Hemorrhoids, or piles, are dilated and inflamed vascular cushions located in the anal canal, representing one of the most common proctological disorders globally¹. The etiology includes increased intra-abdominal pressure due to chronic straining, constipation, pregnancy, or prolonged sitting². They are classified into internal (above the dentate line), external (below the dentate line), or mixed³.

Hemorrhoids are graded I to IV depending on the extent of prolapse⁴. Grade I presents with bleeding but no prolapse; Grade II with prolapse that reduces spontaneously; Grade III requires manual reduction, and Grade IV is irreducible and often thrombosed⁵. While Grades I and II respond well to dietary and pharmacological management, Grades III and IV often necessitate surgical intervention⁶.

Surgical options have evolved significantly over the decades. The traditional open hemorrhoidectomy (Milligan-Morgan technique), although effective, is associated with significant postoperative pain, urinary retention, and delayed wound healing⁷. The closed technique (Ferguson’s method) attempts to reduce these complications by suturing the wounds⁸.

The advent of stapled hemorrhoidopexy (Longo procedure) in the 1990s brought a minimally invasive option⁹. It involves the circumferential excision of mucosal and submucosal prolapsed tissue, repositioning hemorrhoidal cushions back into their normal anatomical position¹⁰. Patients report less postoperative pain and faster return to daily activities¹¹.

Doppler-guided hemorrhoidal artery ligation (DGHAL) further refines this minimally invasive approach. It identifies and ligates the terminal branches of the superior rectal artery using a Doppler transducer¹². This technique reduces blood supply and alleviates hemorrhoidal symptoms without excising tissue¹³.

Despite these advancements, the choice of surgical technique depends on various factors including grade of hemorrhoids, associated prolapse, patient preference, and surgeon experience¹⁴. Studies comparing efficacy, complications, recurrence rates, and patient satisfaction remain vital for guiding clinical decisions¹⁵.

This study aims to compare three commonly used surgical modalities—open hemorrhoidectomy, stapled hemorrhoidopexy, and DGHAL—in terms of operative parameters, pain scores, complications, and outcomes, thus contributing to evidence-based surgical decision-making in hemorrhoid management.

This prospective, comparative study was conducted in the Department of General Surgery at a tertiary care hospital over 18 months.

Inclusion Criteria:

• Age between 20–65 years
• Diagnosed with Grade III or IV internal hemorrhoids
• Fit for spinal or general anesthesia
• Provided written informed consent

Exclusion Criteria:

• Grade I and II hemorrhoids
• Coexisting anorectal conditions (e.g., fissure, fistula)
• History of previous anorectal surgery
• Patients with coagulation disorders
• Pregnancy or lactation
• Immunocompromised individuals

Sample Size: 150 patients were enrolled and randomly assigned to three groups (n=50 each):

• Group A: Open hemorrhoidectomy (Milligan-Morgan)
• Group B: Stapled hemorrhoidopexy
• Group C: Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL)

Surgical Procedure:

• Open hemorrhoidectomy: Performed under spinal anesthesia; hemorrhoidal bundles excised using electrocautery.
• Stapled hemorrhoidopexy: Circular stapler used to excise prolapsed mucosa above dentate line.
• DGHAL: Doppler probe inserted to locate and ligate arteries feeding hemorrhoids.

Data Collection Parameters:

• Operative time
• Intraoperative blood loss
• Postoperative pain (VAS score)
• Duration of hospital stay
• Time to return to routine activity
• Complications (bleeding, infection, urinary retention, anal stenosis)

Statistical Analysis: Data were analyzed using SPSS v24.0. Continuous variables were expressed as mean ± SD and compared using ANOVA. Categorical data were compared using Chi-square test. A p-value <0.05 was considered statistically significant.

Table 1: Demographic Distribution

No significant difference in age or sex distribution among the groups.

Table 2: Operative Time (Minutes)

In table 2, Stapled Hemorrhoidopexy demonstrates the most favorable outcomes with the lowest mean (22.6 ± 4.2), indicating superior efficacy and consistency, while Open Hemorrhoidectomy shows the least favorable results with the highest mean (38.4 ± 6.5) and greatest variability, and DGHAL occupies an intermediate position (30.1 ± 5.3) in both effectiveness and data dispersion.

Table 3: Postoperative Pain (VAS Score at 24 hours)

In table 3, Open Hemorrhoidectomy has the highest pain score (7.2 ± 1.1), indicating significantly more postoperative pain compared to the other methods. Stapled Hemorrhoidopexy shows moderate pain (3.4 ± 0.9), suggesting it is less painful than open surgery. DGHAL (Doppler-Guided Hemorrhoidal Artery Ligation) has the lowest pain score (2.9 ± 1.0), making it the least painful technique among the three.

Table 4: Mean Hospital Stay (Days)

In table 4, Open Hemorrhoidectomy has the longest hospital stay (mean 3.1 days), indicating a more invasive procedure with a prolonged recovery period. Stapled Hemorrhoidopexy shows a significantly shorter stay (1.8 days), reflecting faster recovery. DGHAL (Doppler-Guided Hemorrhoidal Artery Ligation) offers the shortest hospital stay (1.6 days), suggesting it is the least invasive and best-tolerated procedure.

Table 5: Time to Return to Normal Activity (Days)

In table 5, Open Hemorrhoidectomy has the longest recovery time, with patients taking an average of 10.5 days to resume normal activities. Stapled Hemorrhoidopexy significantly reduces recovery time to 5.4 days, indicating a quicker return to daily life. DGHAL (Doppler-Guided Hemorrhoidal Artery Ligation) allows for the fastest recovery, averaging 4.7 days, making it the most favorable option for early mobilization.

Table 6: Postoperative Complications

The management of symptomatic hemorrhoids has evolved significantly, with a shift towards minimally invasive procedures. This study compared three surgical techniques, demonstrating clear advantages in terms of pain and recovery for the newer methods.

The findings are consistent with previous research by Longo et al. who introduced the stapled hemorrhoidopexy technique and noted reduced postoperative pain and faster recovery compared to conventional hemorrhoidectomy¹⁶. Similarly, Hetzer et al. emphasized the benefits of Doppler-guided ligation in reducing recurrence and complications¹⁷.

Open hemorrhoidectomy remains the gold standard for large, prolapsing hemorrhoids with external components¹⁸. However, its drawbacks include high postoperative pain, urinary retention, and longer recovery times, as noted in our study and others by Altomare et al.¹⁹

Stapled hemorrhoidopexy, though costlier, significantly reduced operative time, pain, and hospital stay. These findings align with studies by Ganio et al. and Mehigan et al., who reported high patient satisfaction with stapled techniques²⁰⁻²¹. Nevertheless, its use is limited in cases with large external components²².

DGHAL, a non-excisional technique, was associated with the least complications and pain. Studies by Ratto et al. confirmed its efficacy in early hemorrhoids, although long-term recurrence can be a concern²³. In this study, its recurrence rate was comparable to other techniques.

This study highlights the importance of individualizing treatment based on hemorrhoid grade, patient preference, and available expertise. While open hemorrhoidectomy offers definitive treatment, stapled and DGHAL techniques provide effective, less painful alternatives with faster recovery—particularly suitable for Grades III internal hemorrhoids.

Limitations include the single-center design and short follow-up duration. Larger multicenter trials with long-term follow-up are necessary to validate these findings.

All three surgical techniques were effective in managing hemorrhoids. Open hemorrhoidectomy is best suited for extensive disease but causes significant postoperative discomfort. Stapled hemorrhoidopexy and DGHAL offer excellent alternatives with minimal pain, reduced hospital stay, and quicker return to normal activities. Personalized surgical selection enhances outcomes and patient satisfaction.

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