Hemorrhoids, a prevalent clinical anorectal condition, significantly impact the quality of living of affected individuals mainly by symptoms such as pain, bleeding, and discomfort during defecation.(1) Open hemorrhoidectomy remains one of the most common and gold standard surgical interventions for treating advanced or refractory cases of hemorrhoids, particularly when conservative treatments fail to provide relief.(2) However, this procedure is frequently associated with postoperative pain, which poses a significant challenge in patient recovery and satisfaction.(3,4) Adjunctive lateral internal sphincterotomy, a procedure traditionally performed for anal fissures but now considered for its potential role in reducing postoperative pain in hemorrhoidectomy patients. Lateral internal sphincterotomy works by reducing the resting anal pressure and decrease tension at the surgical site.(5,6) Few studies showing sphincterotomy after hemorrhoidectomy can significantly decrease postoperative pain and early recovery, others raise concerns about the potential for complications such as incontinence and impaired sphincter function.(7) These conflicting findings underscore the need for further investigation to clarify the role of sphincterotomy in the context of open hemorrhoidectomy, especially in diverse patient populations.(8) This research was undertaken to determine whether the addition of sphincterotomy offers a significant advantage in reducing postoperative pain without compromising patient safety. The findings from this study are expected to contribute valuable insights into the management of postoperative pain in hemorrhoidectomy patients and guide evidence-based clinical decision-making in the treatment of hemorrhoidal disease. Hence, the present study was aimed to provide a comprehensive comparative analysis of postoperative pain following open hemorrhoidectomy with and without sphincterotomy among patients in a tertiary care centre in Northern Kerala by examining pain scores, analgesic requirements, and complication rates. Aim and Objectives 1. To compare the pain relief in Open Hemorrhoidectomy with Internal Sphincterotomy versus Open Hemorrhoidectomy 2. To compare the hospital-stay in Open Hemorrhoidectomy with Internal Sphincterotomy versus Open Hemorrhoidectomy 3. To compare the post operative complications in Open Hemorrhoidectomy with Internal Sphincterotomy versus Open Hemorrhoidectomy

It was a prospective, cross-sectional comparative study which was conducted at Department of General Surgery, Malabar Medical College Hospital & Research Centre, Modakkalur, Kerala, India between September 2023 and February 2025. Informed and written consent was obtained after the full explanation of the study, its purpose and any potential risks. The study was carried out within the facilities of this hospital, ensuring that all participants received standard care under the supervision of trained healthcare providers. The inclusion criteria were patients aged between 20-60 years of either gender with diagnosis of grade 3 or Grade 4 hemorrhoids and patients who were fit for surgery. Patients with inflammatory bowel disease such as Crohn 's disease or ulcerative colitis, anal fissures, anal fistulas, recurrent hemorrhoids, patients with any form of colorectal malignancies, cirrhosis of liver, portal hypertension, pregnancy and severe comorbid conditions (e.g., severe cardiovascular or respiratory diseases) were excluded from the study. Convenient sampling method was selected to recruit the study participants. The sample size was calculated based on a previous study published by Das DK et al.,(9) which was reported that 14% of patients experienced severe pain after surgery. A total of 128 cases divided into two groups of 64 patients each (Group A: Open Hemorrhoidectomy + Internal Sphincterotomy; Group B: Open Hemorrhoidectomy only). The study focused on evaluating several key parameters to compare the postoperative outcome and these parameters were designed to assess the effectiveness of internal sphincterotomy reducing postoperative pain and complications. Postoperative pain: It was measured by using the Visual Analog Scale (VAS)(10), a common and reliable tool for pain assessment and time points for measurement were 12, 24, 48 hours and 2 weeks of post-surgery.(11) Length of hospital stay: From the time of admission to discharge (number of days each patient stayed in the hospital post- surgery was recorded) Postoperative complications: Urinary retention (6 hours post-surgery), bleeding (6, 12 hours after surgery)(12), faecal incontinence (1, 2 weeks and 2 months), wound healing and recovery (1, 2 weeks and 2 months), patient satisfaction and quality of life (QoL)(13), anal fissures and anal stenosis.(14–16) Statistical analysis Data will be expressed as percentages, frequencies, mean and standard deviation. Comparison of means among independent study groups was analysed by unpaired t-test. Discrete and categorical data was analysed by using chi-square test. All tests of statistical significance were two-tailed. The analyses were carried out using the SPSS statistical package.

A total of 198 patients were screened out of these, 70 patients were excluded from the study based on the exclusion criteria. Finally, 128 study participants were selected for the study which were allocated to 64 each in two study groups based on the convenient sampling method. Baseline demographic details among study groups were showed in Table 1. The mean±SD age of the study participants in the group A and B were 44.03±11.2 and 46.23±12.1 (P=0.287) respectively. All the study participants were between the age of 21-60 years in both the groups. The age distribution reveals that the majority of participants in both groups were middle-aged, particularly in the 41-50 years category (32.8%). This finding aligns with the age-related prevalence of Grade 3 and 4 hemorrhoids, as factors such as prolonged sedentary lifestyles, chronic constipation, and vascular degeneration are common in this demographic. The even distribution across other age groups ensures a diverse representation, allowing for robust comparative analysis. Table 1: Baseline demographic details among study groups Parameter Group A (Open Hemorrhoidcctomy + Sphincterotomy) Group B (Open Hemorrhoidcctomy) P-Value N= 64 64 - Age in years, mean±SD 44.03±11.2 46.23±12.1 0.287 Range 22-60 21-60 - Gender, n (%) Male 40 (62.5% 38 (59.4%) 0.717 Female 24 (37.5%) 26 (40.6%) Age distribution, n (%) 20-30 10 (15.6%) 8 (12.5%) 0.907 31-40 16 (25.0%) 18 (28.1%) 41-50 22 (34.4%) 20 (31.3%) 51-60 16 (25.0%) 18 (28.1%) Body mass index (BMI), n (%) <18.5 4 (6.3%) 6 (9.4%) 0.852 18.5-24.9 30 (46.9%) 28 (43.8%) 25.0-29.9 20 (31.3%) 22 (34.4%) >30 10 (15.6%) 8 (12.5%) Comorbid conditions, n (%) DM 12 (18.8%) 14 (21.9%) 0.882 HTN 22 (34.4%) 20 (31.3%) None 30 (46.9%) 30 (46.9%) SD=Standard deviation; DM=Diabetes mellitus; HTN=Hypertension; Chi-square test was used to calculate the P-value; Difference in means of age among groups was calculated by using Unpaired t-test The gender distribution indicates a male predominance in the study population constituting 60.9% of all participants. This could be due to a higher prevalence of hemorrhoids in males or increased healthcare-seeking behaviour among this demographic in the study setting. Despite this, the inclusion of 39. l % female participants ensures that the study findings are applicable across genders. The BMI distribution highlights that most of the study participants were either in the normal weight (45.3%) or overweight (32.8%) categories. Very less participants were either underweight (7.8%) or obese (14.1 %). These findings reflect those dietary habits and sedentary lifestyle, rather than obesity alone, play a crucial role in hemorrhoid development. The analysis of comorbidities shows that 32.8% of participants had hypertension and 20.3% had diabetes mellitus. However, nearly half (46.9%) of the participants had no comorbidities. This distribution suggests that while systemic conditions like hypertension and diabetes are common among individuals with hemorrhoids, they are not universal, emphasizing the multi factorial etiology of the condition. Pain scores at different time intervals Mean visual analog scale pain scores at different time intervals among study groups were showed in Figure 1. Postoperative pain scores were assessed at 12 hours, 24 hours, 48 hours, and 2 weeks after surgery with significant lower VAS scores in Group A (Open Hemorrhoidectomy + Internal Sphincterotomy) compared to Group B (Open Hemorrhoidectomy). The mean pain scores in Group A steadily decrease from 3.2 at 12 hours to 1.2 at 2 weeks, while Group B consistently shows higher scores across all intervals (6.1 at 12 hours to 2.3 at 2 weeks). This demonstrates that adding internal sphincterotomy effectively reduces pain in the immediate and long-term postoperative period, with statistically significant p-values (<0.05). Secondary outcome parameters among study groups were showed in Table 2. The average hospital stay for Group A is 2.4 days, significantly shorter than the 3.6 days recorded for Group B. This highlights that the inclusion of internal sphincterotomy contributes to a faster recovery and reduces hospital stay duration, which is statistically significant (P<0.0001). Group A experienced a lower incidence of urinary retention (4.7%) compared to Group B (15.6%). This significant difference (P=0.040) suggests that internal sphincterotomy may mitigate the risk of this complication, likely due to reduced anal sphincter spasticity. Table 2: Secondary outcome parameters among study groups Category Group A (Open Hemorrhoidcctomy + Sphincterotomy) Group B (Open Hemorrhoidcctomy) P-value Length of hospital-stay in Days (Mean±SD) 2.4±0.6 3.6±0.7 0.0001 Incidence of urinary retention, n (%) Yes 3 (4.7%) 10 (15.6%) 0.0405 No 61 (95.3%) 54 (84.4%) Postoperative bleeding, n (%) After 6 hours 2 (3.1%) 8 (12.5%) 0.0481 After 12 hours 1 (1.6%) 6 (9.4%) 0.0500 Incidence of fecal incontinence, n (%) Yes 1 (1.6%) 0 (0.0%) 0.9315 No 63 (98.4%) 64 (100.0%) Wound healing time in days (Mean±SD) 15.2±2.4 18.7±2.8 0.0001 Patient satisfaction scores, n (%) Highly satisfied 48 (75.0%) 32 (50.0%) 0.0122 Satisfied 14 (22.0%) 26 (41.0%) Neutral 2 (3.0%) 6 (9.0%) Incidence of anal stenosis, n (%) Yes 2 (3.1%) 8 (12.5%) 0.04814 No 62 (96.9%) 56 (87.5%) Analgesic requirement in Doses (Mean±SD) 3.8±0.9 6.1±1.2 0.0001 Postoperative infection rate, n (%) Yes 3 (4.7%) 10 (15.6%) 0.0405 No 61 (95.3%) 54 (84.3%) Time to first bowel movement in hours (Mean±SD) 8.5±1.4 11.2±1.9 0.0001 Postoperative constipation, n (%) Yes 3 (4.7%) 10 (15.6%) 0.0405 No 61 (95.3%) 54 (84.3%) Ambulation time in hours (Mean±SD) 6.2±1.6 10.5±2.0 0.0001 Postoperative quality of life score (Mean±SD) 8.2±0.7 6.3±1.1 0.0001 SD: Standard deviation The incidence of bleeding is consistently lower in Group A compared to Group B. After 6- and 12-hours bleeding occurs in 3.1% and 1.6% of Group A patients versus 12.5% and 9.4% in Group B respectively. These statistically significant differences (P<0.05) underscore the effectiveness of internal sphincterotomy in reducing bleeding risks post-surgery. Group A demonstrates faster wound healing with a mean time of 15.2 days compared to 18.7 days for Group B which was statistically significant (P<0.0001) and suggests that internal sphincterotomy positively influences the healing process, possibly by reducing sphincter spasm and improving tissue recovery. A greater proportion of patients in Group A (75%) report being highly satisfied with their outcomes compared to 50% in Group B. The difference is statistically significant (P<0.05) indicating that internal sphincterotomy contributes to higher satisfaction by improving pain relief and overall recovery. Postoperative infection rates are significantly lower in Group A (4.7%) than in Group B (15.6%), with p-values indicating statistical significance. Group A patients ambulate significantly earlier (mean 6.2 hours) compared to Group B (mean 10.5 hours). This statistically significant difference (P<0.0001) indicates faster recovery and mobility with the addition of internal sphincterotomy. Group A achieves higher post-surgery quality of life scores (mean 8.2) compared to Group B (mean 6.3). This statistically significant result (P=0.0001) demonstrates the broader benefits of internal sphincterotomy in enhancing patient well-being and recovery.

The primary aim of this study is to evaluate the postoperative outcomes of open hemorrhoidectomy with and without internal sphincterotomy in patients with Grade 3 and 4 hemorrhoids, focusing on key parameters such as pain relief, recovery time, complications, and patient satisfaction. Specifically, the study seeks to determine whether the addition of internal sphincterotomy improves short-term and long-term recovery outcomes, reduces complications such as pain, urinary retention, and anal stenosis, and enhances the overall quality of life for patients undergoing surgical treatment. The significance of this study lies in addressing a critical clinical challenge by managing postoperative pain and complications associated with hemorrhoidectomy, a common surgical procedure for advanced hemorrhoids.(2) Despite being effective in removing hemorrhoidal tissue, open hemorrhoidectomy is often accompanied by significant postoperative discomfort and a prolonged recovery period due to anal sphincter spasm.(17) By evaluating the impact of internal sphincterotomy, a simple and minimally invasive adjunctive procedure, this study aims to provide evidence-based recommendation for optimizing surgical protocol.(5) This study is significant in its potential to improve patient outcomes, enhance recovery trajectories, and reduce healthcare costs. Faster wound healing, shorter hospital stays, and fewer complications not only benefit patients but also alleviate the burden on healthcare systems.(18,19) Additionally, the study addresses a gap in existing literature by providing comprehensive data from a tertiary care center, particularly in the Indian context, where similar studies are limited. The age distribution shows that the majority of participants fall within the 41-50 years age group, comprising 34.4% of Group A and 31.3% of Group B. These results are collaborate with Fernandes & Tauro(20) which identified a median age of 45 years among hemorrhoidectomy patients. Such data support the hypothesis that hemorrhoids predominantly affect individuals in their middle age, where lifestyle factors intersect with aging physiology. Gender analysis indicates a male predominance, with 62.5% of Group A and 59.4% of Group B. This male predominance could be due to higher hemorrhoid prevalence in men or greater healthcare-seeking behaviour among this demographic. Similar trends were reported by Saxena et al.(21), where males constituted 65% of the study cohort, and Zulfikar et al.(22), which reported a male proportion of 68%. The results of this study demonstrate that internal sphincterotomy significantly reduced postoperative pain in patients undergoing open hemorrhoidectomy. This consistent pain reduction highlights the efficacy of internal sphincterotomy in alleviating anal sphincter spasm and tissue irritation, key contributors to postoperative discomfort. These findings align with past studies, reinforcing the role of internal sphincterotomy in pain management. Fernandes & Tauro(20) observed significantly lower pain scores in patients undergoing hemorrhoidectomy with lateral internal sphincterotomy (LIS) compared to those without, reporting P-values < 0.005 across all measured intervals. Similarly, Saxena et al.(21) documented mean pain scores of 3.1 at 24 hours and 1.2 at 7 days in the LIS group, compared to 5.4 and 3.0 respectively in the non-LIS group (P < 0.0001). Wang et al.(6), in their meta-analysis, found a standardized mean difference of -0.75 (95% CI: -1.14 to -0.36, p=0.0002), indicating a clear reduction in pain with LIS. Zulfikar et al.(22) further supported this with a significant mean pain reduction from 2.82 ± 2.51 to 1.59 ± 1.58 (p < 0.05) when LIS was added. Despite its efficacy, the concern of potential complications such as fecal incontinence remains. Emile et al.(23) noted a median fecal incontinence rate of 7.7% in LIS patients, compared to 1.25% without LIS. However, our study observed minimal incontinence (1.6% in Group A, P=0.931), suggesting that the careful application of LIS minimizes risks. The reduction in pain scores, confirmed across various studies and meta-analyses, establishes internal sphincterotomy as a valuable adjunctive procedure. It not only enhances postoperative comfort but also improves overall patient satisfaction and recovery outcomes, as corroborated by the consistent findings in our study and the existing literature. In the present study, the shorter hospital stay in Group A is also likely linked to fewer complications, such as reduced urinary retention and bleeding, discussed in subsequent sections. Wang et al.(6), in their meta-analysis of 1,560 patients, observed no significant differences in hospital stay between LIS and non-US groups; however, this variation could be attributed to differences in perioperative care protocols across centres. The economic implications of shorter hospital stays are noteworthy. Reduced healthcare resource utilization, lower costs, and improved bed turnover rates. These results were align with findings by Palraj & Hameed(24), who noted that quicker recovery and earlier discharge contributed to better overall patient satisfaction and cost-effectiveness. Postoperative bleeding was notably lower in Group A than in Group B in all measured intervals. At 6 hours postoperatively, bleeding occurred in 3.1% of Group A patients compared to 12.5% in Group B (P=0.048). These findings suggest that LIS aids in minimizing tissue trauma and promoting better haemostasis during recovery. The mechanism for reduced bleeding with LIS is likely multi factorial by alleviating sphincter spasm, minimizes tension on surgical wounds, reducing the likelihood of vascular disruption. Additionally, improved tissue perfusion and relaxation may facilitate better coagulation and healing processes.(22) Patient satisfaction scores were significantly higher in Group A, with 75% of patients reporting being highly satisfied, compared to 50% in Group B (P=0.012). Comparable results have been documented with Palraj & Hameed(24) observed that 83.3% of patients in the LIS group rated their outcomes as excellent or highly satisfactory, compared to 56.7% in the non-US group. Zulfikar et al.(22) also found a significant association between LIS and patient-reported satisfaction, with 95% of US patients expressing positive outcomes versus 78% in the control group. The time to first ambulation after surgery was significantly shorter in Group A, with a mean time of 6.2 ± 0.4 hours compared to 10.5 ± 0.5 hours in Group B (P<0.0001). Faster ambulation reflects reduced pain, earlier recovery, and improved overall patient well-being, demonstrating the role of internal sphincterotomy in enhancing postoperative mobility. Palraj & Hameed(24) reported similar benefits, with LIS patients resuming ambulation nearly 3 days earlier than non-LIS patients. This quicker recovery is attributed to reduced pain levels and fewer mobility-restricting complications. Fernandes & Tauro(20) also emphasized the importance of early ambulation in reducing secondary complications, such as deep vein thrombosis and pulmonary issues, both of which were less frequent in the LIS group. Post-surgery quality of life scores were significantly higher in Group A, with a mean score of 8.2 ± 0.7 compared to 6.3 ± 1.1 in Group B (P<0.001). This improvement reflects the comprehensive benefits of US, including reduced pain, faster recovery, and fewer complications. Our findings align with this literature(6,20,22), demonstrating that US significantly enhances patient well-being, both during the recovery period and in the long term. By addressing the root causes of postoperative discomfort and complications, US facilitates a more seamless and satisfactory recovery experience.(13)

This study establishes that adding internal sphincterotomy to open hemorrhoidectomy significantly improves postoperative outcomes in patients with Grade 3 and 4 hemorrhoids. The findings strongly advocate for the routine inclusion of internal sphincterotomy in hemorrhoidectomy protocols. One of the most notable outcomes is the significant reduction in postoperative pain. Group A consistently reported lower pain scores across all time points, indicating the effectiveness of internal sphincterotomy in addressing sphincter spasm and reducing nerve irritation. Pain management is a critical determinant of recovery, influencing hospital stays, patient satisfaction, and long-term outcomes. By alleviating pain, internal sphincterotomy also reduces the reliance on postoperative analgesics, further enhancing the patient experience. ln conclusion, this study provides robust evidence supporting the inclusion of internal sphincterotomy as a standard adjunct to open hemorrhoidectomy. The procedure not only enhances immediate postoperative outcomes but also contributes to better long-term recovery and patient satisfaction. These findings should inform clinical guidelines and surgical practices, promoting the adoption of internal sphincterotomy to optimize the management of Grade 3 and 4 hemorrhoids.

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