STAPLED HAEMORRHOIDECTOMY VERSUS OPEN HAEMORRHOIDECTOMY (MILLIGAN MORGAN) FOR GRADE IV HAEMORRHOID

Haemorrhoids or piles are the most frequently presenting anorectal disorder. They are considered to be the most common cause of bleeding per rectum1. Piles are symptomatic anal cushions. They are more common when intraabdominal pressure is raised, e.g. in obesity, constipation and pregnancy. Primarily, they occur in the 3, 7 and 11 o’clock positions with the patient in the lithotomy position.2

External haemorrhoids are aggregations of congested inferior haemorrhoidal plexus covered by perianal skin; while, internal haemorrhoids originate from the sub-epithelial plexus of the anal canal above the dentate line3.The symptoms include discomfort, itching, mucous discharge, bleeding, pain, and prolapse associated with a feeling of fullness and incomplete evacuation4. Internal hemorrhoids are classified into 4 grades, Grade I- Prominent haemorrhoidal vessels with no prolapse, Grade II-Prolapse which reduce spontaneously, Grade III- Prolapse and have to be manually reduced, Grade IV- Permanently prolapsed4.

The treatment options for symptomatic haemorrhoids vary from conservative medical management, to various surgical techniques depending on the grade of haemorrhoids. The nonsurgical options include rubber band ligation, injection sclerotherapy, cryotherapy, infrared coagulation, laser therapy, and diathermy coagulation.5 Most nonoperative procedures are reserved for firstand second-degree haemorrhoids. Operative options are clamp and cautery haemorrhoidectomy, open hemorrhoidectomy, closed haemorrhoidectomy, submucosal haemorrhoidectomy, whitehead circumferential haemorrhoidectomy, stapled haemorrhoidopexy, radiofrequency ablation suture fixation haemorrhoidopexy, pile suture’ method, bipolar diathermy haemorrhoidectomy and the LigaSure haemorrhoidectomy. Operative haemorrhoidectomies are reserved mainly for third and fourth-degree haemorrhoids.6

Haemorrhoidectomy is indicated in grade III and grade IV haemorrhoids. Milligan-Morgan open haemorrhoidectomy is the most popular surgical technique in management of 3rd and 4th grade haemorrhoids and is considered the gold standard. However, some early and late post-operative complications like anal pain, acute retention of urine, anal stenosis and incontinence has been reported.

In 1998, Longo provided an initial description for the correction of prolapsed haemorrhoids by applying a circular stapling device. The important concept underlying this technique involved drawing up the haemorrhoidal tissue, and reducing the redundant mucosa, interfering with the branches of the superior haemorrhoidal artery. Patients, therefore, eliminate the painful skin wound. Haemorrhoidal prolapse is corrected by relocating the pile masses into the anal canal and by decreasing the venous engorgement with division of the feeding arteries and redundant mucosa. Through this method, resultant stapled mucosa anastomosis is formed in the rectum, approximately 30 millimetres proximal to the dentate line where sensitive receptors are sparse.

The precise treatment of haemorrhoids is still topic of considerable debate. There are only limited studies on Grade IV Haemorrhoids, which provide evidence comparing the methods of Stapled Haemorrhoidectomy versu