Aust. N.Z. J . Surg (1996) 66, 830-831

SURGICAL TECHNIQUE

SUTURE HAEMORRHOIDECTOMY: A DAY-ONLY ALTERNATIVE

NIRMAL PATEL A N D TERENCE O ' C O N N O R

Department of Colorectal Surgery, St Vincent's Hospital, Sydney. New South Wales, Australia

Background: Haemorrhoidectomy is a common treatment for third degree symptomatic haemorrhoids. and day surgery has increased because of increasing pressure for hospital beds. The aim of the present study is to describe a technique of suture haemorrhoidectomy (SH), conducted as a day-only procedure, and compare the effectiveness and outcomes of this method with the conventional Milligan-Morgan haemorrhoidectomy (MMH). Methods: The results of 18 consecutive patients, mean age 52 years (31-73) undergoing SH between April 1994 and June 1995 were compared with a historical control group of 17 consecutive patients, mean age 45 years (29-72). who had MMH in the preceding year. Seven patients were excluded because of intercurrent anal pathology ( I ) , thrombosed haemorrhoids ( I ) or loss to follow-up (5). An interviewer followed up patients using a telephone questionnaire. Results: Mean follow-up was 6 months in the SH group and 18 months in the MMH group. There was no significant difference i n total operative time. The SH group had a significantly shorter mean time to first void of 3 h versus I I h (P < 0.005). mean time to first bowel action of 1 1 h versus 48 h ( P < 0.005) and mean in-hospital stay of 10 h versus 77 h (P < 0.005). The SH group had a significantly decreased linear analogue pain scale, a mean of 1 versus 3 (P < 0.05). The complications were: two readmissions for pain relief i n the SH group and urinary retention in one MMH patient. None of the study group have had recurrence of haemorrhoids. Conclusion: Suture haemorrhoidectomy as a day-only procedure is safe, less painful and reduces in-hospital admission time. The long-term effectiveness and complications of the technique are as yet undetermined.

, Key words: day-only surgery, haemorrhoid, haemorrhoidectomy.

INTRODUCTION Haemorrhoidectomy is a common treatment for third degree symptomatic haemorrhoids. Suturing as a method of treating symptomatic haemorrhoids is not new.',? Celsus (25 BC-AD 14) in De Medicina refers to the ligature of piles with flax thread.'

As pressure increases for hospital beds and waiting lists lengthen, the use of day surgery has increased. We describe a technique of suture haemorrhoidectomy. conducted as a day- only procedure. The aim of the present study is to compare the effectiveness and outcomes of suture haemorrhoidectomy (SH) with the conventional Milligan-Morgan open haemorrhoidec- tomy (MMH).

METHODS Between April 1993 and June 1995, forty-two patients under- went haemorrhoidectomy under the care of the same surgeon (TO'C). All patients had symptomatic second and third degree haemorrhoids considered unsuitable for phenol injection or rubber band ligation. The results of 18 consecutive patients, mean age 52 years (31-73), 10/18 male, undergoing SH between April 1994 and June 1995 were compared with a his- torical control group of 17 consecutive patients, mean age 45 years (29-72) 11/17 male, who had MMH in the preceding year.

An interviewer followed up patients using a telephone ques- tionnaire. Seven patients were excluded due to intercurrent anal

Correspondence: N. Patel, Flat I I E/30 Churchill Avenue, Strathfield, NSW 2135. Australia.

Accepted for publication 8 August 1996.

pathology ( I ) , thrombosed haemorrhoids ( I ) or loss to follow- up ( 5 ) . Data for time to first void and defecation were obtained either from hospital notes or by patient recall. Postoperative pain was assessed using a linear analogue pain scale (LAPS) at the time of first defecation as subjectively recalled by the patient.

All patients in the SH group were discharged on the same day of operation regardless of voiding or defecation status. In the MMH group, patients were discharged after they had voided, defecated and there was no further requirement for par- enteral analgesia.

Student's t-test with unequal variances was used to compare the two groups. Statistical analysis was performed using Micro- soft Excel Version 4.0.

The technique of suture haemorrhoidectomy Patients were placed early on the operating list, to allow maximal time for recovery. Minimal intra-operative fluid trans- fusion (< 1000 mL) was preferred, to prevent postoperative urinary retention. The patient was placed in the prone jacknife position with buttocks strapped apart to provide optimal exposure.

An assisted local anaesthesia technique was used. Fentanyl citrate and midazolam hydrochloride were given to sedate the patient. Lignocaine 1 % with adrenaline was injected to infiltrate the perianal skin and subcutaneous tissues, because it is less painful and acts rapidly. Approximately 5 mL were delivered through a 25 G needle. Bupivicaine 0.5% with adrenaline was administered into the external and internal sphincteric complex using a 23 G needle, 10 mL were used on each side at 3 and 9 o'clock in a radial fashion to the depth of the needle.

A half Simm's or Ferguson retractor assisted in exposing the

SUTURE HAEMORRHOIDECTOMY 83 I

haemorrhoid to be operated upon. A curved haemostat was placed on the haemorrhoid and used to retract the tissue toward the centre of the anal canal. Using 3/0 Vicryl on a curved tapered needle, three sutures were placed through the haemor- rhoidal tissue in the submucosal plane. The first suture was placed at the apex of the haemorrhoid pedicle, the second at the dentate line and the third halfway between the previous two. More closely placed sutures can produce ischaemia and sloughing.

Diathermy was used to remove the haemorrhoidal tissue distal to the dentate line. This tissue was dissected off the anal sphincters, being careful to leave adequate tissue distal to the dentate line to prevent slipping of a ligature. By careful needle placement and accurate diathermy dissection there should be minimal damage to the anal sphincter musculature.

Careful attention was given to haemostasis. Other affected haemorrhoids were removed in a similar manner One or more pedicles may be suitable for pneumatic banding and phenol injection without the need for suture and excision.

A 100 mg indomethacin suppository was placed i n the rectum and Anal Spongastan (Ferrosan, Denmark) used for a dressing (non-steroidal anti-inflammatory drugs "SAID] are avoided in patients with an allergy to the medication, a history of peptic ulceration or renal impairment). All patients received detailed instructions on postoperative stool softening and pain relief. Med- ications on discharge included dextropropoxyphene, indometh- acin (25 mg t.d.s. for 4 days), ranitidine (300 mg nocte for4 days) to counteract the gastric erosive effects of indomethacin, coloxyl (docusate sodium), metamucil (psyllium husk) and topical proc- tocort (cinchocaine hydrochloride, hydrocortisone) ointment. Although not used in this group of patients, endone (oxycodone hydrochloride) could be used in some patients, lactulose 20-30 mL nocte may be required to counter the constipating effect.

All patients were contacted the following morning to ensure that analgesia was adequate, voiding had occurred and there had been no excessive blood loss.

RESULTS The two groups were well matched for age. There was no sig- nificant difference in total operative time (Table I ) . The MMH patients had all three haemorrhoids removed, compared to a mean of 2.5 haemorrhoids in the SH group.

Mean follow-up was 6 months in the SH group and 18 months in the MMH group. The SH group had a significantly shorter mean time to first void of 3 h versus 1 I h (P < 0.005). mean time to first bowel action of I I h versus 48 h ( P < 0.005) and mean in-hospital stay of 10 h versus 77 h (P < 0.005). The SH group had a significantly decreased LAPS on first defeca- tion, a mean of 1 versus 3 (P < 0.05; Table 2).

Table 1. The number of sigmoidoscopies and colonoscopies performed

SH MMH

Table 2. Tabulated results summary*

SH MMH P

Mean time to first void ( h ) 3 (1-7) 1 1 (2-24) 0.005 Mean time to first bowel

Mean in-hospital stay ( h ) 10 (2-36) 77 (20-132) 0.005 LAPS on first bowel motion I (0-4) 3 (1-4) 0.05

action (h) I I (2-28) 48 (3-116) 0.005

*Results are expressed as mean and range. SH, suture haemorrhoidectomy; MMH, Milligan-Morgan haemorrhoid-

ectomy; LAPS, linear analogue pain scale.

Two patients in the SH group were readmitted for pain relief; they were both discharged when parenteral analgesia was not required (their total length of stay was 32 and 36 h, respec- tively). Urinary retention occurred i n one MMH patient and in none of the SH patients. None of the study group have had recurrence of haemorrhoids.

DISCUSSION Suturing haemorrhoids interrupts vascular flow i n the tissue. The sutured vessels subsequently undergo thrombosis and fibrosis, to produce scar tissue.

Our results agree with larger studies of simple pile suturing, showing a decreased mean time to first void, mean time to first bowel motion, mean in-hospital stay and pain on first defeca- tion in the SH group.' The two patients readmitted for pain relief in the SH group were both non-English speakers and failed to understand the postoperative instructions.

We believe that suture haemorrhoidectomy is less painful than the Milligan-Morgan haemorrhoidectomy because there is less tissue dissection. The commencement of the sensitive anoderm is variable in its position.' Internal sphincter spasm is thought to contribute significantly to postoperative haemor- rhoidectomy pain. I Less dissection leads to reduced internal sphincter spasm and reduced pain.

The present study has several flaws that could confound results. First, the number of patients in each group is low. Second, the study is retrospective and relies on subjective meas- ures for some results (e.g. pain on defecation).

Subject to these limitations, suture haemorrhoidectomy as a day-only procedure is safe, less painful and reduces in-hospital admission time. The long-term effectiveness of the technique is as yet undetermined.

ACKNOWLEDGEMENT

Number of sigmoidoscopies 10 9 Number of colonoscopies 8 8 Mean total operative time (min) 33 30

SH. suture haemorrhoidectomy; MMH, Milligan Morgan haemorrhoid-

I .

2.

ectomy. 3.

We would like to thank Yuvisthi Naidoo (BEc Hons) for assis- tance with statistical analysis.

REFERENCES Keighley M, Williams NJ. Surgery of the Anus. Rectum and Colon. Saunders. 1993; 339-40, 352. Farag AE. Pile suture: A new technique for the treatment of haemorrhoids. Br. J . Surg 1978; 65: 293-5. Williams P. Gray's Anatomy, 37th edn. Livingstone. 1989.