Journal presentation

1. JOURNAL PRESENTATION

2. TOPIC
A Prospective Comparative Study of
Stapler Haemorrhoidectomy Vs Open Haemorrhoidectomy
in its Outcome and Postoperative Complications

3.  Extends from anorectal ring to anal verge.
 3.8 cm long.

6. UPPER MUCOUS PART
 15 mm long.
 Lined by mucous membrane & endodermal in
origin.
 Shows:
6-10 vertical folds called anal columns of
Morgagni.
Lower ends are united to each other by short
transverse folds of mucous membrane called anal
valves.

7. Above each valve, there is depression called anal
sinus.
Anal valves, together form transverse line that runs
all-round called as pectinate line/dentate line.
Middle Part or Transitional Zone or Pecten
 Next 15 mm.
 Also lined by mucous membrane, but anal columns
are absent.

8.  Bluish appearance because of dense venous
plexus that lies between mucosa and muscle coat.
 Lower limit of pecten has whitish appearance
therefore called as white line of Hilton.
Lower Cutaneous Part
 8 mm long.
 Lined by true skin containing sebaceous glands.

10. Internal anal sphincter
 Involuntary in nature.
 Formed by thickened circular muscle.
 Surrounds upper 30 mm of anal canal.
 Extends from upper end of canal to white line of
Hilton.
 Supplied by autonomic nervous system.
 When exposed during life, it is pearly-white in color
& circumferentially placed fibres can seen clearly.

11. External anal sphincter
 Continuous with puborectalis and levator ani
muscles.
 Under voluntary control.
 Made of striated muscle.
 Supplied by inferior rectal branch of internal pudendal
nerve and perineal branch of fourth sacral nerve.
 Surrounds whole length of anal canal.
 Has three parts—subcutaneous, superficial and deep.

13. Internal rectal venous plexus
 Lies in submucosa.
 Drains into superior rectal vein.
 Communicates with external plexus, thus with
middle and inferior rectal veins. Therefore,
important site of communication between portal &
systemic veins.
 Situated at 3, 7 and 11 o’clock positions &
constitute sites for formation of internal piles.

14. External rectal venous plexus
 Lies outside muscular coat.
 Upper part drained by superior rectal vein into
inferior mesenteric vein.
 Middle part by middle rectal vein into internal iliac
vein.
 Lower part by inferior rectal vein into internal
pudendal vein.

16.  Hereditary.
 Morphological
 Weight of blood column causes high pressure.
 Veins in lower rectum are in loose submucosal
plane, but veins above enter muscular layer, which
on contraction increases the venous congestion
below.
 Superior rectal veins have no valves (as they are
tributaries of portal vein) and so more congestion.

17.  Other causes (straining, diarrhoea, constipation,
overpurgation, carcinoma rectum, pregnancy, portal
hypertension).

18. Internal piles or true piles
 Occur above pectinate line.
 Painless.
 Bleed profusely during straining at stool.
External piles or false piles
 Occur below pectinate line.
 Very painful.
 Do not bleed on straining at stool.

19.  First degree - Bleed only. No prolapse.
 Second degree - Prolapse but reduce
spontaneously.
 Third degree - Prolapse & have to be manually
reduced.
 Fourth degree – Permanently prolapse.

20.  Bleeding—bright red & fresh (occurs during
defecation).
 Mass per anum.
 Mucoid discharge.
 Pruritus.
 Pain—may be due to prolapse, infection or spasm.
 Anaemia—secondary.

21.  Inspection - prolapsed piles will be visualized.
 P/R examination - only thrombosed piles can be
felt.
 Proctoscopy - exact position seen as bulge into
proctoscope.
 Colonoscopy - done if there is suspicion of
associated malignancy.

24.  To compare outcome in patients with grade III & IV
haemorrhoids who underwent Stapler or Open
haemorrhoidectomy.

25.  Done by assuming mean operating time of 30 &
43.25 minutes in stapler & 43.25 open group, as
per study by frank H et al.
 Statistical power of 90% & 2- sided alpha error of
5% were considered.
 Required sample size was 37 subjects in each
group.
 To account for loss to follow up of about 5%
another 2 subjects were added to each group.

26.  Sample size was then rounded off to include 40
subjects in each group.

27.  Department of General ofTertiary care
centre, Secunderabad,Telangana.

28.  Patients between 28 to 40 years, diagnosed with
grade III and IV haemorrhoids, were divided into
two groups equally.
 Group- 1 underwent Stapler and Group- 2 Open
haemorrhoidectomy.
 Post-operatively patients were assessed for
bleeding, pain, development of recurrence &
longterm complications.
 Subjects were recruited by convenient sampling till
sample size reached.

29.  Signed informed consent was obtained.
 Confidentiality of study participants was
maintained.
 Hospital’s ethics committee approved research
protocol.
 Data collection was done between June 2016 to
February 2018 for a period of 1.8 years including
follow-up.
 Choice of surgical procedure was based on hospital
protocol and choice of participants.

32.  Performed under spinal anesthesia, in lithotomy
position.
 Anal canal prepared.
 Transparent anal dilator was inserted & secured by
suturing to the perianal skin.
 Suture anoscope was inserted by making a
mucosal purse-string suture, 3-4 cms above
dentate line.
 Purse-string suture was anchored to fully opened
stapling device guiding its two ends through lateral

33. openings of stapler.
 Stapler was closed with continued traction to
sutures until maximum was reached.
 Stapler was deployed and held in place for 2
minutes.
 Then stapler opened with 1 & 1/2 turn & removed.
 Donut was verified.
 Staple line was checked for its position above
dentate line.
 Hemostasis for bleeding sites was attained using
cautery or suture ligatures.

36.  Kelly clamp was placed over haemorrhoidal
pedicle.
 Absorbable suture ligature was made at apex of
haemorrhoidal pedicle.
 V-shaped incision was made to external skin.
 Dissection using sharp scissors & electrocautery
was done until ligated pedicle.
 Hemorrhoid was amputated & wound left open to
heal.

39.  During surgery, intra operative time & intra
operative bleeding were recorded.
 All complications were recorded.
 Cost was assessed by duration of hospital stay,
time to resume to normal activities.
 Patients were followed up for 6 months to assess
development of recurrence & long-term
complications like anal stenosis & anal
incontinence.

40.  Comparative analysis between two groups were
done based on student’s T test using SPSS
software version.
 Level of significance was set at 5% (p < 0.05).

46. 1
Journal of Surgery and
Research, 2021.
 Stapler hemorrhoidectomy
technique was significantly quicker
to perform.
 Significantly lesser intra & post-
operative bleeding, post operative
pain, hospitalization & duration of
resumption to daily activity was
seen in Stapler hemorrhoidectomy
group.
A Prospective Comparative Study
of Stapler Hemorrhoidectomy Vs
Open Haemorrhoidectomy (Milligan
Morgan) in its Outcome and
Postoperative Complications.
Dr. Nambula Malyadri, Dr. Veera
Jayachandra Allu.
Department of Surgery, PES
Hospital, PES Institute of Medical
Sciences and Research, Kuppam,
Chittoor district, Andhra Pradesh,
India.

47. 2
International Surgery
Journal, 2019.
 Intraoperative bleeding, immediate
postoperative pain, & length of
hospital stay was significantly more
in open hemorrhoidectomy group.
Stapled haemorrhoidopexy vs.
open haemorrhoidectomy: a
comparative study.
Naman Aggarwal , Saurabh
Agrawal, Jitendra P. Ray.
Department of General Surgery,
Himalayan Institute of Medical
Sciences, SRHU, Dehradun,
Uttarakhand, India.

48. 3
International Surgery
Journal, 2018.
 Pain in passage of first stool was
significantly higher in open
hemorrhoidectomy.
 Pain in follow up at 3, 7 and 15th
day was also significantly higher in
open hemorrhoidectomy.
Comparison between stapler
hemorrhoidectomy and open
hemorrhoidectomy in the
management of grade III and IV
hemorrhoids: a prospective
randomized study.
Shailendra Pal Singh, Somendra
Pal Singh, Vipin Gupta, Kutubuddin
Quadri, Mohit Gupta.
Department of Surgery, UP
University of Medical Science,
Saifai, Etawah, Uttar Pradesh, India

49. 4
Journal of Evolution of Medical
& Dental Sciences, 2017
 Mean duration of surgery is
significantly low in stapler
haemorrhoidectomy (35 minutes )
as compared to Open
Haemorrhoidectomy (46 minutes) .
 Pain score was significantly higher
in Open Haemorrhoidectomy group
at 6 hrs, 12 hrs & 24 hrs.
OPEN HAEMORRHOIDECTOMY
VERSUS STAPLED
HAEMORRHOIDOPEXY- A
PROSPECTIVE STUDY IN A
TERTIARY HOSPITAL IN SOUTH
INDIA.
Rajesh Daniel1, M. Reegan Jose,
S. Floret, Paneerselvam,
Jeyakumar, Mohamed Mustafa,
Baskaran Selvapathy.
Department of General Surgery,
SRM Medical College Hospital and
Research Centre, Kattankulathur,
Kancheepuram, Tamilnadu.

50. 5
International Surgery
Journal, 2017.
 Stapled hemorrhoidopexy group
had significantly shorter duration of
surgery, less postoperative pain,
shorter duration of hospital stay,
earlier return to work & high patient
satisfaction.
 No recurrence, residual prolapse or
incontinence in follow up period of 6
months in stapled group.
Stapled hemorrhoidopexy versus
open hemorrhoidectomy: a
comparative study of short term
results.
Idoor D. Sachin, Om Prakash
Muruganathan.
Department of General Surgery,
Pushpagiri Institute of Medical
Sciences and Research Centre,
Tiruvalla, Kerala, India.

52.  Title is short & sweet,
yet comprehensive.
 Published in relevant
journal with IF 4.2.
 Recent research.

53.  To compare outcome
in patients with grade
III & IV haemorrhoids
who underwent Stapler
or Open
haemorrhoidectomy.
 Clearly stated.
 Statistical analysis able
to fulfil objectives.

54.  Sample size calculation is clearly stated.
 However, sample size was not large to generalise
findings.

55.  Patients between 28 to
40 years.
 Subjects were
recruited by
convenient sampling
till sample size is
reached.
 Did not mentioned why
this age range was
selected.
 Inclusion and exclusion
criteria was not
mentioned.

56.  Choice of the surgical
procedure was based
on hospital protocol &
choice of participants.
 Did not mentioned
hospital protocol.

57.  Comparative analysis
between two groups
was done based on
Student’s t test with a
p value less than 0.05
as significant.
 Suitable test applied for
quantitative data.

58.  Appropriate results were obtained to draw conclusion.

59.  Stapler hemorrhoidopexy is associated with shorter
duration of surgery, less bleeding, less
postoperative pain, & shorter duration of hospital
stay.
 It has emerged as an alternative to Open
Haemorrhoidectomy.