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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 39-43

Harmonic scalpel hemorrhoidectomy versus bipolar diathermy hemorrhoidectomy – A prospective evaluation


Department of Surgery, SKIMS Medical College, Srinagar, Jammu and Kashmir, India

Date of Submission24-Sep-2020
Date of Acceptance22-Apr-2021
Date of Web Publication09-Nov-2021

Correspondence Address:
Dr. Shams Ul Bari
Department of Surgery, SKIMS Medical College, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcs.ijcs_33_20

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  Abstract 

Background: Hemorrhoidal disease is a very common anorectal disorder occurring more frequently in individuals who are older than 40 years. Although early-stage diseases can be managed conservatively, late-stage diseases usually need surgical treatment. Aims and Objectives: The aim of the study was to compare harmonic scalpel hemorrhoidectomy with bipolar diathermy hemorrhoidectomy in terms of operative time, intraoperative bleeding, hospital stay, pain expectation score, time to start normal activity, and complications if any. Materials and Methods: The study entitled, "Harmonic scalpel hemorrhoidectomy versus bipolar diathermy hemorrhoidectomy-A prospective evaluation" was conducted in the Department of General and Minimal invasive Surgery SKIMS and SKIMS Medical College Srinagar from July 2017 to June 2019. The study was performed on all patients with Grade 3 and Grade 4 hemorrhoids. The total number of patients studied was 64, who were randomly subjected either to the harmonic scalpel hemorrhoidectomy or to bipolar diathermy hemorrhoidectomy. Results: Thirty-one patients were subjected to harmonic scalpel hemorrhoidectomy and 33 patients were subjected to bipolar diathermy hemorrhoidectomy. Mean operative time and intraoperative bleeding were significantly less in harmonic scalpel hemorrhoidectomy as compared to that of bipolar hemorrhoidectomy. The patients who underwent harmonic scalpel hemorrhoidectomy experienced significantly less pain and had significantly shorter hospital stay and early return to routine work in contrast to bipolar diathermy hemorrhoidectomy. Conclusion: Harmonic scalpel hemorrhoidectomy is recommended in patients with symptomatic Grade 3 internal hemorrhoids in association with large external components and those with Grade 4 hemorrhoids.

Keywords: Hemorrhoids, bipolar, bleeding, harmonic, prolapse, recurrence


How to cite this article:
Ul Bari S, Malik AA, Kangoo AA. Harmonic scalpel hemorrhoidectomy versus bipolar diathermy hemorrhoidectomy – A prospective evaluation. Indian J Colo-Rectal Surg 2021;4:39-43

How to cite this URL:
Ul Bari S, Malik AA, Kangoo AA. Harmonic scalpel hemorrhoidectomy versus bipolar diathermy hemorrhoidectomy – A prospective evaluation. Indian J Colo-Rectal Surg [serial online] 2021 [cited 2021 Dec 4];4:39-43. Available from: https://www.ijcrsonweb.org/text.asp?2021/4/2/39/330165


  Introduction Top


Although conservative treatment is often sufficient for early stages (Grade 1 and Grade 2), late-stage diseases (Grade 3 and Grade 4) usually need surgical treatment.[1],[2],[3] Surgical treatment of hemorrhoids has undergone several modifications from time to time.[4] Various surgical options which are available at present include closed hemorrhoidectomy, open hemorrhoidectomy, stapled hemorrhoidopexy, harmonic scalpel hemorrhoidectomy, bipolar diathermy, and direct current electrotherapy.

Several randomized trials have been conducted till date comparing harmonic scalpel hemorrhoidectomy with other techniques and the results have been found to be inconsistent. Several studies have shown clear-cut benefits of harmonic scalpel hemorrhoidectomy over other methods with respect to various parameters.[5],[6]

Aims and objectives

The present study was undertaken to compare the results of harmonic scalpel hemorrhoidectomy with bipolar diathermy hemorrhoidectomy in terms of operation time, hospital stay, pain expectation score, day of first bowel movement, time to start routine normal activity, wound healing, patient satisfaction score, and any complications.


  Materials and Methods Top


The study was conducted prospectively in the Department of General and Minimal Invasive Surgery SKIMS and SKIMS Medical College Srinagar from July 2017 to June 2019. The study was performed on all patients with Grade 3 and Grade 4 hemorrhoids [Figure 1] and the total number of patients studied was 64. Patients were taken randomly either for harmonic or for bipolar hemorrhoidectomy. Out of 64, 31 patients were taken for harmonic scalpel hemorrhoidectomy and 33 patients were taken for bipolar hemorrhoidectomy. Patients having associated fissures, fistula, thrombosed hemorrhoids, and anal stenosis or having any other anorectal pathology were excluded from the study.
Figure 1: Preoperative picture showing Grade 3 hemorrhoids

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Preoperative assessment

All patients were evaluated as per our pro forma. Patients were subjected to detailed clinical history, complete physical examination including DRE, proctoscopy, and sigmoidoscopy, and all baseline investigations.

Operative technique

The steps of surgery were the same as is being done in Milligan and Morgan hemorrhoidectomy. However, instead of using monopolar cautery, we used either bipolar cautery [Figure 2] and [Figure 3] or harmonic scalpel [Figure 4] and [Figure 5]. We adopted the open method to avoid the debate around the effect of using the closed technique on postoperative pain perception. All the procedures were performed under spinal anesthesia and free of cost as ours is a government hospital. Intraoperative data noted included total operative time from the start of incision to end of surgical procedure and the amount of postoperative bleeding.
Figure 2: Intraoperative picture of bipolar hemorrhoidectomy

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Figure 3: Immediate postoperative picture of bipolar hemorrhoidectomy

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Figure 4: Intraoperative picture of harmonic scalpel hemorrhoidectomy

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Figure 5: Immediate postoperative picture after harmonic bipolar hemorrhoidectomy

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Postoperative care

All the patients were put on intravenous fluid during the first 12 h. Two doses of intravenous antibiotics were given. The first dose was given half an hour before surgery and the second dose was given 12 h after surgery. Intramuscular injection of tramadol was given 12 hourly for the first 24 h for postoperative pain control. Patients were monitored for pulse rate, BP, temperature, respiratory rate, urinary retention, anal bleeding, first bowel movement, and duration of hospital stay. The pain was assessed using a Visual analog scale (VAS) at postoperative hours 6, 12, and 24 h, and the same was recorded in the pro forma.

Follow-up

Most of the patients were discharged on the 2nd postoperative day. In addition to stool softeners, sitz bath, and high fiber diet, they were advised to take analgesics in tablet form (Aceclofenac 100 mg) on a need basis and were asked to keep a record of it. Patients were followed on weekly basis for 6 weeks, followed by further follow-up at 3 months [Figure 6], 6 months, and 1 year after surgery. During this follow-up, patients were evaluated for any pain, bleeding, anal stenosis and recurrence of disease. Patient satisfaction was evaluated as the patient's response to the outcome of surgery.
Figure 6: Follow-up picture at 3 months after harmonic hemorrhoidectomy

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Statistical analysis

The data were compiled and entered into a spreadsheet (Microsoft Excel) and then exported to the data editor of SPSS Version 20.0 (SPSS Inc. Chicago, Illinois, USA). Continuous variables were expressed as mean (Standard deviation) and categorical variables were summarized as frequencies and percentages. Student's independent t-test was used for comparing continuous variables. For comparing categorical variables, either the Chi-square test or Fisher's exact test was applied. P < 0.05 was considered statistically significant. All P values were two tailed.


  Results and Observation Top


A total of 64 patients with Grade 3 and Grade 4 hemorrhoids were included in the study. In harmonic scalpel hemorrhoidectomy group, out of 31 patients, 17 had Grade 3 hemorrhoids, 9 patients had Grade 4 hemorrhoids, and 5 patients had a combination of both Grade 3 and Grade 4 hemorrhoids. On the other hand, in the bipolar hemorrhoidectomy group, out of 33 patients, 16 had Grade 3 hemorrhoids, 9 patients had Grade 4 hemorrhoids, and 8 patients had a combination of both Grade 3 and Grade 4 hemorrhoids.

The mean age of the patients in harmonic scalpel hemorrhoidectomy group was 31.9 (13.06) years, while the patients belonging to the bipolar diathermy hemorrhoidectomy group had a mean age of 32.4 (14.34) years [Table 1]. In the harmonic scalpel hemorrhoidectomy group, 20 patients were male and 11 were female, while as in the bipolar hemorrhoidectomy group, 23 were male and 10 were female. Mean operation time for harmonic scalpel hemorrhoidectomy was less than that of bipolar hemorrhoidectomy (19 ± 3 min versus 30 ± 5 min), with P = 0.1 (statistically insignificant). Intraoperative bleeding in harmonic scalpel hemorrhoidectomy was also less than that of bipolar hemorrhoidectomy (18 ± 4 ml versus 30 ± 5 ml), which was statistically significant with P = 0.004 [Table 1].
Table 1: Postoperative complications

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In the harmonic scalpel hemorrhoidectomy group, 10 patients stayed in the hospital for 1 day, while the remaining 21 patients stayed in the hospital for 2 days. In the bipolar hemorrhoidectomy group, 3 patients stayed in the hospital for 1 day, 28 for 2 days, and 2 for 3 days [Table 2].
Table 2: Comparison of study variables between two groups

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The patients belonging to the harmonic scalpel group experienced less pain on a visual analog scale (VAS). The overall pain score was 2.30 (1.022) in case of harmonic scalpel group and 2.86 (1.184) in bipolar diathermy group. This difference in pain between the two groups was statistically significant with P < 0.001 [Table 2]. The amount of analgesia required in early postoperative and late postoperative period was significantly higher in the bipolar group as compared to harmonic scalpel group with P = 0.002, which is statistically significant (P < 0.05). Thus, the harmonic scalpel hemorrhoidectomy group had a better pain expectation score on all postoperative days as compared to the bipolar hemorrhoidectomy group.

In the harmonic scalpel group, 13 patients returned to normal activity in the 1st week, 16 patients in the 2nd week, and 2 patients in the 3rd week. In the bipolar hemorrhoidectomy group, only 3 patients returned to normal activity in the 1st week, 22 patients in the 2nd week, and 8 patients in the 3rd week. The difference was statistically significant (P = −0.003).

Among postoperative complications in harmonic scalpel hemorrhoidectomy group, 6 patients had urinary retention, 6 patients had wound edema at 1 week, 2 patients had wound infection, while none of the patients had postoperative bleeding, [Table 1]. Among patients with bipolar hemorrhoidectomy, 2 patients had postoperative bleeding, which settled within 48 h of its own, 8 patients had urinary retention, 5 patients had wound edema at 1 week, and 3 patients had wound infection. Flatus incontinence, anal stenosis, or recurrence of the disease was not seen in any of the patients in both the groups [Table 1].


  Discussion Top


Surgical hemorrhoidectomy is generally reserved for symptomatic Grade 3 internal hemorrhoids with prominent external components or for Grade 3 disease. For internal hemorrhoids alone (Grade 1, 2, and 3), less invasive fixation procedures are appropriate such as rubber band ligation, cryoablation, and infra-red coagulation. If the fixation procedure is attempted in the presence of an external component of hemorrhoids, the resultant venous congestion produces painful engorgement of this external component which frequently requires urgent surgical hemorrhoidectomy.[7],[8],[9] The obvious disadvantage of surgical hemorrhoidectomy is the postoperative pain resulting from the surgical raw area in the sensitive perianal skin and the anoderm. Much of this discomfort arises from the thermal injury induced by electrocautery or laser machines.[8] The harmonic scalpel possesses the unique advantage of causing very little lateral thermal injury in the tissues. A decreased lateral thermal injury (<1.5 mm) at the surgical site is translated into decreased postoperative pain. The depth of thermal injury in porcine small bowel mesentery was found to be up to 15 mm with monopolar electrocautery, up to 9 mm with bipolar electrocautry, up to 4 mm when using CO2 laser, and up to 4.2 mm using Nd: YAG laser.[8],[9]

Armstrong et al.[5] published a similar study but they used both open and closed techniques in hemorrhoidectomy in their series although it did not affect their final conclusion. In the same study done by Armstrong et al.,[5] narcotic analgesics were used for the whole period of postoperative follow-up. We believed that long-term use of such narcotic analgesics may lead to habituation or even drug addiction. Therefore, the narcotic analgesics were replaced by aceclofenac from the 2nd day for the rest of the postoperative period. Chung et al.[6] reported that harmonic scalpel hemorrhoidectomy is as good as bipolar scissor hemorrhoidectomy in terms of reduced blood loss. However, harmonic scalpel hemorrhoidectomy is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits were small and the time taken to return to normal activity remained similar.

Tan and Seow-Choen[7] have reported that harmonic scalpel hemorrhoidectomy is comparable to bipolar diathermy hemorrhoidectomy in terms of postoperative pain and complications. In our study, there was significantly reduced postoperative pain, better hemostasis, and less analgesic consumption in patients who underwent harmonic scalpel hemorrhoidectomy. Our results were comparable to those of Ivanov et al.[8] and Ozer et al.[9] who mentioned that harmonic scalpel hemorrhoidectomy significantly reduced postoperative pain, induced better hemostasis, and there was less analgesic consumption.

In our study, the amount of analgesia required in early as well as late postoperative period was significantly higher in the bipolar group as compared to harmonic scalpel group (P = 0.002), which is statistically significant. This is in contrast to the results mentioned by Ramadan et al.[4] They found that there was no statistically significant difference noted in the overall amount of analgesics used in the two groups during 1st week, but it was significantly lower in the harmonic scalpel group in the 2nd and 3rd weeks postoperatively. This difference may be attributed to the rapid rate of healing after harmonic scalpel hemorrhoidectomy and improvement in surgical training


  Conclusion Top


Although the use of the harmonic scalpel has some disadvantages in the form of prolonged learning curve and increased cost over the electrocautery hemorrhoidectomy, it has several advantages as well. The obvious advantages include reduced postoperative pain, reduced need of analgesics, excellent hemostasis, reduced amount of vapor released during the procedure, significantly reduced incidence of postoperative urine retention, and finally reduced time-off work for patients. In view of all these merits, we recommend using harmonic scalpel hemorrhoidectomy in patients with symptomatic Grade 3 internal hemorrhoids in association with large external components and those with Grade 4 hemorrhoids.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Talha A, Bessa S, Abdel Wahab M. Ligasure, harmonic scalpel versus conventional diathermy in excisional haemorrhoidectomy: A randomized controlled trial. ANZ J Surg 2017;87:252-6.  Back to cited text no. 1
    
2.
Dumlu EG. Hemorrhoidectomy in patients with Grade III or IV disease: Harmonic scalpel compared with conventional closed technique. Int Arch Med 2015;8:1755-7682.  Back to cited text no. 2
    
3.
Bulus H, Tas A, Coskun A, Kucukazman M. Evaluation of two hemorrhoidectomy techniques: Harmonic scalpel and Ferguson's with electrocautery. Asian J Surg 2014;37:20-3.  Back to cited text no. 3
    
4.
Ramadan E, Vishne T, Dreznik Z. Harmonic scalpel hemorrhoidectomy: Preliminary results of a new alternative method. Tech Coloproctol 2002;6:89-92.  Back to cited text no. 4
    
5.
Armstrong DN, Ambroze WL, Schertzer ME, Orangio GR. Harmonic scalpel vs. electrocautery hemorrhoidectomy: A prospective evaluation. Dis Colon Rectum 2001;44:558-64.  Back to cited text no. 5
    
6.
Chung CC, Ha JP, Tai YP, Tsang WW, Li MK. Double-blind, randomized trial comparing harmonic scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: Ligation technique. Dis Colon Rectum 2002;45:789-94.  Back to cited text no. 6
    
7.
Tan JJ, Seow-Choen F. Prospective, randomized trial comparing diathermy and harmonic scalpel hemorrhoidectomy. Dis Colon Rectum 2001;44:677-9.  Back to cited text no. 7
    
8.
Ivanov D, Babović S, Selesi D, Ivanov M, Cvijanović R. Harmonic scalpel hemorrhoidectomy: A painless procedure? Med Pregl 2007;60:421-6.  Back to cited text no. 8
    
9.
Ozer MT, Yigit T, Uzar AI, Mentes O, Harlak A, Kilic S, et al. A comparison of different hemorrhoidectomy procedures. Saudi Med J 2008;29:1264-9.  Back to cited text no. 9
    


    Figures

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

  [Table 1], [Table 2]



 

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