Harmonic Scalpel® vs. electrocautery hemorrhoidectomy:: A prospective evaluation

INTRODUCTION: Management of posthemorrhoidectomy pain remains a very unsatisfactory clinical dilemma. Compared with electrocautery and laser, the Harmonic Scalpel(R) causes minimal lateral thermal injury during tissue dissection. PURPOSE: The aim of the study was to establish whether decreased lateral thermal injury translated into diminished posthemorrhoidectomy pain. METHODS: A prospective randomized trial comparing Harmonic Scalpel(R) hemorrhoidectomy and electrocautery was undertaken. Fifty consecutive patients were randomized into two groups: Harmonic Scalpel(R) and electrocautery hemorrhoidectomy. The indications included Grade III internal hemorrhoids with external components or Grade IV disease. Patients with additional anorectal pathology (fissure or fistula) were excluded, as were patients with neurologic deficits, chronic pain syndrome, and those already taking narcotic analgesics. Pain was assessed using a visual analog scale preoperatively and on postoperative Days 1, 2, 7, 14, and 28. Twentyfour-hour narcotic usage (Hydrocodone, 10 mg) was recorded on postoperative Days 1, 2, 7, 14, and 28. A three-quadrant modified Ferguson hemorrhoidectomy was performed with each patient in the prone jackknife position. RESULTS: Pain in the Harmonic Scalpel(R) hemorrhoidectomy group was significantly less than in electrocautery patients on each postoperative day studied. Analgesic requirements were also significantly less in the Harmonic Scalpel(R) group on Days 1, 2, 7, and 14. There was no correlation between postoperative pain and grade of hemorrhoid, status of the surgical incision (open vs. closed), or any other study variable. Fifty-five percent of Harmonic Scalpel(R) patients returned to work within one week of surgery, compared with 23 percent of electrocautery patients. CONCLUSION: The study demonstrates significantly reduced postoperative pain after Harmonic Scalpel(R) hem orrhoidectomy compared with electrocautery controls. The diminished postoperative pain in the Harmonic Scalpel(R) group likely results from the avoidance of lateral thermal injury.