ORIGINAL ARTICLE

Outcome of Open haemorrhoidectomy versus Haemorrhoidal Artery

Ligation in the treatment of Hemorrhoids Grade 3 and 4
JAVERIA FARID1, ZEESHAN ZIA QURESHI2, BILAL RASOOL3, JAMSHED BASHIR4, SOHAIL YOUSIF5, SHAHNAWAZ
KHATTI6
1
Ex-Assistant Professor, General surgery department of Isra University Hospital Hyderabad
2
General surgeon, Liaquat University Hospital (LUH) Hyderabad
3
Senior registrar, General surgery department of LUMHS Jamshoro
4
Assosiate Professor, General surgery department of Muhammad Medical College Mirpurkhas
5
Consultant Surgeon, General surgery department of Muhammad Medical College Mirpurkhas
6
Senior registrar, General surgery department, LUMHS, Jamshoro
Correspondence to: Dr. Javeria Farid, Email: [email protected], Ph #: 03332522315

ABSTRACT
Objective: To determine the comparative outcome of Open haemorrhoidectomy (OA) versus Haemorrhoidal
Artery Ligation (HALs) with recto-anal repair (RAR) in the treatment of Hemorrhoids Grade 3rd and 4th at tertiary
care Hospital.
Material and methods: This comparative study was conducted at Isra university Hospital Hyderabad, from Jan
2017 and December 2017. All the patients presented with hemorrhoids grad III and IV and either of gender were
included. Patients were divided in two groups. Patients of (HALs group) underwent HA +/- RAR and the patients
of (OA group) underwent open haemorrhoidectomy. Outcome was evaluated in terms of post-operative
complications including post-operative pain and hospital stay. All the data was collected via study proforma. Data
was analyzed by using SPSS version 20
Results: Mean age of the patients HALs group was 34.56+4.22 years and OA group was 37.11+6.41. Males
were in majority in both groups as 20(80.0%) in HALs and 16(64.0%) in OA group. Average postoperative pain
(VAS) and post-operative Hospital stay were significantly lower in HALs group as compared to OA group
(p=0.001), while average of operative time was significantly lower in OA group (p-0.001). Postoperative
complications like urinary retention, bleeding and painful defecation were significantly higher in OA group as
compared to Hals group (p=0.001).
Conclusion: Haemorrhoidal Artery Ligation (HALs) with RAR found to be feasible and effective in terms of less
post-operative pain, less complications and less hospital stay in contrast to Open haemorrhoidectomy (OA) in the
treatment of 3rd and 4th degree Hemorrhoids.
Key words: Hemorrhoids, HALs, OA, Pain, Hospital stay

INTRODUCTION Haemorrhoidal Artery Ligation with RAR is the safe and the
Haemorrhoidal disease result from expansion of the plexus significantly painless surgical option with best results in the
of the hemorrhoids and the pathological alteration in the management of symptoms of haemorrhoids.8 On other
cushions of the anus, an anal canal normal component.1 hand it is observed that the Haemorrhoidal Artery Ligation
Intended causative factors are constipation, pregnancy, “HAL” is the more painful.1 However this study was
ageing, prolonged staining, obesity, internal anal instability, conducted to assess the comparative outcome of Open
hereditary factors, blood vessel weakness and the absence haemorrhoidectomy (OA) versus Haemorrhoidal Artery
of the valves in portal vein.2 Human erect posture is also Ligation (HALs) with recto-anal repair (RAR) in the
one of the suggested predisposing factors.2 Although in treatment of Hemorrhoids Grade 3rd and 4th at tertiary care
many studies, the exact pathologies still remains unclear Hospital.
of haemorrhoids.2,3 Around 4% of the population is affected MATERIAL AND METHODS
by the hemorrhoids and out of then 50% cases over fifty This comparative study was conducted at Isra university
years old suffer from the symptoms at certain points in their Hospital Hyderabad, from Jan 2017 and December 2017.
life.4 Internal hemorrhoids are categorized according to its All the patients presented with hemorrhoids grad III and IV
presence and the severity of prolapse as; grade I and either of gender were included. All the patients having
(hemorrhoids without prolapsing), grade II: (don straining hemorrhoids grade I and II, inflammatory bowel disease,
prolapsing hemorrhoids but spontaneously shrink), grade rectal malignancy and those who were not willing to
III; ( manually reductive prolapsing hemorrhoids) and grade participate in the study were excluded. Complete clinical
IV: ( un-reducible prolapsing haemorrhoids that comprises examination and required laboratory investigation were
the acutely thrombosed, incarcerated hemorrhoids.5,6 done. After taking informed consent patients were divided
Treatment strategies depends on the severity and nature of in two groups. Patients of (HALs group) underwent HA +/-
the haemorrhoids, preferences of the patients and surgeon RAR and the patients of (OA group) underwent open
expertise.5 Throughout the previous 2 decades the haemorrhoidectomy. Outcome was evaluated in terms of
treatment concept has been progressed, in attemed to post-operative complications including post-operative pain
decreases the post-operative pain and complications of and hospital stay. Pain was measured by using the VAS.
haemorrhoids.7 Several studies showed different surgical All the data was collected via study proforma. Data was
outcomes of surgical techniques as some reported that the analyzed by using SPSS version 20.

1460 P J M H S Vol. 15, NO. 4, APRIL 2021

 Javeria Farid, Zeeshan Zia Qureshi, Bilal Rasool et al

RESULTS haemorrhoids and its severity, but is still under

In this study mean age of the patients HALs group was investigation for more progression.9 However in this study
34.56+4.22 years and mean age of OA group was Haemorrhoidal Artery Ligation (HALs) with recto-anal repair
37.11+6.41. Majority patients were males in both groups as (RAR) was found to be effective as the average
20(80.0%) in HALs and 16(64.0%) in OA group. Most of the postoperative pain (VAS), postoperative complications and
patients were married in both groups i.e 17(68.0%) in Hal post-operative Hospital stay were significantly lower in HAL
group and 19(66.0%) in OA group. Haemorrhoidal 3rd group as compared to OA group (p=0.001). Similarly in the
degree was more prevalent 17(68.0%) in HALs group and study of Scheyer M et al10 observed that the Haemorrhoidal
15(60.0%) in OA group out of 25 cases in each group. Artery Ligation and RAR provide protracted relief among
Table.1 cases having haemorrhoids whose presenting with
Average postoperative pain (VAS) and post-operative common symptoms including bleeding, pain and the
Hospital stay were significantly lower in HALs group as pruritus, while not for those having prolapsed haemorrhoids
compared to OA group (p=0.001), while average of as the initial indication. On other hand Khalil MM et al11
operative time was significantly lower in OA group (p- observed that the doppler-guided Haemorrhoidal Artery
0.001) as showed in table.2 Ligation is the easy to learn, painless and non-invasive
Postoperative complications like urinary retention, therapeutic technique which can be used as the good
bleeding and painful defecation were significantly higher in alternative to all other recognized treatment options of the
OA group as compared to Hals group (p=0.001) as showed symptomatic hemorrhoids. All stages of haemorrhoidal
in table.3 disease can be treated using HAL. In the study of Ghaleb
Kadem S et al12 they also concluded that the doppler
Table.1 Descriptive statistics of basic variables n=50 guided HAL with RAR technique is the effective
Variables Study groups alternative management option for the stage two, three and
HALs group OA group
four of haemorrhoids and its most common benefit is the
less postoperative pain.
Age(years) Mean+SD 34.56+4.22 37.11+6.41 In this study mean age of the patients HALs group
Male 20(80.0%) 16(64.0%) was 34.56+4.22 years and mean age of OA group was
Gender Female 05(20.0%) 09(36.0%) 37.11+6.41. The median age was 50 (range 22–84) years.
Marital status Un married 08(32.0%) 06(24.0%) Scheyer M et al10 reported that the median age of the
patients was 50 years with range of 22–84 years and
Married 17(68.0%) 19(66.0%) further they sated that the grade III hemorrhoids were 74%
Degree of 3rd degree 17(68.0%) 15(60.0%) and grade IV were 9%. These findings were similar to this
Hemorrhoids study as haemorrhoidal 3rd degree was more prevalent
4th degree 08(32.0%) 10(40.0%)
HALs= Haemorrhoidal artery ligation OA= Open 17(68.0%) in HALs group and 15(60.0%) in OA group out
haemorrhoidectomy of 25 cases in each group.
In this study males were in majority in both groups as
Table.2 Average comparison for VAS and operative time n=103 20(80.0%) in HALs and 16(64.0%) in OA group. Scheyer M
Study groups et al10 also reported that out of all study participants 57%
Variables were males and 43% were females. On other hand Ghaleb
HALs group OA group p-value
Kadem S et al12 also found males in majority as 90% and
Post-operative pain
3.21+1.34 6.45+2.58 0.001 females only 10%. The rectoanal repair (RAR), which
VAS
combines doppler-guided haemorrhoidal artery ligation
Operative time (minutes) 50.87+10.42 38.30+8.44 0.001 (HAL) and mucopexy via lifting of the haemorrhoidal
Hospital stay (days) 01.22+0.81 3.18+1.55 0.001 prolapse, offers a minimally invasive alternative to
HALs= Haemorrhoidal artery ligation OA= Open conventional hemorrhoidectomy.10
haemorrhoidectomy

Table.2 Comparison of post-operative complications n=50

CONCLUSION
Haemorrhoidal Artery Ligation (HALs) with RAR technique
Complications Study groups
p-value found to be feasible and effective in terms of less post-
HALs group OA group operative pain, less post-operative complications and less
Urinary retention 01(04.0%) 03(12.0%) hospital stay as in contrast to Open haemorrhoidectomy
Bleeding 01(04.0%) 10(40.0%) (OA) in the treatment of 3rd and 4th degree Hemorrhoids.
0.001 Due to small sample size of the study and short term follow
Stenosis 0 01(04.0%)
Painful defecation 0 10(40.0%)
up, further large scale studies are recommended in this
comparison.
HALs= Haemorrhoidal artery ligation OA= Open
haemorrhoidectomy
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