Background
Hemorrhoids is one of the oldest known medical conditions. Description of hemorrhoids is
found as early as 2250 Before Christ (BC) in the code of king Hammurabi in Babylon. Even
though first recorded treatment is thought to be found in the "Edwin Smith Papyrus" from 1700
BC as of today the treatment of this benign state is still debated. A wide range of
prevalence rates of hemorrhoids have been stated in part because of the varying definition
,but the general consensus is that hemorrhoidal disease is a common anorectal disease
affecting the quality of life of millions of people worldwide. Operation for hemorrhoid is
one of the most common operations for benign disease in Denmark.
Hemorrhoids arise from the normal vascular structures in the anal canal also referred to as
anal cushions or sinusoids as they do not contain muscular cells like arteries or veins.
These cushions are typically arranged in three main columns or piles in the anal canal
forming an important part of the intricate mechanism of the anal canal preventing
incontinence.
Hemorrhoids is a pathologic term describing the symptomatic abnormal downward displacement
and enlargement of the anal cushions. The term hemorrhoidal disease is used when the
hemorrhoids cause symptoms.
Treatment of hemorrhoidal disease consists of conservative management with lifestyle and diet
changes or local treatment, minor surgery and surgical treatment depending on the severity of
disease and symptoms. The staging of internal hemorrhoids in four categories by the Goligher
classification is the classification that generally forms the basis of the treatment in
Denmark.
Local treatment consists of corticosteroids and anaesthetic ointments. Minor surgery includes
rubber band ligation and sclerotherapy. Operation is reserved for subjects with prolapse,
Goligher grade II and IV. Grade II hemorrhoids may be treated by operation if still
symptomatic after banding or sclerosing.
The gold standard in the operative treatment of hemorrhoidal is the Milligan-Morgan
Hemorrhoidectomy also referred to as hemorrhoidal excision or Open Hemorrhoidectomy (OH). The
operation can also be performed as a Closed Hemorrhoidectomy when the wound is closed with
sutures (Ferguson's Hemorrhoidectomy).
The conventional excisional operation has been associated with postprocedural pain and
delayed healing of wounds. In recent years there have been suggestions for and a development
toward a less traumatic Open Hemorrhoidectomy. Injuries to the internal anal sphincter during
dissection is thought to be one cause for pain. The less traumatic operations include
dissection of the hemorrhoid preserving the fascia over the internal anal sphincter and also
smaller excision of skin and mucosa - the technique used in this study is described in more
detail under Methods.
Several new procedures have been proposed in the last decades. Common for all is the
implementation of a new technical device, meaning increased operative costs.
LigaSure Trademark (TM) hemorrhoidectomy (LH) is a hemorrhoidectomy performed with the use of
the LigaSure TM instrument in stead of the traditional diathermy. The LigaSure TM technology
patented in 1998 as "Energy Delivery System for Vessel Sealing" creates vessel fusion by a
combination of pressure and energy17. The LigaSure device excises the hemorrhoids and seals
the wound in the same procedure delivering the energy in a controlled way between the
diathermy forceps theoretically limiting thermal spray and tissue charring.
Rationale
Hemorrhoidal Disease is a benign disease and should be evaluated by it's effect on
hemorrhoidal symptoms together with its effect on quality of life.
Hemorrhoidal symptoms should be the main outcome variable when evaluating surgery for
hemorrhoidal disease. This information is largely lacking.
The use of a validated symptom score with long term follow-up could yield important
information for the choice of treatment of haemorrhoidal disease.