Doppler-guided hemorrhoidal artery ligation with hemorrhoidopexy: source and prevention of postoperative pain

Background: Transanal hemorrhoidal dearterialization, although it showed reliability, has not completely removed the issue of postoperative pain. Objective: We investigated the causes of postoperative pain and proposed some changes of the technique in order to eliminate it. Patients: One hundred six out of 188 operated patients were considered. Postoperative pain was investigated using a Visual Analogue Score dividing patients into three groups: 0 to 3, 4 to 6, and 7 to 10. On the basis of these results, we proposed some variations of the technique. A second group of 25 patients was therefore treated with the modified technique. Statistical analysis was conducted using the Fisher’s exact test, two-tailed. Main outcome: Pain intensity, surgical approach, and changes in the technique were analyzed, and a new proposal for a modified technique has been developed. Results: The group of 106 patients, 64 males and 42 females, were divided: 71 III grade and 35 IV grade. Pain was detected in 37 cases (35 %).Fifteen males (23.50 %) were divided as follows: 8 mild and 7 medium or intense. Twenty-two females (52.38 %) were divided as follows: 11 mild and 11 with medium or intense. For what concerns the variable grade, the pain was present in 15 III G and 22 IV G with statistic significant difference (p value 0.00333). Among the 18 patients (7 males and 11 females) who had severe pain, they all had a number of mucopexies >4, while among 19 patients (8 males and 11 females) with mild pain, only 5 had a number of mucopexies >4, resulting in a statistic significant difference (p value 0.031). In the second group, pain was drastically reduced. Limitations: We believe it is necessary to extend the sample in order to definitively adopt the proposed amendments. Conclusions: The review of the causes of postoperative pain and the changes adopted compared with those proposed in literature have allowed us to greatly reduce postoperative pain.