (p = 0.46; 95 % CI = -14.8 to 6.8), respectively. The mean blood loss using LigaSure versus conventional bipolar instruments was 38 vs. 33 mL (p = 0.73; 95 % CI = -22.7 to 32.2). Various subjective efficacy and instrument handling parameters of the two instruments varied among participating centers.

CONCLUSION

There were no significant differences in operating time and blood loss with the use of LigaSure compared to conventional bipolar instruments during laparoscopic salpingo-oophorectomy, even after correction for potential confounders.

A randomized clinical trial comparing Ligasure versus stapled hemorrhoidectomy

Stapled hemorrhoidectomy (SH) and Ligasure hemorrhoidectomy (LH) are standard for hemorrhoidal disease treatment, but the surgical principle is different. This randomized clinical trial compared the 2 methods. We included 98 patients with grade 3 hemorrhoidal disease: 46 patients treated by SH and 52 patients by LH. Incidence of complications, recurrence, postoperative pain, wound healing time, and time off everyday activity were observed. The follow-up period was 24 months. We found that LH has a significantly shorter wound healing time. The recurrence rate and the overall postoperative complication rate was higher after SH but not significantly (recurrence LH vs. SH: 1.9% vs. 11.1%; complications LH vs. SH: 13.5% vs. 23.9%). Postoperative pain level, analgesic consumption, and time off everyday activity were practically the same in both groups. Both procedures can be used to treat grade 3 hemorrhoidal disease with the same efficacy, but analysis of recurrence after SH is necessary.

[Consensus statement haemorrhoidal disease]

Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.

Optimal treatment of symptomatic hemorrhoids

Hemorrhoids are the most common anorectal complaint, and approximately 10 to 20 percent of patients with symptomatic hemorrhoids require surgery. Symptoms of hemorrhoids, such as painless rectal bleeding, tissue protrusion and mucous discharge, vary. The traditional therapeutic strategies of medicine include surgical, as well as non-surgical, treatment. To alleviate symptoms caused by hemorrhoids, oral treatments, such as fiber, suppositories and Sitz baths have been applied to patients. Other non-surgical treatments, such as infrared photocoagulation, injection sclerotherapy and rubber band ligation have been used to fixate the hemorrhoid's cushion. If non-surgical treatment has no effect, surgical treatments, such as a hemorrhoidectomy, procedure for prolapsed hemorrhoids, and transanal hemorrhoidal dearterialization are used.

Diathermy excisional hemorrhoidectomy: a prospective randomized study comparing pedicle ligation and pedicle coagulation

BACKGROUND

In hemorrhoidectomy, pedicle coagulation has been claimed to be associated with less postoperative pain compared with pedicle ligation.

OBJECTIVE

This study was designed to compare the effects of pedicle ligation vs pedicle coagulation on postoperative pain in patients undergoing diathermy excisional hemorrhoidectomy.

DESIGN

The study was conducted as a single-blind prospective randomized clinical trial.

SETTING

Patients were treated at a single tertiary-level teaching hospital (Main University Hospital) in Alexandria, Egypt, from February 2009 to October 2010.

PATIENTS

Patients with symptomatic grade III or IV hemorrhoids were eligible.

INTERVENTION

Patients were randomly allocated to receive either pedicle coagulation or pedicle ligation during 3-quadrant diathermy excision hemorrhoidectomy.

MAIN OUTCOME MEASURES

Patients reported postoperative pain daily on a visual analog scale (0-10, with 10 corresponding to the most severe pain) during the first 10 postoperative days. On-demand parenteral analgesic requirements were recorded during the first 24 hours after surgery. Operative time, postoperative complications, and wound healing rates at 6 weeks postoperatively were also recorded.

LIMITATIONS

No a priori power calculation could be performed, so it was not possible to tell whether nonsignificant differences were real or a result of chance.

RESULTS

A total of 136 patients were randomly assigned, and 120 patients completed the study (60 in each group). The overall median pain score for the first 10 postoperative days was significantly lower in the pedicle coagulation group than in the pedicle ligation group (4.65 vs 6.56, P < .001), and daily median pain scores were significantly lower for pedicle coagulation than for pedicle ligation throughout the first 6 postoperative days (P < .001). Postoperative pain scores followed different courses in the 2 groups. In the coagulation group, pain levels were lowest during the first 3 postoperative days, increasing from day 4 and then falling after day 8. In the ligation group, pain levels were highest during the first 4 postoperative days, then gradually decreased. The median number of analgesic ampoules required during the first 24 hours was also significantly lower for pedicle coagulation than for ligation: 1 (range, 0-3) vs 3 (range, 1-3); P < .001). The median operative time was 15 (range, 14-20) minutes with coagulation and 14.5 (range, 12-18) minutes with ligation (P < .001). No significant differences were observed in the incidence of postoperative complications or wound healing rates at 6 weeks postoperatively. No anal stenoses or recurrences were observed.

CONCLUSIONS

Pedicle coagulation is safe and provides a superior alternative to pedicle ligation by decreasing postoperative pain in the first 6 postoperative days, as well as reducing parenteral analgesic requirements during the first 24 hours postoperatively.

Perioperative outcomes using LigaSure compared with conventional bipolar instruments in laparoscopic hysterectomy: a randomised controlled trial

OBJECTIVE

To compare the effects of LigaSure versus the conventional bipolar technique on operating time and blood loss during laparoscopic hysterectomy.

DESIGN

A randomised controlled trial.

SETTING

Three teaching hospitals.

POPULATION

Women undergoing a laparoscopic hysterectomy for benign indications.

METHODS

140 women undergoing a laparoscopic hysterectomy were randomised for LigaSure or conventional bipolar instruments.

MAIN OUTCOME MEASURES

Primary outcome was operating time from initial skin incision till detachment of the uterus. Secondary outcome measures were total operating time (from initial skin incision till final skin closure), time to dissect the adnexal ligaments, intra-operative blood loss and subjective evaluation by the surgeon of the instrument used.

RESULTS

No differences in operating time (from initial skin incision till uterine detachment and initial skin incision till final skin closure) using LigaSure versus conventional bipolar instruments: 97.6 versus 91.8 minutes (P = 0.39, 95% CI - 7.6 to 19.2), and 148.1 versus 142.1 minutes (P = 0.46, 95% CI - 10.1 to 22.3), respectively. The mean blood loss using LigaSure versus conventional bipolar was 234.1 versus 273.1 ml (P = 0.46, 95% CI -39.1 to 52.7). Various subjective efficacy and instrument handling parameters were significantly different between the two instruments and between the different participating centres. CONCLUSIONS There were no significant differences in operating time and blood loss between the use of LigaSure and the use of conventional bipolar instruments during laparoscopic hysterectomy, even after correction for potential confounders. User satisfaction parameters were assessed as significantly different by surgeons of the participating centres.

LigaSure hemorrhoidectomy versus stapled hemorrhoidopexy: a prospective, randomized clinical trial

PURPOSE

This study was designed to compare the outcome of LigaSure hemorrhoidectomy and stapled hemorrhoidopexy for prolapsed hemorrhoids.

METHODS

Consecutive patients with grade III or IV hemorrhoids were randomly assigned to undergo either LigaSure hemorrhoidectomy or stapled hemorrhoidopexy. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, number of parenteral analgesic injections, duration of hospital stay, and time to return to work were all prospectively collected. Postoperative complications and recurrence of prolapse were also recorded. Patients were regularly followed for a total period of 12 months.

RESULTS

A total of 68 patients completed the study (34 per group). Patient demographic and clinical characteristics were similar in the 2 groups. No significant differences between LigaSure hemorrhoidectomy and stapled hemorrhoidopexy were observed in mean operating time, postoperative pain score, number of parenteral analgesic injections, duration of hospital stay, or time to return to work. The groups were also similar regarding postoperative complications, except that at 4 weeks postoperatively, residual prolapse was observed in 8 patients (23.5%) in the stapled hemorrhoidopexy group vs. 2 patients (5.9%) in the LigaSure group (P = .040). Rate of recurrence of prolapse at 1 year was higher with stapled hemorrhoidopexy (4 patients, 11.8%) than with the LigaSure procedure (1 patient, 2.9%), but the difference was not significant (P = .163).

CONCLUSIONS

LigaSure hemorrhoidectomy and stapled hemorrhoidopexy yield comparable good results, with a short operative time and minimal side effects in the treatment of grade III and IV hemorrhoids, but with a lower rate of residual prolapse for the LigaSure procedure. Both procedures offer low levels of postoperative pain and therefore are excellent therapeutic options for prolapsed grade III and IV hemorrhoids. A larger controlled study is needed to reach solid conclusions regarding risk of postoperative recurrence of hemorrhoidal prolapse.