Hemorrhoids are one of the most common benign anorectal problems worldwide with high prevalence, estimated worldwide prevalence ranges from 2.9% to 27.9%, of which more than 4% are symptomatic1 (nearly 50% of proctological visits in a colorectal unit3).1 The disease is called as piles when the patient complains of a swelling and ‘haemorrhoids’ when he or she complains of bleeding2,3. Hemorrhoids are normal anatomic clusters of vascular tissue, smooth muscle, and connective tissue that lie along the anal canal in 3 columns, forming the anal cushions; they lie in left lateral, right anterior, and right posterior positions4. Hemorrhoids are classified to external or internal. External hemorrhoids develop distal to the dentate line and are usually associated with pain while internal hemorrhoids develop proximal to the dentate line and are typically painless5. Hemorrhoidal disease is a very prevalent disorder that arises from engorgement of internal and/or external vascular plexuses surrounding the anal canal6. The fundamental symptoms are bleeding, pain, prolapsing, and itching7-8.

Depending upon the severity they are classified into 4 degrees. In many cases hemorrhoidal disease can be treated conservatively, in grade III and IV surgical procedures are required to provide satisfactory long-term relief.  Hemorrhoidectomy is the most definitive way of treating 3rd and 4th degree hemorrhoids8.  It is one of the most commonly performed anorectal operations. Although it is considered a minor procedure, the postoperative course is protracted and the postoperative complications are not negligible, postoperative pain9 is a major concern, and the surgery itself is not without complications, including notably bleeding and anal stricture10. Harmonic scalpels (HS) include the ultrasonic scalpel instruments that effectively incorporate automatic vessel-sealing systems for undertaking the surgical intervention including hemorrhoidectomy11. It is known for its ability to coagulate small and medium-sized vessels of 5-7 mm8 in diameter thus, potentially it may minimize postoperative bleeding, swelling and edema to the surrounding tissue12

AIM

To study the operative efficacy of harmonic scalpel method of hemorrhoidectomy over conventional hemorrhoidectomy.

The study is a hospital-based comparative investigation conducted over a period of 18 months, from April 2023 to September 2024, at the Department of Surgery, S.P. Medical College and P.B.M. Hospital, Bikaner. The study population comprises all patients who undergo hemorrhoidectomy surgery within the specified timeframe. The sampling method involves including all eligible patients who report to the Surgery Department during the study period. Inclusion criteria are patients of any gender aged 18 years or older, with grade 3 or grade 4 hemorrhoids, and who are medically and mentally fit to undergo the surgical procedure. Exclusion criteria include individuals younger than 18 years, those with grade 1 or grade 2 hemorrhoids, patients unwilling to participate in the study, and those who are seropositive for HIV, HBsAg, or HCV.

Statistical Analysis:

The recorded data was compiled and entered in a spreadsheet computer program (Microsoft Excel 2007) and appropriate tests were applied. For all tests, confidence level and level of significance were set at 95% and 5% respectively.

Table-1: Distribution of conventional hemorrhoidectomy (C) group and harmonic scalpel (HS) group according to their age (years) and sex

Table 1 shows distribution of C group and HS group according to their age. In C group maximum 48.00% were observed in 46-60 years whereas minimum were 2.00% in 18 – 30 years age group. In HS group maximum 50.00% were observed in 46-60 years whereas minimum were 2.00% in 18-30years age group. Mean age in C group was 45.54±9.8 years whereas 46.08±9.2 years in HS group. (p>0.05)

It also shows distribution of C group and HS group according to their sex. In HS group maximum 80.00% were male whereas 70% in C group.

Table-2: Distribution of conventional hemorrhoidectomy (C) group and harmonic scalpel (HS) group according to their clinical feature

Table 2 shows distribution of C group and HS group according to their clinical feature.

In C group 96.00% were presented with bleeding, 84% constipation, 80% had prolapse and 64% had anal pain whereas In HS group 80.00% were presented with bleeding, 76% had constipation, 84% had prolapse and 68% had anal pain. (p>0.05)

Table-3: Distribution of conventional hemorrhoidectomy (C) group and harmonic scalpel (HS) group according to their duration of symptoms

Table 3 shows distribution of C group and HS group according to their duration of symptoms.

In C group maximum 44.00% were presented after 1 to 3 yr of symptom appearance whereas minimum 6% presented after >5yr. In HS group maximum 46.00% were presented after 1 to 3 yr whereas minimum 4% after >5yr.

Mean duration in C group was 1.5 ± 1.1 years whereas 1.4 ± 1.2 years in HS group. (p>0.05)

Table-4: Distribution of conventional hemorrhoidectomy (C) group and harmonic scalpel (HS) group according to VAS pain score

Table 4 shows distribution of C group and HS group according to their VAS pain score.

The VAS pain score recorded at12 hrs, 24 hrs. and 48 hrs showed that pain score in each reading was more for conventional hemorrhoidectomy as compared to harmonic scalpel hemorrhoidectomy and was statistically significant With a p value which was <0.0001.

Table-5: Distribution of conventional hemorrhoidectomy (C) group and harmonic scalpel (HS) group according to their Days of Hospital Stay (DOHS)

Table 5 shows distribution of C group and HS group according to their days of hospital stay.

In C group maximum 60.00% had 1 to 2 days of hospital stay whereas minimum 4% presented had 0 to 1 days. In HS group maximum 76% had hospital stay of 1 – 2 days whereas minimum 12% had >2 days of stay.

Mean duration in C group was 1.95± 0.45 days whereas 1.35±0.4 day in HS group. (p<0.05)

Table-6: Distribution of conventional hemorrhoidectomy (C) group and harmonic scalpel (HS) group according to their Treatment Outcome and post operative complications

Table 6 shows distribution of C group and HS group according to their outcome.

In C group maximum 96.00% were discharged from hospital whereas minimum 4% were DOR. In HS group all patients were treated and discharge as day care. (p=0.043*)

It also shows distribution of C group and HS group according to post op complication.

In C group maximum 80.00% had complaint of pain, followed by 60% had constipation whereas minimum 22% had itching and 30% had bleeding. In HS maximum 30.00% had complaint of constipation, followed by 18% had itching whereas minimum 12% had bleeding and 16% had pain. The difference was statistically significant. (p=0.049*)

In our study, in group C maximum 48.00% were observed in 46-60 years whereas in HS group maximum 50.00% were observed in 46-60 years with mean age in C group was 45.54±9.8 years whereas 46.08±9.2 years in HS group. (p>0.05)  Similarly Thakur D S et al 2020¹³ observed that the mean age of patients was 46.17 years and are comparable with Ersin Gurkan Dumlu et al¹⁴. Also Lim DR et al 2016¹² found that the mean ages of the conventional and the ultrasonic scalpel groups were, respectively, 20.8 ± 1.6 and 22.4 ± 5.0 years (P = 0.240).

In our study, HS group maximum 80.00% were male whereas 70% in C group. Similarly Thakur D S et al 202052 found that out of 30 patients 7 female and 23 male patients were treated with HS.

In our study, in both group the cases were presented with bleeding, constipation, prolapse and anal pain with mean duration of presentation was 1.5 ± 1.1 years in C group whereas 1.4 ± 1.2 years in HS group. As there is several other traditional techniques of treatment for piles the case will present to surgeon after all the experiments and after no treatment from conventional and conservative treatment.

In our study, mean operative time was 36.5 ± 5.1 min in C group whereas 25.55 ± 3.5 min in HS group and difference was statistically significant. similarly Thakur D S et al (2020)¹³ found that the average operative time in HS group was 19.20±2.14min. Also Lim DR et al (2016)¹² found that on comparing conventional method group and the ultrasonic scalpel group had a shorter operation time (P < 0.005). Similarly mean operating time required for Ersin Gurkan Dumlu et al¹⁴ 2010-2013 was 36.2 mins for group A and 24.2 mins for group B which was significantly less for patients in group B operated by harmonic scalpel method.

In our study, the VAS pain score recorded at12 hrs, 24 hrs. and 48 hrs showed that pain score in each reading was more for conventional hemorrhoidectomy as compared to harmonic scalpel hemorrhoidectomy and was statistically significant With a p value which was <0.0001. Similarly Tariq Ahmed Mala et al 2018¹⁵ found that postoperative pain with VAS in case group on the first postoperative day was 5.92 ± 0.72, while it was 8.52 ± 0 in the control group. Alos Thakur D S et al 2020¹³ VAS pain score in HS group on postoperative Day 1, Week 1, Week 3, Week 6 were 4.77±0.94, 2.83±0.75, 0.20±0.41 and 0. Our study was in line with Lim DR et al 2016¹² observed that conventional method group, the ultrasonic scalpel group had a less postoperative pain(P = 0.034). Similar results were seen in various studies like Hakan Bulus et al (2011)¹⁶ and A.A.Abo-hashem et at (2008)¹⁷.

In our study, maximum 60.00% had 1 to 2 days of hospital stay in C group whereas 76% had hospital stay of 1 – 2 days in HS group. Mean duration in C group was 1.95± 0.45 days whereas 1.35±0.4 day in HS group. (p<0.05) Similarly Thakur D S et al 2020¹³ found that the average postoperative stay was 1.13 ±0.43 days in HS group. Also ABDULLAH AM et al. 2021¹⁸ observed that there was statistically significant association between type of procedure and hospital stay ( p=0.18).

In our study, maximum 96.00% were discharged from hospital C group whereas all patients were treated and discharge as day care in HS group. (p=0.043*) Similarly ABDULLAH AM et al. 2021¹⁸ Patients who underwent Harmonic scalpel hemorrhoidectomy had statistically significant shorter time to complete healing.

In our study, in C group maximum 80.00% had complaint of pain and constipation whereas in HS maximum 30.00% had complaint of constipation and 18% had itching and the difference was statistically significant. (p=0.049*). Similarly Lim DR et al 201612 found no significant differences in postoperative complications were observed between the 2 groups. Also Thakur D S et al 2020¹³ found that the incidence of post-operative hemorrhage was low and 1 of 30 cases i.e. 3.3% in HS group.

In conclusion, the Harmonic Scalpel hemorrhoidectomy (HSH) technique demonstrates clear advantages over the conventional Ferguson’s hemorrhoidectomy. The HSH method offers reduced operation time, less intraoperative bleeding, and minimal postoperative pain due to its effective coagulation of tissue, which mitigates bleeding and minimizes thermal damage. This results in quicker recovery, shorter hospital stays, and faster return to regular activities. Despite the higher cost and longer learning curve associated with the Harmonic Scalpel, its benefits in terms of efficiency, safety, and patient comfort make it a superior option for hemorrhoidectomy.

1. Saclarides, T. J., and M. I. Brand. "Evolving Trends in the Treatment of Anorectal Diseases." Diseases of the Colon & Rectum, vol. 42, no. 10, 1999, pp. 1245–52. DOI: 10.1007/BF02234468.
2. Keighley, M. R. B., and C. A. Williams. Surgery of the Anus, Rectum and Colon. 3rd ed., vol. 1, Saunders Publications, 2008, pp. 351–422.
3. Corman, M. L. "Hemorrhoids." Colon and Rectal Surgery, 6th ed., Lippincott Williams & Wilkins, 2004, pp. 272–340.
4. Sun, W. M., R. J. Peck, A. J. Shorthouse, and N. W. Read. "Haemorrhoids Are Associated Not with Hypertrophy of the Internal Anal Sphincter, but with Hypertension of the Anal Cushions." British Journal of Surgery, vol. 79, 1992, pp. 592–94. DOI: 10.1002/bjs.1800790610.
5. Noorchashm, H., and D. J. Maron. "Procedures for Benign Anorectal Disease." In Gowned and Gloved Surgery: Introduction to Common Procedures, WB Saunders, 2009, pp. 145–56.
6. Ho, Y. H., F. Seow-Choen, M. Tan, and A. F. Leong. "Randomized Controlled Trial of Open and Closed Haemorrhoidectomy." Journal of British Surgery, vol. 84, no. 12, 1997, pp. 1729–30. DOI: 10.1002/bjs.1800841217.
7. Riss, S., F. A. Weiser, K. Schwameis, T. Riss, M. Mittlböck, G. Steiner, and A. Stift. "The Prevalence of Hemorrhoids in Adults." International Journal of Colorectal Disease, vol. 27, 2012, pp. 215–20. DOI: 10.1007/s00384-011-1378-3.
8. MacRae, H. M., and R. S. McLeod. "Comparison of Hemorrhoidal Treatment Modalities." Diseases of the Colon & Rectum, vol. 38, no. 7, 1995, pp. 687–94. DOI: 10.1007/BF02051463.
9. Sanchez, C., and B. T. Chinn. "Hemorrhoids." Clinical Colon and Rectal Surgery, vol. 24, no. 1, 2011, pp. 5. DOI: 10.1055/s-0031-1279608.
10. Kuehn, H. G., O. Gebbensleben, Y. Hilger, and H. Rohde. "Relationship Between Anal Symptoms and Anal Findings." International Journal of Medical Sciences, vol. 6, no. 2, 2009, pp. 77. DOI: 10.7150/ijms.6.77.
11. Cartwright, E. L. "The Management of Strangulated Hemorrhoids." American Journal of Digestive Diseases, vol. 4, no. 7, 1937, pp. 425–27. DOI: 10.1007/BF01886524.
12. Lim, D. R., D. H. Cho, J. H. Lee, and J. H. Moon. "Comparison of a Hemorrhoidectomy With Ultrasonic Scalpel Versus a Conventional Hemorrhoidectomy." Annals of Coloproctology, vol. 32, no. 3, 2016, pp. 111–16. DOI: 10.3393/ac.2016.32.3.111.
13. Thakur, D. S., H. Joshi, U. Somashekar, R. Kothari, V. Kumar, and D. Sharma. "A Prospective Study to Determine the Outcome and Efficacy of Harmonic Scalpel Hemorrhoidectomy." Journal of Medical Sciences & Clinical Research, vol. 8, no. 02, 2020, pp. 874. DOI: 10.18535/jmscr/v8i2.09.
14. Dumlu, E., A. Gurer, M. Tokac, et al. "Hemorrhoidectomy in Patients with Grade III or IV Disease: Harmonic Scalpel Compared With Conventional Closed Technique." International Archives of Medicine, vol. 8, 2015. DOI: 10.3823/1674.
15. Mala, T. A., S. A. Malla, A. A. Shah, M. Kapoor, and V. B. Gupta. "Comparative Study of Harmonic Scalpel Haemorrhoidectomy Versus Conventional (Milligan and Morgan) Haemorrhoidectomy." Journal of Surgical Arts, vol. 11, no. 1, 2018, pp. 7–12. DOI: 10.9748/jsa.2018.04.11.
16. Sato, T., K. Yamazaki, J. Akaike, J. Toyota, Y. Karino, and T. Ohmura. "Retrospective Analysis of Endoscopic Injection Sclerotherapy for Rectal Varices Compared with Band Ligation." Clinical and Experimental Gastroenterology, vol. 3, 2010, pp. 159. DOI: 10.2147/CEG.S12061.
17. Abo-hashem, A. A., A. Sarhan, and A. M. Aly. "Harmonic Scalpel Compared with Bipolar Electro-cautery Hemorrhoidectomy: A Randomized Controlled Trial." International Journal of Surgery, vol. 8, no. 3, 2010, pp. 243–47. DOI: 10.1016/j.ijsu.2010.01.003.
18. Abdullah, A. M., E. M. Ahmed, R. S. Abuelanin, and A. K. Kareem. "Comparative Study Between Hemorrhoidectomy with Harmonic Scalpel Versus Electrocautery." The Medical Journal of Cairo University, vol. 89, no. June, 2021, pp. 535–41. DOI: 10.21608/tmju.2021.153962.