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Introduction
Open haemorrhoidectomy, as described by Milligan et al
in 1937, has been accepted worldwide as the best choice
for treatment of symptomatic haemorrhoids.1,2 Although
this technique is safe and effective, it is associated with
postoperative pain because of external wounds in the
sensitive perianal skin and requires local care because
of prolonged discharge from the anal skin wounds.
As a matter of fact, surgical haemorrhoidectomy has a
reputation for being a painful procedure for a fairly benign
disease and for these reasons, the technique is not well
Address correspondence and reprint requests to Dr Davide Lomanto, Minimally Invasive Surgical Centre, Department of
General Surgery, Yong Loo Lin School of Medicine, National University of Singapore, 5 Lower Kent Ridge Road,
Singapore 119074.
E-mail: surdl@nus.edu.sg Date of acceptance: 22 March 2006
2007 Elsevier. All rights reserved.
29
Surgical technique
The procedure was performed under general anaesthesia in
264 patients (88%) and in 36 (12%) using spinal anaesthesia.
Table 1. Characteristics of patients who underwent stapled
haemorrhoidopexy
Number of patients
496
Sex ratio
Male:female = 252:244
43 (2177)
Grade of haemorrhoids in
300 patients with longer
follow-up, n (%)
II
30
IV
54 (18%)
18 after failure of
sclerotherapy
24 after failure of rubber
band ligation
216 (72%)
Six after previous M-M
haemorrhoidectomy
30 (10%)
264 (88)
36 (12)
Position, n (%)
Lithotomy
Jack-Knife
282 (94)
18 (6)
23 4 (1245)
2.3 (14)
184 (37)
6 (1.2)
6 (1.2)
VAS
10
9
8
7
6
5
4
3
2
1
0
Postoperative care
All patients were admitted for overnight observation and
discharged home the day after the operation. Stool softening agents and oral analgesics were prescribed. Oral
metronidazole was also prescribed (500 mg tid) for 3 days
postoperatively.
Follow-up study
All patients were followed up at fixed intervals: 2 weeks,
1 month, 3 months, 6 months and at intervals of 1 year.
An interview with per rectal examination was done at
6 months after operation and, subsequently, proctoscopy
was also performed every 12 months.
Results
Regarding our early results with our series of patients, the
duration of the procedure ranged from 12 to 45 minutes
(mean, 23 4). Intraoperative bleeding from the staple
line occurred in 184 (37%) of our total number of patients
(n = 496) and was treated with absorbable suture to stop
ooze bleeding. In eight cases (1.6%), the mucosal resected
doughnut was found to be incomplete, and again the
defect was oversewn with 3-0 absorbable suture. Patients
assessed their pain on a visual analogue scale (VAS) ranging
from 0 to 10 at 1, 5, 10 and 15 days postoperatively. Eightyone percent (n = 403) reported, after 24 hours, values ranging from 2 to 4 (mean, 2.3) and after 5 days, from 1 to 3
(mean, 1.9) (Figure). In six patients (1.2%), for different
reasons (breakage of the suture = 4; inadvertent
5
10
7 8
Days
15
10 11 12 13 14 15
Figure. Visual analogue scale (VAS) assessment at 1, 5, 10 and 15 days after operation.
31
n (%)
Bleeding
Urinary retention
Temporary gas incontinence
Anal fissure
Stricture
21 (4.2)
27 (5.5)
6 (2.8)
4 (1.3)
11 (3.6)
Patients, n (%)
Treatment
2 (0.6)
2 (0.6)
3 (1)
23 (7.6)
5 (1.6)
Conservative
Conservative
Conservative
Digital dilation
Surgery
18 (6)
4 (1.3)
Surgery
Surgery
32
Discussion
The management of posthaemorrhoidectomy pain has
always been a major concern for surgeons and the main
reason for refusing surgery by patients. Multiple complementary treatments have been proposed to reduce postoperative pain, including the use of different surgical
instruments (diathermic scalpel, bipolar scissors, laser,
ultrasonic forceps), local and/or systemic injection of
analgesics, antibiotics. All of these treatments have yielded
unsatisfactory results, because the main unsolved problem
is that the sensitive anal mucosa is severely traumatized
during the removal of haemorrhoids.
The operation proposed by Longo does not damage
the anal mucosa, which is lifted higher up in the anal
canal by resection of a variable ring of insensitive mucosa
of the anorectal junction. It is the redundant mucosa that
is resected and not the haemorrhoids when a stapled
anopexy is performed; the blood supply to the haemorrhoidal tissue is interrupted by excision of the submucosal layer in which the vessels run. Several prospective
randomized trials have demonstrated that, after short
and medium follow-up, this new technique is as effective
as the standard M-M operation, but better tolerated by
patients owing to less postoperative pain and an earlier
return to work.715
In our series, intraoperative problems were minor.
Bleeding at the staple line was identified in 37% of
patients. Bleeding is more an integral part of this operation rather than a complication. Attention to haemostasis along the staple line is a requirement in every case and
undertaking this step can possibly prevent postoperative
bleeding. We had a completely different experience with
the latest model of the PPH stapler (PPH03). Our initial
experience in more than 40 cases showed a significant
decrease in the incidence of intraoperative bleeding, with
References
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