A PROSPECTIVE STUDY OF EARLY POST OPERATIVE COMPLICATIONS AND THEIR MANAGEMENT FOLLOWING OPEN HAEMORRHOIDECTOMY

Background: Hemorrhoids are very common problem experienced by the human beings due the erect posture and they are defined as the abnormal dilatation and displacement of the fibrovascular cushions commonly at the 3,7and 11o clock position. The common presenting complaints being bleeding per anus, mass per anum, itching in the peri anal region, pain while passing stools. Open hemorrhoidectomy is the gold standard technique in the management of  the hemorrhoids and it is associated with its own post operative complications like post operative pain which is mainly complained by the patients in the immediate post operative period and during defecation. Remaining immediate post operative complications include urinary retention which is due to the spasmodic contraction of the sphincter muscles and is managed by catheterization of the patients after initial analgesia and sitz bath if the patient is unable to pass the urine on his own. Bleeding which can be early postoperative bleeding or late post operative bleeding and wound infection will occur if the perineum is not cleaned well. The above described are seen  in early post operative period and complications like anal canal stenosis, incontinence for faecal matter and fissure in ano will be seen in the long term post operative period. As hemorrhoidal cushions also help in maintaining the faecal continence initially patients may complain of soiling of under garments with stools but           this cant be considered as faecal incontinence because they will regain the ability to maintain the continence in few days.

Methods: This is A Prospective study of early post operative complications and their management following open haemorrhoidectomy was conducted in SVRRGGH, TIRUPATHI for duration of 1 year from approval of Institutional Ethics Committee. The diagnosis of the haemorrhoids is made by taking detailed history, general physical examination, per rectal examination and proctoscopy and the patients are graded into 1,2,3 and 4^th grade accordingly. All the patients who got admitted and diagnosed with haemorrhoids are evaluated for the co-morbidities such as diabetes and fasting and post prandial blood sugars are taken.   All patients who got admitted were checked for blood pressure and were kept on anti-hypertensives, if blood pressure was found to be on higher side. And routine investigations like CBC, LFT, RFT, ECG, CHEST X RAY were done and investigations like ultrasound abdomen was done to rule out portal hypertension. After thorough evaluation of the patient informed and written consent was taken from the patient. Then after obtaining the fitness for surgery the patients are kept on oral liquid diet from morning of the day before surgery. And was kept on nil per oral since 10 pm of the day before surgery. Soap water enema was given two times. All the above bowel preparation is done to keep the operative field sterile during surgery and to prevent immediate soiling of wound. 100 patients are included in the study based on the inclusion and exclusion criteria as mentioned below.

Results: My study includes 100 patients admitted in SVRRGGH, TIRUPATHI and after informed and written consent and after thorough explanation of the procedure and its advantages and disadvantages the patients had undergone Milligan Morgan open hemorrhoidectomy. In my study the incidence of hemorrhoids is noted among the age group of 40 years and males are predominantly involved. Grade 3 hemorrhoids were the most commonly observed type. Post operative pain is the most commonly encountered complication and it is managed by  giving tramadol intravenously. In my study the incidence of severity of pain is mild type-40%, moderate type -42% and severe type -18%. Based on the severity of the pain along with the tramadol, another oral analgesic is given. Urinary retention is the second most complication managed by Foleys catheterization. Males are the most commonly involved gender. Bleeding is observed in 14% of the population. Early bleeding is the only complication noted and no late bleeding cases are noted. Only 4 of them required the intervention by shifting them to operation theater. Wound infection is only noted in 5% of the studied group and it is noticed in the persons who has not followed the post operative instructions like sitz bath, taking oral antibiotics, taking laxatives.

Conclusion: Open hemorrhoidectomy is the gold standard technique for the management of the hemorrhoids as per the literature. Now a days there are many procedures  available like stapler hemorrhoidectomy and hemorrhoidectomy done using energy devices like harmonic scalpel, ligasure. Some additional procedures like lateral internal sphincterotomy are used to augment the procedure to improve the post operative morbidity. The most common complications following the open hemorrhoidectomy were post operative pain and urinary retention and they can be prevented by meticulous dissection and minimal tissue handling during surgery to avoid creation of wide raw areas there by decreasing the post operative morbidity to the patient. In the articles I have studied lateral sphincterotomy has decreased the post operative complications in the immediate post operative period and this can be assessed in the further studies conducted.