|Year : 2016 | Volume
| Issue : 1 | Page : 1-6
An evaluation of postoperative pain relief in open hemorrhoidectomy with and without lateral sphincterotomy
Aaron Marian Fernandes, Leo Francis Tauro
Department of General Surgery, Father Muller Medical College, Mangalore, Karnataka, India
|Date of Web Publication||5-May-2016|
Aaron Marian Fernandes
Department of General Surgery, Father Muller Medical College, Mangalore - 575 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Hemorrhoids are a common human disease for which the best option available for the surgical management has remained conventional open hemorrhoidectomy. The most common complication of open hemorrhoidectomy is postoperative pain caused by spasm of the internal sphincter. Lateral sphincterotomy is a commonly performed procedure for relieving spasm and pain. Hence, we decided to evaluate whether addition of lateral sphincterotomy along with hemorrhoidectomy can help in the postoperative pain relief. Aim: Comparison of postoperative pain after hemorrhoidectomy with and without lateral internal sphincterotomy. Settings and Design: This was a prospective study conducted between November 2013 and December 2015 on 102 consenting patients who chose conventional open hemorrhoidectomy after obtaining an ethical clearance for the study. Subjects and Methods: The patients were randomized into two groups using the lottery method. Group A in addition to conventional open hemorrhoidectomy received lateral internal sphincterotomy. In Group B, only conventional open hemorrhoidectomy was performed. Pain assessment was done on the day - 0, 1, 2, and 7, respectively, by visual analog scale. Statistical analysis was done using Chi-squared test (two-tailed) and a P < 0.005 was considered statistically significant. Results: On assessment of pain on the day - 0, 1, 2, and 7, respectively, by visual analog scale; we found statistically significant pain relief in the group whom lateral sphincterotomy was added. Conclusions: In this study, we conclude that in conventional open hemorrhoidectomy for 2 nd degree hemorrhoids addition of lateral sphincterotomy is an effective, convenient, and simple way to reduce the postoperative pain.
Keywords: Hemorrhoidectomy, lateral sphincterotomy, pain
|How to cite this article:|
Fernandes AM, Tauro LF. An evaluation of postoperative pain relief in open hemorrhoidectomy with and without lateral sphincterotomy. Saudi Surg J 2016;4:1-6
|How to cite this URL:|
Fernandes AM, Tauro LF. An evaluation of postoperative pain relief in open hemorrhoidectomy with and without lateral sphincterotomy. Saudi Surg J [serial online] 2016 [cited 2021 Jun 15];4:1-6. Available from: https://www.saudisurgj.org/text.asp?2016/4/1/1/181807
| Introduction|| |
Hemorrhoids are common human afflictions since the dawn of history. Since the time, he assumed the upright position which leads to enormous pain, discomfort, and reduced quality of life. Many advances have occurred in the treatment of hemorrhoids recently, yet open hemorrhoidectomy remains the main stay of surgical therapy for hemorrhoids worldwide. Postoperative pain is one of the most common complications of conventional open hemorrhoidectomy. Lateral internal sphincterotomy is commonly used procedure for relieving spasm and pain in fissure in ano.  In our study, we decided to evaluate the postoperative pain relief in open hemorrhoidectomy with and without lateral sphincterotomy.
| Subjects and Methods|| |
This was a prospective study conducted at Father Muller Medical College, Mangalore, Karnataka, India between November 2013 and December 2015, after obtaining an ethical clearance for the study.
Patients who were chosen were explained of the various options available for the treatment of hemorrhoids along with their advantages and disadvantages, and they were allowed to choose the line of treatment they preferred. One hundred and two patients who choose conventional open hemorrhoidectomy as the treatment modality were included in the study.
All consenting patients who were symptomatic for 2 nd degree hemorrhoids were chosen by purposive sampling technique after they met the predefined criteria.
- Patients who had undergone prior intervention for hemorrhoids
- Patients on evaluation found to have pathological hemorrhoids or bleeding tendencies
- History and clinical examination and who were not fit for anesthesia
- Patients who have neurological disorders, renal and liver dysfunction.
Patients were prepared for the procedure as follows. Patients were kept nil per oral for a minimum period of 6 h before surgery. Mechanical bowel cleansing was done using two phosphate enemas before the planned surgery, one at night and the other at the morning of surgery. A third generation cephalosporin along with intravenous doses of metronidazole was given an hour before and 6 h after the procedure followed by a course of oral antibiotics for a period of 5 days.
- Age between 20 and 60 years
- Available for follow-up.
The patients were randomized into two groups using lottery methods. Group A in addition to conventional open hemorrhoidectomy received lateral sphincterotomy. In Group B, only conventional open hemorrhoidectomy was performed.
Following the procedure hemostasis was confirmed, if any bleeding points were noted, they were controlled using cautery. Postoperatively, analgesic was given only if the patient had pain. Diclofenac 50 mg intramuscular preparation was used for analgesia, no analgesic was used for discomfort; following 3 h of intensive care in a high dependency postoperative ward patient was shifted to the ward.
Pain assessment was done on the day - 0, 1, 2, and 7, respectively, by visual analog scale which included scoring 0 to 10 [Figure 1].
- No pain: 00-01score
- Mild annoying pain: 02-03 score
- Nagging uncomfortable pain: 03-04 score
- Distressing miserable pain: 04-05 score
- Intense, dreadful, horrible pain: 06-07 score
- Worst, excruciating, unbearable pain: 07-08 score
- Severe pain: 09-10 score.
Patients were given sitz bath twice daily, and syrup lactulose 20 ml twice daily was used as a stool softener. Patients were discharged 48-72 h after the procedure if there were no complications occurred and were prescribed lactulose 20 ml twice daily along with sitz bath twice daily and a course of oral antibiotics until return of normal bowel function and they were stable with stool softeners. They were asked to review after a week for follow-up.
| Results|| |
Observation and results
In our study, we found the following results:
The test group in whom in addition to conventional open hemorrhoidectomy received lateral sphincterotomy had statistically significant lesser pain during the postoperative period with a Chi-squared test (two-tailed) and P < 0.0001 on day-0 [Table 1] and [Figure 2].
The test group in whom in addition to conventional open hemorrhoidectomy received lateral sphincterotomy had statistically significant lesser pain during the postoperative period with Chi-squared (two-tailed) and P < 0.0001 on day-1 [Table 2] and [Figure 3].
The test group in whom in addition to conventional open hemorrhoidectomy received lateral sphincterotomy had statistically significant lesser pain during the postoperative period with Chi-squared (two-tailed) and P < 0.0001 day-2 at the time of discharge, there was no difference in the pain perception in the group A on day-1 and day-2 [Table 3] and [Figure 4].
The test group in whom in addition to conventional open hemorrhoidectomy received lateral sphincterotomy had lesser pain during the postoperative period on day-7 at the time of follow-up [Table 4] and [Figure 5].
| Discussion|| |
Hemorrhoids are one of the oldest and most common problems which have been tormenting humanity since the beginning of history.  Studies done at the Mayo Clinic as early as 1960 recorded the prevalence of 52% in a large series of patients examined proctoscopically suggesting that the incidence of patients suffering from hemorrhoids is quite significant.  Pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."  "Pain is what the patient says it is, and exists whenever the patient says it does."  Postoperative pain is usually attributed to conventional open hemorrhoidectomy as an unpleasant experience of the surgery. Assessment of pain can be a simple and straightforward task when dealing with acute pain and pain as a symptom of trauma or disease. Open hemorrhoidectomy remains the mainstay of surgical therapy for hemorrhoids worldwide. 
Postoperative pain is sequelae of conventional open hemorrhoidectomy, which is the main drawback of hemorrhoidectomy, especially in the 1 st postoperative week.  High anal canal pressure, especially in the younger patients was documented in studies related to patients with hemorrhoids. ,, Anal canal pressure remains mostly higher in younger patients due to tight internal sphincter (high tone) than the older people. Postoperative pain is attributed to the spasm of the internal sphincter that is exposed after open hemorrhoidectomy, especially in younger patients with higher anal tone. ,
Over the decade, several authors have reported a significant reduction of postoperative pain for conventional open hemorrhoidectomy and decrease in associated complications which was achieved by adding an internal sphincterotomy to hemorrhoidectomy.  A study done by Asfar et al.  reported that the routine performance of internal sphincterotomy through one of the hemorrhoidectomy wounds significantly reduces posthemorrhoidectomy pain and associated complications. Addition of internal sphincterotomy was found to be a suitable procedure to reduce posthemorrhoidectomy pain, but it is not totally devoid of transient complications in early postoperative period. It is more useful in young patients with higher anal pressure.
In our study, we evaluated 102 cases of which the most common age group suffering from hemorrhoids was 45-50 years followed by 35-40 years with 42 cases and 39 cases, respectively. In the cases treated all were primary 2 nd degree hemorrhoids, males had a higher incidence with the ratio being 1.83 with 66 males 36 females. The mean duration of hospital stay was 3.75 days (postoperatively) with the duration ranging from a minimum of 2 days to 7 days. Apart from postoperative pain, the most common complication was urinary retention which was seen in 7 males and 1 female. All males who had postoperative urinary retention were above 50 years.
In our study, we found that in patients who had an addition of lateral internal sphincterotomy to open hemorrhoidectomy, there was a lesser need for analgesia throughout the postoperative period as shown by the pain scales.
Das et al.  evaluated 50 patients (38 male, 12 female) aged between 24 and 50 years who were treated for 3 rd and 4 th degree hemorrhoids in a prospective randomized study. Patients were randomly divided into two equal groups. Group I (control group) were subjected to classical open hemorrhoidectomy and Group II (study group) were subjected to classical open hemorrhoidectomy along with a lateral internal sphincterotomy. They concluded that internal sphincterotomy can be safely added to hemorrhoidectomy, especially for younger patients to reduce the agonizing postoperative pain and associated complications.
A study by Galizia et al.  evaluated 42 consecutive patients with prolapsed pile. Forty-two patients were randomized: Group I (n = 22) patients underwent hemorrhoidectomy plus lateral internal sphincterotomy; Group II (n = 20) patients underwent hemorrhoidectomy alone justified by anorectal manometry. The study concluded that the addition of lateral internal sphincterotomy to hemorrhoidectomy seems to improves postoperative course related to symptoms of postoperative pain and associated complications.
Kanellos et al.  evaluated 78 patients with 4 th degree hemorrhoids and were divided into two groups. Patients from Group I underwent Milligan-Morgan hemorrhoidectomy. Patients from Group II, quite apart from Milligan-Morgan hemorrhoidectomy, underwent lateral internal sphincterotomy up to the dentate line. The results of the study showed that after the first bowel movement, there were 3 (7.7%) patients who did not experience any pain in the internal sphincterotomy group, while in the noninternal sphincterotomy group, all patients experienced mild or moderate pain.
Diana et al.  studied 699 patients with II Grade, III Grade, IV Grade hemorrhoids with 16, 464, and 219 patients, respectively, and found that lateral internal sphincterotomy reduces pain significantly only in the first postoperative period, but not in the medium- and long-term follow-up. The comparison of our findings with other studies is mentioned in [Table 5].
| Conclusions|| |
Addition of lateral internal sphincterotomy decreased postoperative pain and also reduced the need for postoperative analgesia in a significant number of patients.
Hence, through this study, we concluded that in conventional open hemorrhoidectomy for 2 nd degree hemorrhoids, addition of lateral internal sphincterotomy is an effective, convenient, and simple way to reduce the postoperative pain.
Financial support and sponsorship
- To all the unit heads of the surgical units for supporting in conducting the study
- To the administration of the institution for allowing to conduct the study
- To the anesthesia and general residence for their prompt services whenever required.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Liratzopoulos N, Efremidou EI, Papageorgiou MS, Kouklakis G, Moschos J, Manolas KJ, et al.
Lateral subcutaneous internal sphincterotomy in the treatment of chronic anal fissure: Our experience. J Gastrointestin Liver Dis 2006;15:143-7.
Buie LA. Practical Proctology. Vol. 2. Springfield: Charles C Thomas; 1960. p. 737-40.
Welling DR, Wolff BG, Dozois RR. Piles of defeat. Napoleon at Waterloo. Dis Colon Rectum 1988;31:303-5.
Teunissen SC, Wesker W, Kruitwagen C, de Haes HC, Voest EE, de Graeff A. Symptom prevalence in patients with incurable cancer: A systematic review. J Pain Symptom Manage 2007;34:94-104.
Bajwa ZH, Warfield CA. Overview of Cancer Pain; 2007.
Agbo SP. Surgical management of hemorrhoids. J Surg Tech Case Rep 2011;3:68-75.
Allen-Mersh TG, Mann CV. Open haemorrhoidectomy (ST Mark's ligation/excision method). In: Fielding LP, editor. Operative Surgery. Surgery of the Colon, Rectum & Anus. 5 th
ed. London: Butterworth Heinemann Ltd.; 1993. p. 789-96.
Schouten WR, van Vroonhoven TJ. Lateral internal sphincterotomy in the treatment of hemorrhoids. A clinical and manometric study. Dis Colon Rectum 1986;29:869-72.
Favetta U, Amato A, Interisano A, Pescatori M. Clinical, manometric and sonographic assessment of the anal sphincters. A comparative prospective study. Int J Colorectal Dis 1996;11:163-6.
Mathai V, Ong BC, Ho YH. Randomized controlled trial of lateral internal sphincterotomy with haemorrhoidectomy. Br J Surg 1996;83:380-2.
Kanellos I, Zacharakis E, Christoforidis E, Angelopoulos S, Kanellos D, Pramateftakis MG, et al.
Usefulness of lateral internal sphincterotomy in reducing postoperative pain after open hemorrhoidectomy. World J Surg 2005;29:464-8.
Khubchandani IT. Internal sphincterotomy with hemorrhoidectomy does not relieve pain: A prospective, randomized study. Dis Colon Rectum 2002;45:1452-7.
Asfar SK, Juma TH, Ala-Edeen T. Hemorrhoidectomy and sphincterotomy. A prospective study comparing the effectiveness of anal stretch and sphincterotomy in reducing pain after hemorrhoidectomy. Dis Colon Rectum 1988;31:181-5.
Das DK, Choudhury UC, Lim ZS. Effectiveness of internal sphincterotomy in reducing post open hemorrhoidectomy pain: A randomized comparative clinical study. Int J Collab Res Intern Med Public Health 2013;5:428-33.
Galizia G, Lieto E, Imperatore V, Pelosio L, Castellano P. The usefulness of lateral internal sphincterotomy combined with hemorrhoidectomy in the treatment of hemorrhoids: A randomized prospective study. G Chir 2000;21:127-34.
Diana G, Guercio G, Cudia B, Ricotta C. Internal sphincterotomy reduces postoperative pain after Milligan Morgan haemorrhoidectomy. BMC Surg 2009;9:16.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]