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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 1  |  Page : 24-29

Harmonic scalpel versus conventional hemorrhoidectomy


Department of General Surgery, Faculty of Medicine, Al-Azhar University, New Damietta, Egypt

Date of Submission02-Oct-2018
Date of Acceptance10-Apr-2019
Date of Web Publication12-Sep-2019

Correspondence Address:
Hazem A Megahed
Hassan Said Street from Ahmed Maher Street, Elmansoura, 35511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_104_18

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  Abstract 


Introduction In this study, harmonic scalpel hemorrhoidectomy was compared with the classical Milligan–Morgan hemorrhoidectomy regarding the outcome and the postoperative complication rates.
Patients and methods Between June 2014 and September 2018, 40 patients aged between 30 and 60 years old underwent a hemorrhoidectomy operation in Al-Azhar University Hospital, New Damietta. The patients were randomly subdivided into two groups: group A included 20 patients who underwent the classical Milligan–Morgan hemorrhoidectomy operation, which represented the conventional method, and group B included 20 patients who underwent a hemorrhoidectomy with the use of a harmonic scalpel. The outcome and postoperative complications were compared between the two groups.
Results In the harmonic scalpel group (group B), the posthemorroidectomy static pain was significantly lesser on the postoperative days 3, 7, and 14, but it was nonsignificantly lesser on the first postoperative day. Moreover, there was significant decrease in mean hospital stay in group B (1.0±0.2 days) vs. in group A (conventional method group) (1.3±0.4 days). The operative time was significantly decreased in group B (15±1.1 min) versus group A (20±2.1 min). Regarding early complications such as minor bleeding and urinary retention, they were lesser in group B, but without significance.
Conclusion Harmonic scalpel hemorrhoidectomy is a less time-consuming bloodless procedure and has lesser postoperative pain and bleeding when compared with conventional hemorrhoidectomy.

Keywords: conventional hemorrhoidectomy, harmonic scalpel, hemorrhoidectomy


How to cite this article:
Megahed HA. Harmonic scalpel versus conventional hemorrhoidectomy. Al-Azhar Assiut Med J 2019;17:24-9

How to cite this URL:
Megahed HA. Harmonic scalpel versus conventional hemorrhoidectomy. Al-Azhar Assiut Med J [serial online] 2019 [cited 2019 Oct 22];17:24-9. Available from: http://www.azmj.eg.net/text.asp?2019/17/1/24/266727




  Introduction Top


Hemorrhoidal disease is a very prevalent disorder that arises from engorgement of internal and/or external vascular plexuses surrounding the anal canal [1]. The fundamental symptoms are bleeding, pain, prolapsing, and itching [2],[3]. The disease has four grades. Surgical treatment is the first choice in patients with grade III or grade IV hemorrhoids who have symptoms. Unluckily, the procedure may have significant postoperative complications such as pain, bleeding, and anal stricture, which may delay the patient discharge from the hospital [1],[4].

The newly developed surgical equipment such as bipolar-diathermy, harmonic, and ligasure scalpels in addition to circular staplers are recently used in the surgical treatment of hemorrhoids, and the results are good regarding the lesser bleeding and better pain control, which decreased the need for analgesics postoperatively when compared with hemorrhoidectomies performed with the conventional surgical methods [5],[6],[7]. The previous advantages of harmonic scalpel hemorrhoidectomy are owing to better hemostasis and lesser tissue damage [5],[6].

The aim of this study is to make a comparison between harmonic scalpel hemorrhoidectomy and the classical Milligan–Morgan hemorrhoidectomy regarding outcomes and complications.


  Patients and methods Top


Between June 2014 and September 2018, 40 patients aged between 30 and 60 years old underwent a hemorrhoidectomy operation for grade III or grade IV internal hemorrhoids in the Department of Surgery, Al-Azhar University Hospital, New Damietta. Approval of the ethical committee of Al-Azhar University and a written informed consent from all the patients were obtained. The patients were randomly subdivided into two groups:
  • Group A: 20 patients who underwent a hemorrhoidectomy performed with classical Milligan–Morgan hemorrhoidectomy, which represented the conventional method.
  • Group B: 20 patients who underwent harmonic scalpel hemorrhoidectomy.


Inclusion criteria for surgical treatment include patients presented with grade III or grade IV hemorrhoids.

Exclusion criteria included patients with previous anorectal surgery; patients with associated anorectal pathology such as perianal fistula or fissure; patients with acute thrombosed hemorrhoids, uncontrolled diabetes, or previous cerebrovascular accidents; and patients with liver cirrhosis, hemorrhagic blood diseases, anticoagulant use or cancer.

All patients underwent complete history taking, complete physical examination (both general and local), sigmoidoscopic examination, routine preoperative investigations such as ECG and chest radiography, routine clinical laboratory tests, and urine analysis. The patients were admitted to the surgery department in the hospital one day before the operation to be prepared for the operation. The patient is instructed to do a glycerin enema 12 h before surgery, and the nurse is instructed to give the patient prophylactic antibiotic before going to the surgical room. Patients were discharged from hospital 24 h after the surgery if they had no complications postoperatively.

Harmonic scalpel was used intraoperatively for the first time in the year 1992 [8]. By converting ultrasound waves to thermal energy, the harmonic scalpel can seal blood vessels with minimal thermal spread, minimizing the tissue damage and giving the surgeon a bloodless shorter time operation. Many general surgery procedures have become more easier after introduction of harmonic scalpel such as hemorrhoidectomy, cholecystectomy, and thyroidectomy. Regarding hemorrhoidectomy, a lot of centers perform it nowadays routinely by the usage of harmonic scalpel. This is owing to the advantage of harmonic scalpel in minimizing the postoperative pain [9].

Surgical technique

Under spinal anesthesia, patients were placed in a lithotomy position ([Figure 1]). The anus is exposed by attaching tape to both sides of the buttocks. Situation of hemorrhoids was determined with an anoscope. In this study, the conventional method performed was the classical Milligan–Morgan hemorrhoidectomy in which dissection of the hemorrhoid and ligation of the vascular pedicle was done with preservation of the underlying anal sphincter complex.
Figure 1 3rd degree piles in lithotomy position.

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In harmonic scalpel hemorrhoidectomy, excision of hemorrhoids was done with the help of vascular forceps and without damaging the internal anal sphincter ([Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]).
Figure 2 Grasping of hemorrhoid by Allis.

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Figure 3 Harmonic scalpel haemorroidectomy.

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Figure 4 Harmonic scalpel haemorroidectomy.

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Figure 5 Harmonic scalpel haemorroidectomy.

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Figure 6 Harmonic scalpel haemorroidectomy.

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A lignocaine-soaked multiple elongated wrapped gauss was inserted in the anal canal postoperatively to control pain and to help in hemostasis ([Figure 7]). Diclofenac potassium tablets, metronidazole tablets, and lactulose syrup were prescribed three times daily postoperatively.
Figure 7 Lignocaine soaked gause insertion after hemorroidectomy.

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Scores of pain at rest and after defecation were recorded on visual analog scale (VAS) from 0 to 10. The patients were evaluated for early and late complications such as hemorrhage, retention of urine, anal verge stenosis, fecal incontinence, and anal sepsis or gangrene just after the operation and along the period of follow-up. Bleeding was considered major if the patient needed blood transfusion, reoperation, or close observation for the vital signs.

Patients were followed up on the first and third days and at 1, 2, 3, 6, 12 weeks after surgery, and the patients were assessed by other assessors who were blind to the type of operation done for the patient.

Verbal and written consent was obtained from each patient, and randomization was done by making odd number patients for group A and even number patients for group B.

During hemorrhoidectomy, keeping of skin bridges between the excised hemorrhoids was put in mind to avoid anal stenosis whatever the technique of excision used. Sites of hemorrhoids excision were left to heal by secondary intention.

Statistical analysis

It was done by the usage of the Statistical Package for Social Science (SPSS), version 18 (IBM, SPSS, Chicago, Illinois, USA). Qualitative variables between the two groups were compared by using Pearson χ2 test, whereas quantitative variables were done by using the independent samples t test. Significant data were referred when P values were less than 0.05.


  Results Top


Regarding the demographic data, there were no statistical variations between the two groups ([Table 1]).
Table 1 Demographic data

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The postoperative static pain was significantly lower on the postoperative days 3, 7, and 14 but it was nonsignificantly lower on the first postoperative day. There was significant decrease in mean hospital stay in days (1.0±0.2) in harmonic scalpel group versus (1.3±0.4) in conventional method group. Moreover, the operative time in minutes was significantly decreased in harmonic scalpel group (15±1.1) versus conventional method group (20±2.1) ([Table 2]).
Table 2 Comparison of the outcomes of the hemorrhoidectomies

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Regarding early complications such as minor bleeding and urinary retention, they were lesser in harmonic scalpel group but without significance ([Table 3]).
Table 3 Complications of hemorrhoidectomies

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  Disscussion Top


Hemorrhoidectomy is the standard treatment for grade III or grade IV internal hemorrhoids; in spite of this, pain after conventional hemorrhoidectomy is still a major challenge. Several devices such as harmonic and ligasure scalpels have been developed for reducing intraoperative bleeding, postoperative pain, and postoperative complications such as bleeding, anal incontinence, and anal stenosis [4],[10].

The harmonic scalpel was used for coagulation and cutting simultaneously and exhibited minimal surrounding thermal spread (<2 mm) and limited tissue charring which contributed to lower postoperative pain, reduced risk for infection, and faster wound healing [11].

Moreover, the harmonic scalpel exhibited less intraoperative blood loss, better exposure of the operative field, and lesser operative time [12].

Ravi Kumar and colleagues conducted a study on 60 patients to compare harmonic scalpel hemorrhoidectomy with conventional open method (Milligan–Morgan); they found that the VAS pain scores at days 1, 7, and 14 postoperatively were lesser in harmonic scalpel group compared with Milligan–Morgan group. Moreover, the blood loss during the procedure was lesser in harmonic scalpel group (6.1 ml for harmonic scalpel group vs. 19.4 for Milligan–Morgan group). Other postoperative complications such as hemorrhage and urinary retention were more in Milligan–Morgan group [13].

Lim and colleagues conducted a prospective study on 50 patients who had grade III or grade IV internal hemorrhoids. Hemorrhoidectomy operation was done for all patients: 25 by harmonic scalpel and 25 sutured by 3-0 vicryl material after excision (conventional method). The harmonic scalpel group had a shorter procedure time, lesser pain in the postoperative period as assessed by the VAS, and lesser postoperative hemorrhage (P=0.034). The postoperative complications showed no significant variations between the two groups [14].

Bulus and colleagues concluded that hemorrhoidectomy done by harmonic scalpel is more safe and effective, has fewer complications, and causes lesser blood loss and lesser postoperative pain when compared with conventional techniques. Their results were significant regarding operative time, mean hospital stay, and postoperative static pain for postoperative days 1, 7, and 28, respectively. The postoperative complications such as bleeding, anal incontinence, and anal stenosis were lesser in HS hemorrhoidectomy group but without significance [6].

Talha and colleagues showed that both harmonic scalpel and ligasure were superior to conventional diathermy in hemorrhoidectomy, in having lesser operative time, lesser postoperative pain, and lesser analgesic consumption during the first day postoperatively in addition to faster wound healing [15].

Abo-Hashem and colleagues reported a significant fast wound healing in harmonic scalpel hemorrhoidectomy. They attributed this higher rate of wound healing at 6 weeks postoperatively to the minimal tissue trauma, minimal charring, lesser local edema in the surrounding tissues, and absence of tissue necrosis [16].

Both Ozer and colleagues and Abo-Hashem and colleagues concluded that harmonic scalpel hemorrhoidectomy is superior to conventional hemorrhoidectomy regarding significant reduction in postoperative pain scoring, induction of better hemostasis of the wound, and lesser consumption of analgesic [16],[17].

Chung and colleagues compared the results of hemorrhoidectomy done by three different techniques: scalpel of harmonic, bipolar scissors, or by excision-ligation technique (Milligan–Morgan) using the ordinary surgical scissor. Both harmonic scalpel hemorrhoidectomy and bipolar scissors hemorrhoidectomy showed better results than Milligan–Morgan hemorrhoidectomy regarding reduction of blood loss. Harmonic scalpel hemorrhoidectomy had the lowest pain score and best satisfaction score when compared with the other two methods [18].

However, Tan and colleagues showed that harmonic scalpel was nearly similar to diathermy hemorrhoidectomy regarding postoperative pain and complications, which is different from the previous studies.

In this study, the static pain after the procedure was significantly lower on the postoperative days 3, 7, and 14 but it was nonsignificantly lower on the first postoperative day, and this was in agreement with the previous studies. Moreover, there was significant decrease in mean hospital stay in days (1.0±0.2 in harmonic scalpel group in comparison with 1.3±0.4 in conventional method group). Moreover, the operation time in minutes was significantly decreased in harmonic scalpel group (15±1.1) versus conventional method group (20±2.1). Regarding early complications such as minor bleeding and urinary retention, they were lesser in harmonic scalpel group, but without significance. These results are also in agreement with the previous studies.


  Conclusion Top


Harmonic scalpel hemorrhoidectomy is less time-consuming bloodless procedure and has lesser postoperative pain and bleeding when compared with conventional hemorrhoidectomy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ho YH, Seow-Choen F, Tan M, Leong AF. Randomized controlled trial of open and closed hemorrhoidectomy. Br J Surg 1997; 84:1729–1730.  Back to cited text no. 1
    
2.
Riss S, Weiser FA, Schwameis K, Riss T, Mittlbock M, Steiner G, Stift A. The prevalence of hemorrhoids in adults. Int J Colorectal Dis 2012; 27:215–220.  Back to cited text no. 2
    
3.
Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation.An epidemiologic study. Gastroenterology 1990; 98:380–386.  Back to cited text no. 3
    
4.
Goligher JC, Graham NG, Clark CG, De Dombal FT, Giles G. The value of stretching the anal sphincters in the relief of post-haemorrhoidectomy pain. Br J Surg 1969; 56:859–861.  Back to cited text no. 4
    
5.
Jayne DG, Botterill I, Ambrose NS, Brennan TG, Guillou PJ, O’Riordain DS. Randomized clinical trial of ligasure versus conventional diathermy for day-case haemorrhoidectomy. Br J Surg 2002; 89:428–432.  Back to cited text no. 5
    
6.
Bulus H, Tas A, Coskun A, Kucukazman M. Evaluation of two hemorrhoidectomy techniques: harmonic scalpel and Ferguson’s with electrocautery. Asian J Surg 2014; 37:20–23.  Back to cited text no. 6
    
7.
Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev 2006; 4:CD005393.  Back to cited text no. 7
    
8.
Chung CC, Cheung HY, Chan ES, Kwok SY, Li MK. Stapled hemorrhoidopexy vs. harmonic scalpel hemorrhoidectomy: a randomized trial. Dis Colon Rectum 2005; 48:1213–1219.  Back to cited text no. 8
    
9.
Tan JJ, Seow-Choen F. Prospective, randomized trial comparing diathermy and harmonic scalpel hemorrhoidectomy. Dis Colon Rectum 2001; 44:677–679.  Back to cited text no. 9
    
10.
Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP. Meta-analysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy. Arch Surg 2007; 142:1209–118; discussion 1218.  Back to cited text no. 10
    
11.
Sayfan J, Becker A, Koltun L. Sutureless closed hemorrhoidectomy: a new technique. Ann Surg 2001; 234:21–24.  Back to cited text no. 11
    
12.
Khanna R, Khanna S, Bhadani S, Singh S, Khanna AK. Comparison of ligasure hemorrhoidectomy with conventional Ferguson’s hemorrhoidectomy. Indian J Surg 2010; 72:294–297.  Back to cited text no. 12
    
13.
Ravi Kumar GV, Madhu BS, Vishal T, Navin Kumar Reddy M, Pawar PM. Harmonic scalpel compared with conventional open (Milligan-Morgan) method in surgical management of symptomatic haemorrhoids. Int Surg J 2017; 4:2010–2013.  Back to cited text no. 13
    
14.
Lim DR, Cho DH, Lee JH, Moon JH. Comparison of a hemorrhoidectomy with ultrasonic scalpel versus a conventional hemorrhoidectomy. Ann Coloproctol 2016; 32:111–116.  Back to cited text no. 14
    
15.
Talha A, Bessa S, Abdel Wahab M. Ligasure, harmonic scalpel versus conventional diathermy in excisional haemorrhoidectomy: a randomized controlled trial. ANZ J Surg 2017; 87:252–256.  Back to cited text no. 15
    
16.
Abo-Hashem AA, Sarhan A, Aly AM. Harmonic scalpel compared with bipolar electro-cautery hemorrhoidectomy: a randomized controlled trial. Int J Surg 2010; 8:243–247.  Back to cited text no. 16
    
17.
Ozer MT, Yigit T, Uzar AI, Mentes O, Harlak A, Kilic S et al. A comparison of different hemorrhoidectomy procedures. Saudi Med J 2008; 29:1264–1269.  Back to cited text no. 17
    
18.
Chung CC, Ha JP, Tai YP, Tsang WW, Li MK. Double-blind randomized trial comparing harmonic scalpel hemorroidectomy, bipolar scissors hemorroidectomy, and scissors excision : ligation technique. Dis Colon Rectum 2002; 45:789–794.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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