Role of Lateral Anal Sphincterotomy Versus Maximal Anal Dilatation in Reducing Post Operative Pain after Open Hemorrhoidectomy: A Comparative study

INTRODUCTION: Haemorrhoids are one of the most frequent anorectal disorders to affect humans. They are the most common cause of bleeding per rectum and cause considerable pain and suffering. Numerous features have been appealed to be the aetiologies of haemorrhoidal progress and enlargement, which includes constipation and sustained straining while defecation. Lateral Anal Sphincterotomy (LAS) after a Milligan Morgan Haemorrhoidectomy significantly reduces pain in the first post-operative period. High anal pressures are common in patients with haemorrhoids suggesting that they may have a pathogenic role. Internal Sphincterotomy avoids pain, urinary retention and stenosis and is safe. Maximal Anal Dilatation (MAD) is based on careful but firm dilatation of the anal canal in order to reduce the anal canal pressure for management of Fissure in ano. This study was conducted to compare the post-operative pain in two groups of patients treated with Lateral Anal Sphincterotomy and Maximal Anal Dilatation following a Milligan Morgan Haemorrhoidectomy. AIMS AND OBJECTIVES: To assess and compare the outcomes of the postoperative pain in Lateral anal sphincterotomy against Maximal Anal Dilatation following a Milligan-Morgan Haemorrhoidectomy in terms of Postoperative pain. METHODS: 50 patients with a diagnosis of grade 2, 3 or 4 hemorrhoids were taken into the study. Each patient was randomly allotted into one of 2 groups: a) Group A: Patients subjected to Lateral anal sphincterotomy b) Group B: Patients subjected to Maximal anal dilatation All patients underwent Milligan Morgan hemorrhoidectomy followed by either Lateral Anal sphincterotomy or Maximal anal dilatation based on the group allotted. All patients received antibiotics in the form of Inj. Cipro 500mg TDS and Inj. Metrogyl 500mg TDS with first dose given at time of anesthesia. All patients were advised SITZ BATH following removal of anal pack post operatively. Post operative pain, pain during the first postoperative bowel motion, early postoperative complications, (urinary retention/reactionary bleeding/flatus or faeces incontinence) and duration of hospital stay were evaluated. Severity of post-operative pain was assessed according to the frequency of administration of analgesic, needed to control the pain for a patient and using visual analog scale as given below. Objective Pain level was categorised as ‘Mild’ (1 point) if required analgesics were 02/48hours to control the pain, ‘Moderate’(2 points) if numbers were 3-4/48hours and ‘Severe’ (3 points) when analgesics were >4 in numbers. Subjective pain score will be assessed on the 2ndpost operative day using Wong Baker’s Faces pain rating scale. A combined total score is calculated by adding up objective and subjective pain scores. On the 7th postoperative day a careful digital-rectal examination (DRE) was done in all the patients to assess the anal tone and anal stenosis if present. RESULTS: Out of 50 patients, 25 (50%) of them were manages using Lateral Anal Sphincterotomy and 25 of them (50%) were managed using Maximal Anal Dilatation. • Among 50 patients, 33 (66%) of them had normal sphincter tone on day 7 while 8 (16%) of them had low sphincter tone and 9 (n=18%) of them had high sphincter tone. • One-way ANOVA showed that pain management was better using Lateral Anal Sphincterotomy and varies from the group that had maximum anal dilatation. ANOVA was significant with F=60.293 and p-value very highly significant. CONCLUSION: With the above factors and the study results it is safe to conclude that Lateral Anal Sphincterotomy is far better than Maximal Anal Dilatation as an adjunct to Open hemorrhoidectomy to overcome the post operative pain severity