1. Name of Specialty: General Surgery



2. Name of System of Body: Gastrointestinal system




3. Title of Thesis
and year of submission of thesis: A Study of Surgical Management of Hemorrhoids using Minimally Invasive Procedure for Hemorrhoids (MIPH) -Recent Modality of Treatment . - June 2010



4. Name of the candidate: Dr. Sanap Narayan Arjunrao




5. Name of the Supervisor: Dr. N. Raghupathi RAO, M.S., MAMS, FICS, FICA




6. Name of Hospital: Apollo Hospitals Jubilee Hills Hyderabad.





7. Objectives of the study: to study the efficacy of stapled haemorrhoidectomy in terms of ease of use, time of surgery, intraoperative complications, associated morbidity & advantages and disadvantages.





8.1 Study area: Apollo Hospital Jubliee Hills Hyderabad is a well equipped 334 bedded tertiary care hospital with General Surgery Units serving the population of Hyderabad and surrounding regions. Being a tertiary care hospital, referrals are common for various grades of hemorrhoids for management with minimally invasive procedure. This Study was designed to understand the efficacy of the minimally invasive procedure for hemorrhoids done at our centre in dealing with various grades of hemorrhoids.



8.2 Study population: Data was collected from inpatients cases, mixed population of male and female patients from Hyderabad, and the refereed cases to the hospital from other centers.


8.3 Sample size & sample technique: Total 50 patients were selected randomly according to the inclusion and exclusion criterion.
-Inclusion criteria: 1. Grade II, III, IV Internal or external hemorrhoids in 20 to 70 years age group patients.

-Exclusion criteria: 1. associated with synchronous & metachronous malignant lesion found on
Colonoscopy
2. Exclusion of chrohns’ disease
3. Patient where the internal diameter of rectum will not accommodate the instrument and accessories
4. Patients with associated Grade I hemorrhoids



8.4 Data collection technique and tools: It was a prospective study and data was collected as an interview in the proforma mentioned with the desertation.

8.5 Data analysis: Information collected was categorized as per variables and demonstrated as bar charts.

9. Salient findings:
Age distribution of patients

Majority patients found to be in 41-50yrs age group followed by 51-60yrs group. The youngest was 26 years old and the oldest was 65 years old.

Sex distribution of patients

Incidence of males undergoing stapled hemorrhoidectomy was about 76% in males and about 24% in females.

Associated history

Constipation is seen as most associated history, followed by alcoholism.

Grades distribution

Most of presentation was with grade III, grade II contributes 56% & 30% respectively.

Indication for intervention

Bleeding & prolapse constitutes most common indication for surgery.

Emergency surgery

Total no of 50 cases which were studied over two years 42 cases were operated in routine operation theatre timings and 8 cases were operated on emergency basis

Intraoperative Time of surgery

Peri-operative time for application of stapler for hemorrhoid surgeries about 27.1 min which mostly depends on factors mentioned below

1) Patient position
2) Pursue string suture
3) Surgeons Experience

Mode of anesthesia

We recommend that general anesthesia, epidural or spinal anesthesia as per the requirement and patient fitness for it. It results in an increased relaxation of the anal sphincter muscles and therefore facilitates the insertion of the circular anal dilator without the manual stretch






Early complications

Out of 50 cases, 8 % cases had minimal bleeding, 6% suffered from retention of urine, 2% had haematoma. Most of patient had so minimal pain score of 1-2 in 90% cases. Out of 4 patients 3 had mild bleeding & 1 had moderate bleed, which was on anticoagulant agent.

Time of ambulation

Mostly patients ambulated in same day of surgery 66% in 6-12 hrs &
26% in 12-24 hrs.

Time of rejoin to work

Patients resume their work normally in 2- 3 days and without any discomfort for their daily activities to be performed normally
.
Late complications

During Postoperative follow-up found stricture at anal canal in 1 patient.
Study group was found to be recurrence free over six month follow-up

Follow-up

All the operated patients then were followed up to 6 months.
100% patient followed first visit at day 10, then follow up patient’s decreases to 72% in second visit at 3 month & further 38% at third visit at 6 months, may be due to not having any clinical symptoms.

Stay in hospital

Most of patient treated as day care admission & discharged at home same day advising proper analgesics if necessary with anti constipation agent. Some patients needed 1 day admission in view of insurances policy terms. Very few patients admitted for evaluation & other co morbidity.








10. Conclusions: we concluded that staplers is going to become the part and period considering its various advantages as increased speed, efficacy, less tissue trauma, access to difficult areas of the body, reliability and thus increases the quality of life of the patient by decreasing morbidity to some extent. It can eliminate hemorrhoidal bleeding, successfully eliminates pain in hemorrhoidal disease. It is a minimally invasive procedure which is simple when performed by an expert in it. Operative time for stapled hemorrhoidectomy was shorter compared with conventional techniques. Resumption to pain free defecation was significantly faster in stapled hemorrhoidectomy also was the shorter hospital stay and patients resumed there daily activities and work faster compared to others. No continence and defecation problem was noted neither recurrence seen in all theses studied patients. Staplers being precision devices, they are prone to mechanical faults in careless hands and hence proper training and technical expertise is a must before the application of staplers. Despite of its various advantages this technique is prohibitively costly. However like laparoscopy which was also costly to begin with, the cost of staplers may drop down with its frequent use. Indications for their adequately to other treatment grade two and three hemorrhoids also indicated in the uncomplicated grade four hemorrhoids also. Active sepsis, full thicknesses rectal prolapse is some of its contraindication for using this device. It has been concluded that the staplers are a novel way of doing hemorrhoidal surgeries and has increased the horizons of hemorrhoidal surgery to a great extent. However, technical skills, good on table judgment, intelligence and knowledge of all possible pitfalls and errors of stapling are required to achieve optimal results.





11. Recommendations:
1) Being a simple surgery, short operative time, early ambulation and minimal pain; this procedure can be widely accepted as day care surgery.

2) In the initial stages of learning procedure should be carried out under supervision of a senior surgeon as we technical difficulty and error may lead to inadequate or excess excision & sever post operative pain.

3) Despite of its various advantages this technique is prohibitively costly. However like laparoscopy which was also costly to begin with, the cost of staplers may drop down with its frequent use.

4) We recommend that minimally invasive procedure for hemorrhoids (MIPH) should be used as standard treatment for grade II, III, IV hemorrhoids, as good patient compliance is increasing.

5) Randomized trial and long-term follow-up warrant to determine
possible surgical and functional outcome.