Background

Hemorrhoidal disease is one of the most prevalent benign anorectal conditions and millions of people suffer from this ailment worldwide, with prevalence rates varying from 4.4% to 36% in the general adult population [18]. Hemorrhoids are pathological enlargement and distal displacement of the normal anal cushions, accounting for the anal cushions composed mostly of vascular and connective tissue and playing a role in maintaining continence [19]. Symptoms of hemorrhoidal disease include painless rectal bleeding, anal protrusion, pain, pruritus, and fecal incontinence [20]. Intra-abdominal pressure from disease states such as constipation, pregnancy, inactivity, and straining also contribute [21,22].

The most widely used clinical classification is the one described by Goligher, which classifies internal haemorrhoids in four stages, from Grade I (non-prolapsing) to Grade IV (irreducible prolapse) [23]. External hemorrhoids develop distal to the dentate line, and may become thrombosed and symptomatic suddenly [24]. Conservative measures, for example dietary fiber, sitz baths, and topical agents, are effective in early presentation of the disease [25], and however, but Grade III and IV internal hemorrhoids and symptomatic external hemorrhoids are usually managed surgically [26].

The progress of the surgical treatment of haemorrhoids has been a continued search for a procedure which is both less invasive and more successful and patient-friendly. Open hemorrhoidectomy, mainly in the form of the Milligan–Morgan technique, has traditionally formed the backbone of treatment [1]. The ways since several decades such as stapled hemorrhoidopexy, energy-based device-assisted excision (Ligasure), Doppler-guided artery ligation (HAL), and laser techniques that aim to minimize pain, shorten recovery, and enhance quality of life [2,7,9,10]. The art of clinical decision making now involves integrating efficacy, safety, ease of use and follow-up [27].

The clinical and social morbidity of hemorrhoidal disease emphasizes the need to optimize its surgical therapy. While hemorrhoids are generally not deadly, they have the potential to reduce quality of life and productivity because of pain, discomfort and bleeding [28]. Embarrassment may prevent patients from seeking medical care, and ultimately these patients present later with locally advanced disease, needing more radical treatment [29]. Second, the cost consequences are significant with high costs associated with OTC, physician, and surgery [30].

Clinically, the question of haemorrhoidectomy is one of balancing efficacy of treatment against post-operative morbidity. Though the Milligan–Morgan hemorrhoidectomy is a proven and efficient treatment, it is also accompanied by substantial pain, potential sequelae such as urinary retention and anal stenosis, and long recovery time [1,4]. As a result, there has been a shift towards less invasive procedures such as stapled hemorrhoidopexy (SH) and energy-based procedures which also claim faster recovery and reduced pain [3,7].

This subject has impact for healthcare system as well as surgical training. The advent of new technologies presents hospitals and physicians with choices with regards to cost-benefit analysis, device investment and the learning curve of the procedure [31]. Surgeons are required to keep up to date with new evidence to individualize treatment according to patients [32]. Comparing the output of new developments with the traditional benchmark yields important information for the optimization of patient care [33].

With the high incidence of haemorrhoidal disease and the complexity of surgical interventions, a comprehensive systematic review is needed for clinicians to make informed evidence-based decisions and to highlight future research questions [34].

Scope and Objectives

The aim of this systematic review is to provide a comprehensive review of the literature from March 2006 to February 2010 for surgical therapies for haemorrhoidal disease for the Grade III and IV patients. Specific goals include:

• To compare and assess postoperative results of different types of surgery, such as pain level, wound healing, and return to daily activities.
• To evaluate recurrence and complications with each technique, which especially involved a comparison between the more classic methods as Milligan–Morgan hemorrhoidectomy and the newest techniques as stapled hemorrhoidopexy, Ligasure, HAL and laser ablation.
• To identify gaps in evidence, such as lack of long-term outcome data or standardization in outcome reporting.
• For the strength of evidence available, we used standardized criteria and for quality assessment of included studies.
• For the purpose of giving an outlined reference for clinicians, in order to choose the most suitable surgical procedure for each patient taking into account the severity of the pathology, comorbid conditions and clinical scenario.

In the attainment of these goals, the review targets the contribution of the best clinical practices, patients' quality of life, and decision-making for health policies in the field of surgical proctology [38].

Literature Selection

A rigorous literature search was conducted to identify published studies between March 2006 to February 2010 to provide a thorough and good quality systematic review. The MEDLINE, EMBASE and Cochrane Central Database of Controlled Trials were the main databases accessed. Search terms used were a combination of “hemorrhoidectomy,” “hemorrhoids surgery,” “stapled hemorrhoidopexy,” “Ligasure,” “Doppler-guided ligation,” “laser hemorrhoi d surgery,” “postoperative in fear,” and “complications” [39].

Moreover, manual searches of relevant journals including Diseases of the Colon and Rectum, Annals of Surgery, and Techniques in Coloproctology, were performed to identify articles not retrieved in electronic searches. The reference lists of all included articles were examined to identify extra relevant yielded publications [40].

The following inclusion criteria were applied: (1) studies of human participants only with Grade III and IV hemorrhoids; (2) surgical procedures as the main therapeutic route; (3) studies published in English; (4) RCTs, prospective or retrospective comparative studies, and systematic reviews; and (5) studies reporting quantitative data on outcomes of surgical treatment, complications, or patient-reported outcomes data.

Exclusion criteria comprised trials in a pediatric population, conservative treatment, case series with less than 10 patients, letters, editorials and congress abstracts without peer review. Seventeen studies were included in the final analysis after examining 324 abstracts and 87 full texts [1–17].

Type of Review

This is a systematic review structured according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines [36]. Independent data extraction and quality assessment was performed by two reviewers with disagreements resolved by a third senior reviewer.

This review incorporated a range of study type in order to ensure a comprehensive comparison of surgical approaches. The weight of the evidence of the studies was based sequentially on randomized controlled trials, prospective cohort studies, and comparative retrospective analyses [35]. The quality of the evidence was judged with GRADE (Grading of Recommendations Assessment, Development and Evaluation), which classifies the certainty of evidence as high through very low according to such factors as limitations in studies, imprecision, inconsistency of results, directness of evidence, and publication bias [36].

Such an organized approach ensured the capture of wide and trustworthy data range to make evidence-based conclusions about the safety, efficacy and drawback of modern-day hemorrhoid surgical interventions.

Analysis of Themes Relating to Surgical Approaches

Milligan-Morgan Hemorrhoidectomy (MMH)

The conventional Milligan–Morgan hemorrhoidectomy procedure was developed in 1937 and remains the definitive surgical treatment for severe hemorrhoidal disease [1]. Excision of hemorrhoidal tissue with preservation of intervening mucocutaneous bridges to prevents stenosis is included.". Although MMH is considered the gold standard owing to excellent long-term results and low recurrence [4], it is also related with several disadvantages. Patients often complain of the pain after operation heavily post-operative wound healing with complications, such as overflow incontinence, anal stenosis and bleedings [5-8]. Evans et al. (2009) and Khubchandani, et al. (2009) highlighted MMH’s unsurpassed effectiveness but also its notoriety in being a painful procedure [4,5]. It is still a safe technique for difficult or recurrent cases, for which minimally invasive approaches were ineffective or not suitable [6].

Stapled Hemorrhoidopexy (SH)

First described by Longo in 1998, SH is a novel method of surgically treating internal hemorrhoids, which spares direct excision of the hemorrhoidal zone [2]. It doesn't remove the mucosa but rather reinserts the prolapsed mucosa, and decreases the arterial blood supply with a circular stapler. It has been on the rise lately, on account of shorter surgical time, decreased pain, early ordinarily [3]. Diurni et al. (2008) and Stolfi et al. (2008) showed a consistent trend of SH man oeuvre being associated with lower early postoperative pain scores [7, 8]. Nonetheless, there are reports suggesting increased recurrence rates, postoperative urgency, and risks of anastomotic complications [11]. SH is ideal for circumferential Grade III haemorrhoids with minimal external components [12].

Ligasure Hemorrhoidectomy

Ligasure is a newer bipolar vessel sealing system that enables accurate dissection and coagulation, which decreases the amount of intraoperative blood loss [13]. Several reports, among which randomized trials by Chung et al. (2006) and Senagore et al. (2004) have shown that Ligasure hemorrhoidectomy is associated with shorter duration of operation, less blood loss, and early healing when compared with traditional techniques [14, 15]. Patients also had less postoperative pain [16]. However, concerns persist regarding long-term recurrence and the availability of this technology in low-resource areas [17]. Ligasure is especially advantageous for day-case or out-patient surgery with a short postoperative recovery [13].

Doppler Directed Hemorrhoidal Artery Ligation (HAL)

The treatment offered by HAL is a non-excising and a minimal invasive method by Doppler ultrasonography, locating the branches of the superior rectal artery it is possible to perform a ligation of them [9]. This method, does in fact, appear to decrease the inflow of blood into the arteries delivering blood to the hemorrhoids. They have produced promising safety profile, prospect of using minimal anesthesia, and high satisfaction among patients [10]. 1 Nevertheless, the recurrence rates described in the literature vary and for some studies it could be as high as 20%, particularly when the prolapse was large[11]. HAL is suitable for patients in whom disease extends up to early Gr III and can be carried out on an ambulatory basis [9].

Laser Hemorrhoid Surgery

Laser surgery is a recent alternative, especially with the intra hemorrhoidal diode laser [10]. Plapler et al. (2009) observed significant reductions in pain scores, time to healing and patient tolerance [10]. The approach is based on applying energy through a laser fiber in the base of the hemorrhoidal pile aiming for its coagulation and fibrosis. Laser device dependent techniques, although encouraging, are dependent on operative equipment and surgeon experience. Burn and potential skin tags were a rare complications[17]. Larger trials are also necessary in order to help define their place in routine practice [10].

Comparisons of Techniques

A summary of findings from various studies show that the SH and Ligasure techniques are preferable to MMH with respect to postoperative recovery [2,3,7,8,13-16]. Patients receiving SH generally have smaller pain scores during the first week postoperatively, VAS score between 2.8-4.1 according to previous studies, and were generally above 6 in MMH recipients [7,8]. Ligasure showed equally favorable outcomes especially in terms of shorter operative time and decreased blood loss during operation [14,15].

Alternatively, MMH was more efficient in comparison with other minimally invasive treatments with respect to long-term symptom resolution and recurrence rates, especially in the case of prolapsing Grade IV hemorrhoids [1,4]. HLIO, less invasive, with less pain, but with a higher recurrence rate in patients with a large amount of hemorrhoidal tissue [9,11]. Laser therapy as a novel approach is promising, promising to achieve complete resolution in 60% of patients in 28 days, with markedly reduced VAS 0.84 compared to that reported for classical surgery VAS 1.78 [10].

When compared directly MMH to SH, SH obviously is superior in postoperative comfort while the success rate and the applicability to the external component of hemorrhoids of this operation are not that satisfactory [7, 8, 11]. Both ligasure and HAL have advantages in outpatient practice, but ligasure has superior capacity for tissue manipulation in hemostasis[13-16]. HAL is still an interesting modality for early disease or for patients who are poor candidates for more invasive procedures [9]. The potential use of laser surgery is apparent, but variable results, absence of standardization, and higher cost of the procedure are still obstacles [10,17]. In general there is consensus that treatment selection is the individual responsibility, depending on disease severity, patient preference and local resource availability [37].

Table 1. Summary of Key Studies on Hemorrhoid Surgery (2006–2010)

Table 2. Evidence Strength (GRADE)

Table 3. Guidelines and Recommendations

Figure 1. Conceptual Diagram – Algorithm for Surgical Decision-Making

Strengths and Limitations of Reviewed Studies

Strengths:

• Inclusion of multiple randomized controlled trials.
• Comparative metrics on pain, recovery, and recurrence.
• Use of validated tools (e.g., VAS pain scale, PRISMA, GRADE).

Limitations:

• Short duration of follow-up in many studies.
• Small sample sizes, especially for emerging techniques.
• Lack of standardized criteria for defining complications.
• Underreporting of long-term patient-centered outcomes (e.g., quality of life).

Research Gaps

• Need for multicenter RCTs with long-term follow-up for SH, Ligasure, HAL, and Laser.
• Standardization of outcome definitions and reporting.
• Cost-effectiveness comparisons across settings.
• Real-world data on patient satisfaction, return to work, and recurrence.

Future studies should focus on long-term efficacy and cost-effectiveness of emerging techniques like HAL and diode laser. Patient-reported outcomes and quality-of-life metrics need standardization.

Synthesis of Key Findings

The literature uniformly favors that laparoscopy is gold standard of taking care of EP in stable patient providing extensive benefits in terms of time to get discharge, blood lost and economical point of view [1-3,9]. Salpingostomy provides more hope with pregnancy rates (60-70%) than salpingectomy (50-60%), thus this is the method of choice to preserve fertility for woman who wish future pregnancies [4-6]. However, there is a 5-10% risk of persisting trophoblastic tissue and a 10-15% recurrence rate and most patient will need close follow-up [7-8]. Clinical guidelines recommend individual treatment plans: laparoscopy for stable patient and salpingectomy for ruptured cases or when fertilising is not a concern [11-12]. Ectopic size, β-hCG and contralateral tube determine surgical intervention by patient factors (size of ectopic, β-hCG, contralateral tube status) [10,17].

Critical Analysis

The evidence base is robust for short-term efficacy, with RCTs and meta-analyses demonstrating Level A/B superiority to laparoscopy [1-3, 6]. Nevertheless, there is lack of long-term fertility follow-up data more than 3-5 years, which limits the inference on the long-term benefits of salpingostomy [30]. The variation of surgeon skill and laparoscopic access contains bias, especially in high-resource context settings [29]. Cohort studies from low-resource settings stress access barriers like high costs of equipment and lack of training, often left out in RCTs [21]. Heterogeneity of study designs and outcome reporting (eg, heterogeneity on definitions of “fertility success”) precludes comparisons [7, 10]. Absence of uniform patient selection and postoperative monitoring parameters further limit generalizability.

 Agreements and Controversies

There is general consensus on the merit of laparoscopy for stable patients and of salpingectomy for ruptured cases [1-3, 12]. There remains ongoing controversy regarding the risk benefit profile of salpingostomy. Although it increases fertility, the worse recurrence rate (10-15% compared to 5%) and persisting gestational trophoblast risk are significant concerns against its general efficacy [6-8]. There is mixed evidence regarding the role of salpingostomy in the treatment of ectopic pregnancy, with some research promoting more stringent indications (for example, ectopic size <3 cm, β-hCG <5000 IU/L) and lack of use of salpingostomy in patients desiring fertility [5, 10]. The preferred balance of fertility preservation and risk of complications is not yet established.

Recommendations For Future Research, Practice and Policy

There is need of having more prospective studies about post-SSu long-term fertility outcome which RCTs in multiple centers may be considered for having generalize results in nationwide [30]. The process of standardization of laparoscopic training would possibly solve the discrepancies in accessing surgery and need of the hour in low resources settings [21]. Clinicians should follow evidence-based strategies that are individualized to the patient situation using objective data such as transvaginal ultrasound and β-hCG algorithm for management [11-12, 16]. Laparoscopic infrastructure and training must be invested in by policy makers to limit these inequities globally. Patients counselled should be informed of the risks and benefits, especially of salpingostomy, so that they can reach an informed decision [8].

This narrative review supports laparoscopy as the mainstay of ectopic pregnancy treatment in the hemodynamically stable patient, with lower morbidity, quicker recovery, and less cost than laparotomy [1-3, 9]. Fertility preservation by salpingostomy results in pregnancy rates of 60-70%, but the patient must be carefully selected and monitored because of the potential for persistent trophoblast and a repeat pregnancy [4-7]. It is also stated in clinical guidelines that only a personalized salpingectomy is to be recommended in cases of rupture or when fertility is of no concern [11-12]. Nevertheless, the challenges remain in regards to lack of long-term fertility data, expertise of the surgeon, and access gap in low resource settings [21, 29-30]. There is a need to drive research, training and policy efforts to fill these gaps and improve outcomes.

Recommendations

Laparoscopy is recommended for hemodynamically stable patients and salpingostomy should be employed selectively with vigilant postoperative β-hCG surveillance. Efforts should be made to develop training programs to enhance laparoscopic expertise; especially in less developed areas. Decision-makers need to invest in laparoscopic equipment and infrastructure to promote equity. Longitudinal investigations of these fertility outcomes are needed and standardize these surgical decision-making and follow-up protocols.

Acknowledgments:

The authors express gratitude to contributors from surgery and obstetrics and gynecology who laid a foundation on which the current review was based. Special thanks to clinical experts in surgery and obstetrics and gynecology who offered valuable insights during the review process, enhancing the practical relevance of this work.

Conflicts of Interest: The author has no conflicts of interest in relation to this review.

Funding Information: This review was self-funded by the authors, with no external financial support received for its development or publication.

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