Asian Journal of Surgery (2014) xx, 1e6

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Short- and long-term results of harmonic
scalpel hemorrhoidectomy versus stapler
hemorrhoidopexy in treatment of
hemorrhoidal disease
Yusuf Bilgin, Semih Hot*, Ilhami
Soykan Barlas, Arzu Akan,
Yavuz Eryavuz
General Surgery Department, Okmeydanı Training Research Hospital, Istanbul, Turkey
Received 2 May 2014; received in revised form 23 August 2014; accepted 19 September 2014

harmonic scalpel;

Summary Purpose: In this prospective randomized study, our aim is to compare the shortand long-term results of harmonic scalpel hemorrhoidectomy (HSH) and stapler hemorrhoidopexy (SH) methods in the surgical treatment of Grade III and Grade IV hemorrhoidal disease.
Methods: Ninety-nine consecutive patients diagnosed with Grade III or Grade IV internal hemorrhoidal disease were included in the study. Patients were randomized to HSH (n Z 48) or SH
(n Z 51) treatments. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, additional analgesic requirement, postoperative short- and long-term complications, and recurrence of hemorrhoidal disease were
also recorded. Patients were regularly followed for a total period of 24 (6e36) months.
Results: The patient demographic and clinical characteristics were similar in the two groups.
The operative time was significantly shorter in the HSH group compared with the SH group.
Overall pain scores were not significantly different between the groups, although severe pain
was significantly more common in the HSH group. Recurrence was significantly lower in the HSH
group compared with the SH group.
Conclusion: HSH and SH are both safe and effective methods for surgical treatment of Grade III
and Grade IV hemorrhoidal disease. In our study, the HSH method was determined to be safer,
easier, and faster to perform, and associated with fewer long-term recurrences than the SH
Copyright ª 2014, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights

Conflicts of interest: We have no conflicts of interest with any organization or individual.
* Corresponding author. Avrupa Konutları Atakent 1, Number 11A/3 Halkalı Ku
¸ekmece, Istanbul, Turkey.
E-mail address: semihhot@hotmail.com (S. Hot).
1015-9584/Copyright ª 2014, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.

Please cite this article in press as: Bilgin Y, et al., Short- and long-term results of harmonic scalpel hemorrhoidectomy versus stapler
hemorrhoidopexy in treatment of hemorrhoidal disease, Asian Journal of Surgery (2014), http://dx.doi.org/10.1016/j.asjsur.2014.09.004

theoretically it promises less postoperative pain and shorter hospitalization compared to conventional methods. Evaluation parameters included age. which consisted of a circular anal dilator (CAD 33). we compared the short. external hemorrhoids. 2. Prophylactic single-dose first-generation cephalosporin (cephazolin sodium) was delivered parenterally to all patients. with minimal thermal damage to the surrounding tissue. The initial results of five randomized trials conducted in 2000 were encouraging when comparing SH with conventional hemorrhoidectomy.and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease. uses ultrasound energy to cut and coagulate soft tissue.. presenting symptoms. acute thrombosed hemorrhoid. which can be performed with scalpel or electrocautery. there is only one prospective randomized study comparing these techniques in literature.+ MODEL 2 1. Purgative enema was applied 1 day prior to the surgery.asjsur. Following its introduction. Patients with Grade III and Grade IV disease were evaluated together and separately. Detailed physical examination and rigid rectosigmoidoscopy were performed on all patients. postoperative pain is purported to be minimal.13 The analgesic given was diclofenac sodium with a maximum dose of 2. HSH cases were operated using the Ethicon Harmonic Scalpel 300 (Ethicon Endo-Surgery Inc.. Conventional techniques include Ferguson’s closed hemorrhoidectomy and MilliganeMorgan’s open hemorrhoidectomy. moderate (4e6). The exclusion criteria were previous anorectal surgery. The VAS scores were grouped as mild (0e3).and long-term results of HSH and SH. hematologic disease. occurring in approximately 5% of the general population. Patients were randomized to surgery using HSH (n Z 48) or SH (n Z 51) methods. Additionally. and more frequently in individuals who are older than 40 years.004 . harmonic scalpel hemorrhoidectomy (HSH) is used as a routine technique in many centers. gynecological procedures such as myomectomy. and postoperative pain. postoperative complications. SH aims to bring prolapsed rectal mucosa back to a natural level and rectify the topographic relation between the anorectal mucosa and the underlying muscle. as thermal damage to the surrounding tissue is avoided.and long-term complications were assessed on follow-up outpatient visits at postoperative Month 1. All patients with indication for surgical treatment were informed about the procedures. Harmonic scalpel (Ethicon Endo-Surgery Inc. Short. our aim was to contribute to the literature with this study. In HSH. Turkey with various complaints related to the anal area were screened in a time span of 4 years. Local adrenalin infiltration. and to cut internal mammary artery in thorax surgery. OH. a purse-string suture anoscope (PSA). treatment of hemorrhoidal disease in our surgical department. and Month 24. and cancer. local anesthesia. operative time. USA).09.) suture on a round body 16e18 mm needle were used in case of bleeding. a variety of devices and methods have been introduced to help facilitate the procedure and minimize patient discomfort in the postoperative period. in the surgical treatment of Grade III and Grade IV hemorrhoidal disease. surgery may be required when medical treatment fails or in the presence of concomitant conditions such as anal fissures or ulcers. islands of at least 8e10 mm were left between the excised hemorrhoid and the skin. duration of hospitalization.5 In this method.1016/j.6e10 In addition to obliterating submucosal vessels. There are various techniques used in the surgical treatment of hemorrhoidal disease. Cincinnati.org/10. In severe pain. which was introduced for the first time in 1992. So. Short. et al.11 Because SH involves the rectum where pain sensation is absent instead of the anoderm. and thyroidectomy.3 Harmonic scalpel has been used extensively in general surgery procedures such as cholecystectomy. It might seem more logical to compare HSH with the traditional electrical energy of diathermy or traditional open hemorridectomy (MilliganeMorgan). which included only the mucosal and submucosal layers. Bilgin et al. or pudendal nerve block methods were not performed. sex. A PPH01 Kit (Ethicon Endo-Surgery Inc. fistula. When used in hemorrhoidectomy. It has been 15 years since Longo5 introduced the use of stapler hemorrhoidopexy (SH) in prolapsed hemorrhoidal disease in 1998. disrupting distal branches of superior rectal artery feeding the hemorrhoids and restoring the prolapsed hemorrhoidal plexus to original anatomical position. or abscess. and a 33-mm hemorrhoidal circular stapler. return to daily activities. The pursestring was done between 3 cm and 4 cm above the dentate line.2 Surgical treatment is required in cases having symptomatic Grade III and Grade IV hemorrhoids. Materials and methods Patients presenting to the General Surgery Department of Istanbul Okmeydani Training and Research Hospital.doi. http://dx. and an independent blinded assessor. a ring of rectal mucosalesubmucosal tissue is resected approximately 3e4 cm above the dentate line. was used while SH was being performed. 99 patients diagnosed with Grade III or Grade IV internal hemorrhoidal disease were included in the study. hemorrhoidectomy.12 In this prospective study.2014. a suture threader. this method minimizes bleeding of large hemorrhoids and decreases operative time. the purse-string was completed with six to eight stitches. thousands of patients were operated on with this technique in Europe.). and presented our results in comparison with the existing literature. Additionally. Istanbul. after physical and sigmoidoscopic examination. Medical history and current symptoms were investigated in detail.5 mg/kg/d (intramuscularly in the first 24 hours and via the oral route thereafter). concomitant anal diseases such as anal fissure.1. anticoagulant use. During the surgery. All 99 patients were operated on while they were in the lithotomy position. opioid analgesic (pethidine 1 mg/kg) was given in one or two doses Please cite this article in press as: Bilgin Y.). harmonic scalpel seals bleeding vessels and forms protein coagulum. but it should be noted that we are using both SH and HSH techniques in the Y. Introduction Hemorrhoidal disease is a very common anorectal disorder. disease grade. Postoperative pain was assessed with a linear visual analogue pain scale (VAS) by the patient. surgeon. Month 6.4 Currently. and severe (7e10). two techniques that are routinely used all over the world. Suture was not used. Asian Journal of Surgery (2014). Additionally. and hemostatic stitches using a 3e0 vicryl (Ethicon Endo-Surgery Inc. under general anesthesia.

and severe in only one patient (2%) in the SH group. 4. and flatulence.2014.4) Long-term complications Recurrence 1 (2.1%). pruritus ani.8%) 37 (72. significantly more patients had severe pain in the HSH group compared with the SH group. itching. and edema in five cases (10.7) d d 1 (1. Patients in the HSH and SH groups returned to daily activities in 6. prolapse. Student t test was used for group comparisons of continuous variables. respectively.2%). perioperative and follow-up data of HSH versus SH. age. and follow-up data of patients are summarized in Table 1. Discussion The treatment for hemorrhoidal disease aims to provide a long-term relief from present symptoms and complaints. postoperative pain within the first 24 hours was mild in 16 patients (33.and long-term complications.3%) had Grade IV disease. HSH (n Z 48) Short-term complications Wound problems 6 (12.05 NS HSH Z harmonic scalpel hemorrhoidectomy. and time to return to daily activities. and 39 females (39. none of the patients complained of fecal urgency or of liquid or solid incontinence.7%] recurred in the SH group.004 .05 NS NS 34 (70. Long-term complications included recurrence in one case (2.and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease. stenosis in two cases (4.2) Wound problems 2 (4.4%). The male/female ratio was 28:20 for the HSH group and 32:19 for the SH group.asjsur.6) d 7 (13.4) Edema 5 (10.2) Perianal fistula d SH (n Z 51) p 8 (15. Short-term complications in the HSH group included wound problems in six cases (12. At the end of 2 years postoperatively.7%) and perianal fistula in one case (1.4 days in the HSH group and 2. Please cite this article in press as: Bilgin Y. Table 1 Demographic. sex.2 days. 3. Out of 51 cases in the SH group.5%).8%) had Grade III and 15 (31.+ MODEL Results of harmonic scalpel hemorrhoidectomy 3 in the 1st day.5%) 18 (37.2%) had Grade IV disease. respectively. perioperative. The presenting symptoms were pain. The mean duration of follow-up was 24 (6e36) months.3%) 12 (25%) 6 (12. According to the VAS scores.2 NS NS NS <0. 2. USA). whereas Chi-square test and Fisher’s exact test were used for group comparisons of categorical variables. The level of statistical significance was set at p < 0. yielding a total of 99 patients. on 60 males (60. Hospital stay was 2. UT. The same pain scoring showed mild pain in 22 patients (43. 33 (68.6) 8 (15. and moisture. Table 2 Short. SH Z stapler hemorrhoidopexy. No statistically significant difference was found between the groups in terms of disease grade. Out of 48 cases in the HSH group. Statistical analysis Statistical analysis was performed using Number Cruncher Statistical System NCSS 2007and PASS 2008 Statistical Software (Kaysville.6%). moderate in 14 patients (27.3%).4%). HSH Z harmonic scalpel hemorrhoidectomy. bleeding.doi. bleeding in five cases (10.7%) had Grade III and 17 (33. standard deviation.05 Data are presented as n (%). respectively. The number of patients requiring additional analgesic dose was 18 (37.1. moderate in 12 patients (25%)..1) Stenosis 2 (4. The mean operative time for the HSH and SH groups was 17 and 22 minutes.1 44.6%). Study data were summarized using descriptive statistics (mean.6 days in the SH group.5) Bleeding 5 (10. The mean age of patients in the HSH and SH groups was 44.9 28/20 33/15 17 2.5%) in the HSH group.5) with Grade IV disease. The recurrence rate was significantly lower in the HSH group compared with the SH group. There was no significant difference between the two groups in terms of wound problemsdincluding irritation. The mean operative time for the HSH group was significantly shorter than that for the SH group.6%) NS 16 (33. whereas a total of seven cases [3 (8. additional analgesic requirement.org/10. Short.9%. and severe in six patients (12. Short-term complications in the SH group included bleeding in eight cases (15. et al. Asian Journal of Surgery (2014). During the follow-up assessment. mucous discharge. Results This study was conducted in the General Surgery Department of Okmeydani Training and Research Hospital. http://dx.5%). Bleeding as a short-term complication was higher in the SH group compared with the HSH group.05.1%) with Grade IV disease recurred in the HSH group. frequency).1%) 14 (27.4%). Table 2).3 years.5%) 22 (43.5%) in the HSH group and 15 (29%) in the SH group.2%). SH Z stapler hemorrhoidopexy. NS Z not significant. Demographic. 13. Patient age ranged from 23 years to 73 years. clinical characteristics.6%) and wound problems in eight cases (15. whereas long-term complications included recurrence in seven cases (13.09.5%) 1 (2%) 15 (29%) NS NS <0.8%) with Grade III disease and 4 (23.1 days and 6.6 6. Patients with moderate or high levels of pain requiring additional doses of analgesics were recorded.3 32/19 34/17 22 2.1%).4 6. and wound problems in two cases (4. only one case (2. Overall pain scores were not significantly different between the two groups.1016/j. Age (mean) Sex (M/F) Grade III/grade IV Operation times (min) Mean hospital stay (d) Time to return to daily activity (d) Postoperative pain (total) Mild pain Moderate pain Severe pain Additional analgesic requirement HSH (n Z 48) SH (n Z 5 1) p 44.9 years and 44. 34 (66.9) <0. However. hospital stay. No septic complications occurred in our study.

22 in their study encompassing 12 centers and including 1107 patients. anorectal stricture. In the study of Tan and Seow-Choen. Although Longo’s10 technique was popularized by studies reporting low pain scores and short hospital stay with SH. anal stenosis. but no sphincter defect was detected. bleeding rate of 4% was reported.asjsur. and only three patients (0. which has a 10% mortality. The rate of gas incontinence was 0.3. Post-SH sepsis is more frequent. reported severe pain in 5% of patients at postoperative Week 1. and pseudo-obstruction. other studies found no evidence of reduced pain levels with HSH. Short. Chung et al3 compared the HSH and SH techniques in 88 patients and reported significantly lower VAS scores of postoperative pain. and 12. fissure.3% of cases. Ramadan et al16 reported postoperative pain in 4.25 which have been reported in association with the HSH technique. owing to the use of disposable materials. however. whereas in a prospective study Armstrong et al14 showed significantly less postoperative pain in HSH compared with electrocautery hemorrhoidectomy. five patients in the HSH group developed edema as a short-term complication. rectovaginal fistula. peritonitis is rarely seen in other methods. Some authors have proposed severed branches of superior hemorrhoidal artery as the cause of short-term abundant bleeding. These findings concur with Oughriss et al’s23 study. we also find the frequency of pain higher in the HSH group than in the SH group. patients were evaluated pre.39 which have been reported in association with the SH technique. Ravo et al. In support of these latter reports. However. faster return to daily activities. no significant differences were reported.35. In the literature. Tan and Seow-Choen4 did not find a significant difference between the two groups in terms of postoperative pain.14 However.5% in Grade III.33. http://dx. Cheetham et al21 reported pain in 31% of patients who underwent SH. Rectal perforation and peritonitis are SH-specific complications. incontinence was not encountered in the HSH group. Asian Journal of Surgery (2014). although it was not demonstrated in following studies.org/10. postoperative bleeding was less in the HSH group compared with the SH group. Another important aim is to increase the quality of life.2014.004 . et al.34 In our study. Thus.6.1016/j. we did not encounter complications such as urinary retention.16. continued to have the same complaint (2%). rectocele. it must be remembered that all surgical and interventional methods recommended for hemorrhoid treatment carry a risk of life-threatening sepsis. the mean operative time was significantly shorter in the HSH group compared with the SH group (17 minutes vs. postoperative bleeding rates for SH vary from 6% to 25%.doi.31.41 Rectal obstruction.5%) and the technique was reported to have no adverse effect on anal functions.. In our study.3 Incontinence is a short-term complication and one of the most important parameters affecting patient comfort and satisfaction. the number of patients with gas incontinence was 11 (4. Bilgin et al.3 in our study. 22 minutes). In a multicenter randomized clinical trial.38 and permanent postoperative rectal pain. no significant time difference was determined by Chung et al. By contrast.25 abscess. where patients with Grade III and Grade IV hemorrhoids were followed for a mean of 33 months and no recurrence Please cite this article in press as: Bilgin Y. In the study conducted by Riss et al30 on SH including 242 patients. shorter hospitalization. rectal pocket syndrome or rectal diverticulum. Endoanal ultrasonography showed no sphincter defect in this patient. mean scores of overall pain did not reach statistical significance between the two groups. 23. Thaha et al24 compared SH and closed hemorrhoidectomy and defined “pain after defecation” as a special complication related to stapler use.09. These aims can be achieved through a dependable surgical technique and preservation of anorectal functions. In another study. distance between the stapler line and the dentate line was seen to be approximately 1 cm.37.8% in Grade IV.9% overall. by contrast. Early recognition of septic complications can prevent severe morbidity. the surgeon performing SH should be very careful and examine the patients presenting with high fever and severe pain in the operation room. whereas no patients had edema in the SH group.and postoperatively by anal manometry and three-dimensional ultrasonography. No septic complication was seen in our study. This was regarded as an adverse side effect of HSH compared with SH.42.43 Studies claiming to have successfully implemented Longo’s10 technique were supported by Pernice et al’s27 study. only one patient whose primary complaint prior to the surgery was gas incontinence. Finco et al12 determined the postoperative bleeding rate as 10.26e29 In a study comparing the hemorrhoidectomy results of Grade III versus Grade IV hemorrhoids.35 rectal or vaginal perforation. One of the most important short-term complications of hemorrhoidectomy is bleeding. In a prospective randomized study comparing diathermy and HSH. and showed that. in the SH group.15 In a first and foremost study. and higher patient satisfaction in the SH group. and rectal intussusception are other rare complications that can occur following the SH procedure.40 possibly because of the increased recent interest in the technique. none of the patients had short-term postoperative bleeding.4 a reasonable postoperative Y. SH may result in severe sepsis.36 Fournier disease. As postoperative pain is thought to be caused by thermal damage. HSH turns out to be 10 times more expensive than hemorrhoidectomy using regular cautery.2% in the Armstrong et al25 study on HSH. where early and late complications of the technique were investigated and the presence of severe pain was determined in 2.5.6%) had secondary bleeding in postoperative Days 7e14. fistula.+ MODEL 4 especially pain. In our study. In our study gas. under anesthesia.4. the number of studies reporting the superiority of SH in postoperative pain control compared with conventional methods is high. and harmonic scalpel results in less thermal damage compared with laser and electrocautery. In our study. In only one case of severe pain in the SH group. or sphincter damage.3% of patients undergoing HSH.and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease. HSH was proposed as a less painful operation. In a study by Armstrong et al25 conducted on 500 patients undergoing HSH.32 In other studies comparing conventional and SH techniques using the continence score.17e20 later studies with opposite findings created confusion. severe pain was reported significantly more with HSH than with SH. Ho et al31 used endoanal ultrasonography to evaluate internal sphincter function following SH and found it within normal limits. Despite these results. Contrary to the results of Chung et al.

9%) with Grade IV hemorrhoidal disease during a follow-up of 6 years. in a prospective study comparing SH with conventional techniques. and endoanal ultrasound assessments at up to three months. In our series of 99 patients with a follow-up of approximately 24 months. and the conventional scissors excisioneligation technique (MilliganeMorgan). Stapled hemorrhoidectomy cost and effectiveness. 10. Lancet.7% vs. compared with SH. HSH procedure can turn out to be more cost-effective than SH.1%) is an important reason to prefer HSH. both methods have considerable positive effects on patient comfort and satisfaction over the long term. whereas eight of 15 cases had recurrent prolapse in the SH group. 1998.48:1213e1219. we only used one harmonic scalpel for each patient once in accordance with a suggestion by Ethicon EndoSurgery Inc. 28:230e231.44:677e679.7%). 2000. In conclusion. Br J Surg. compared with single use of circular staplers. In addition. Alternatives to surgical hemorrhoidectomy. Conclusion Both the SH technique described by Longo10 and HSH are routine procedures used in the surgical treatment of hemorrhoidal disease. Cheong WK. 3. J Egypt Soc Parasitol. According to this study. Prospective. 11. in our study. Merigliano S. In a systematic review of seven randomized controlled trials including 537 cases.004 . http://dx. 2. Lester et al51 reported that reprocessed harmonic scalpels that pass acceptance tests exhibit functional and safety capabilities that are equivalent to their new counterparts. Stapling procedure for hemorrhoids versus MilliganeMorgan hemorrhoidectomy: randomized controlled trial.45 where SH was compared with diathermy. Hartley JE. considering the reusability of the harmonic scalpel. 62:542e552. Surg Laparosc Endosc PercutanTech. the significantly higher recurrence rates seen with SH compared with the more reasonable recurrence rates of HSH (13. Arslani N. Rome. in another prospective study by Ortiz et al. Sarzo G. A randomized clinical trial comparing Ligasure versus stapled hemorrhoidectomy. postoperative pain. Savastano S.. Additionally. Altarac S. Symposium on outpatient anorectal procedures. Also. However. Cheung HY. Bulus et al50 evaluated harmonic scalpel and Ferguson’s with electrocautery techniques in the management of hemorrhoidal disease. 12. Treatment of hemorrhoid disease by reduction of mucosa and hemorrhoidal prolapse with a circular suturing device: a new procedure. HSH was considered to be a safer and a faster technique associated with lower long-term recurrence rates.asjsur. 5 5. Cohen Z. June 3e6. Stapled hemorrhoidopexy vs. Li MK.8% recurrence rate in Grade III disease. Khalil KH. Monson JR. Dis Colon Rectum. Can J Surg. 1985.+ MODEL Results of harmonic scalpel hemorrhoidectomy was found. Rajkovic Z. They reported that both HSH and bipolar scissors hemorrhoidectomy were superior to MilliganeMorgan hemorrhoidectomy in terms of reduced blood loss.1016/j. HSH is safe. However. Longo A. during a follow-up period of 4 months.87:1352e1355. controlled trial including incontinence scoring. Patrlj L.2014. 2001. SH was determined to have a higher long-term recurrence rate. harmonic scalpel hemorrhoidectomy: a randomized trial. However. By contrast. the significantly shorter operative time with HSH compared with SH is a major advantage of this method. 2.355:779e781. They reported that HSH is preferred for surgical treatment of Grade III or Grade IV hemorrhoids. Please cite this article in press as: Bilgin Y. and causes less blood loss.org/10. bipolar scissors. Ortiz et al44 reported that SH was less successful in patients with Grade IV hemorrhoidal disease. Edema seen in HSH as an early postoperative complication is a disadvantage compared with SH. Tsang C. at the end of a 2-year follow-up there was recurrence in only one patient (2.5% recurrence rate in Grade IV disease and the 8. Finco C. Thompson WH. Moreover. Short. 7. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled trial. Dis Colon Rectum. anorectal manometry. HSH had the best satisfaction score among the three groups. no recurrent cases were seen in the diathermy group. which is the biggest factor accounting for its failure in Grade IV cases. Chan ES. 2005.22:58e61. HSH had the best pain score when compared with bipolar scissors hemorrhoidectomy and MilliganeMorgan hemorrhoidectomy. Ho YH.355:782e785.1%) with Grade IV disease in the HSH group. Chung CC. and the authors concluded that SH was not an effective method in patient with Grade IV hemorrhoidal disease. Asian Journal of Surgery (2014). 6. we believe that there is a need for more studies on this topic. Bello M. Considering the 23. O’Bichere A. Stapling procedure for hemorrhoids versus conventional hemorrhoidectomy. however. Br J Surg. 8. Goulimaris et al17 stated that SH has higher recurrence rates. 5.43:1666e1675. 2000. The nature of hemorrhoids. et al. Mehigan BJ. effective. SH can be regarded as more successful for Grade III disease. Chung et al49 compared the outcome of patients receiving hemorrhoidectomy using harmonic scalpel. Burch et al47 compared SH and conventional techniques and found no significant difference between them in terms of cost-effectiveness and complications. Degregori S. In a systematic review of 2279 cases. 2000.30: 951e958.50 The price of harmonic scalpel handpiece is approximately twice the price of Longo’s10 circular stapler. Helmy MA. 9. Stapled haemorrhoidopexy in fourth degree haemorrhoidal prolapse: is it worthwhile? Colorectal Dis. Seow-Choen F. 2012. 1975. as opposed to seven patients (3 patients with Grade III and 4 patients with Grade IV disease) in the SH group (13. The rate of recurrence was significantly lower in the HSH group compared with the SH group. However. Jayaraman et al48 determined 23 recurrences in 269 patients in the SH group compared with four recurrences in 268 patients in the conventional hemorrhoidectomy group.8:130e134. Randomized. In our study. 2000. Moreover. Kwok SY. the cost-effectiveness of HSH is to be evaluated by a shorter operative time and lower recurrence rates. Zacharakis et al46 reported recurrence in 33 of 56 patients (58. Also.doi. 2006. and complications compared to Ferguson’s with electrocautery hemorrhoidectomy. In: Proceedings of the 6th World Congress of Endoscopic Surgery.09. 2000. Lancet. despite minimum postoperative pain. Sellu D. Tan JJ. 4. References 1. Papes D.49 Recently. Furthermore. randomized trial comparing diathermy and harmonic scalpel hemorrhoidectomy.and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease. Rowsell M. et al. Randomized clinical trial of sutured versus stapled closed hemorrhoidectomy. Hemingway DM. the rate of severe pain in the early postoperative period was higher in the HSH group. Dis Colon Rectum.

Naznedar R.. Riss S. Pramateftakis MG. Tsang C. 30. Yver R. Frankum C. 51. Complications after stapled hemorrhoidectomy: can they be prevented? Tech Coloproctol. Li MK. Double-blind. Altomare DF. Sheppeard H. Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy. Ravo B. 27. Boers A. Life-threatening sepsis following treatment for haemorrhoids: a systematic review. Goulimaris I. Orsini S.5:56e57. et al.8:748e755. Armstrong DN. Mentes‚ BB. randomized trial comparing closed excisional hemorrhoidectomy and Harmonic Scalpel technique of excisional hemorrhoidectomy. Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial. 33. Voirin D.88:1449e1455. Tai YP. 38. 34. Amato A. 2002.asjsur. 2006. Scott AN. 2002. 35. Orangio GR. Rinaldi M. Fournier gangrene as a rare complication after stapler hemorrhoidectomy. Licata A.361:1437e1438. Wexner SD. Int J Colorectal Dis. Asian Journal of Surgery (2014). 49. Report of a case. 2008. Altomare DF.20:e150ee159. Marti L. Sutherland LM. Ambroze WL.12:1e193. Catarzi S. Prospective randomized multicenter trial comparing stapled with open haemorrhoidectomy. Long-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity. Nuorva K. Br J Surg. Di Cataldo A. Arch Surg.88:1487e1491. Marzo J. 2002. Impact of stapled haemorrhoidopexy on stool continence and anorectal functiondlong term follow-up of 242 patients. McCloud JM. Pawlak SE. Tech Coloproctol. Stapledhaemorrhoidectomy (haemorrhoidopexy) for the treatment of haemorrhoids: a systematic review and economic evaluation. Harris DC. et al. Ramadan E. Transanal stapled excision of rectal mucosa prolapse. Lester BR. Baker RP.37:20e23. 42. Bo ¨nner C. Kairaluoma M. bipolar scissors hemorrhoidectomy and scissors excision: ligation technique. 2010. diathermy excision for fourth-degree hemorrhoids: a randomized. Naldini G. 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