Comparative Study of Post-Operative Outcomes in Patients Undergoing Open Hemorrhoidectomy with or Without Lateral Internal Anal Sphincterotomy at a Tertiary Care Centre Experience

Introduction

Hemorrhoids are common benign anorectal disorders that arise from the enlargement and displacement of anal cushions, causing symptoms like rectal bleeding, prolapse, pain, mucus discharge, and anal itching. They are highly prevalent among adults, with many requiring medical or surgical treatment based on severity. Advanced hemorrhoids (Grade III and IV) often necessitate surgical intervention due to persistent symptoms despite conservative management [1]. A screening colonoscopy reveals hemorrhoids in up to 40% of the population, with about 44.7% of affected individuals experiencing symptoms that require treatment. Excisional hemorrhoidectomy (EH) is the most effective option for high-grade symptomatic hemorrhoids, showing a 2% medium-term and 10% long-term recurrence rate [2,3].

Open hemorrhoidectomy, especially the Milligan-Morgan technique, is a common and effective treatment for advanced hemorrhoids, yielding low recurrence rates and good long-term results. However, it has notable postoperative morbidity, primarily severe pain, often caused by internal anal sphincter spasm due to irritation and exposure following the removal of hemorrhoidal tissue [4].

Postoperative pain after hemorrhoidectomy can hinder recovery and decrease patient satisfaction. Strategies to alleviate this pain include pharmacological approaches like topical nitroglycerin and calcium channel blockers, as well as surgical techniques such as anal dilatation and lateral internal anal sphincterotomy (LIAS). LIAS is particularly notable for relieving sphincter spasm and decreasing resting anal pressure, thus reducing postoperative discomfort [5,6].

Lateral internal anal sphincterotomy involves partial division of the internal anal sphincter to reduce sphincter tone and enhance local blood supply. Clinical studies indicate that combining this procedure with open hemorrhoidectomy significantly lowers postoperative pain scores compared to hemorrhoidectomy alone. Furthermore, some studies report a reduced incidence of complications, including urinary retention and postoperative bleeding, in patients who underwent the combined treatment [7].

Meta-analyses and randomized controlled trials indicate that lateral internal sphincterotomy is beneficial, significantly reducing postoperative pain and anal stenosis after hemorrhoidectomy. However, concerns about increased transient gas or fecal incontinence risks lead to ongoing debate among colorectal surgeons regarding its routine use [8,9].

Long-term complications post-combined procedures, such as anal fissure, anal stenosis, and hemorrhoid recurrence, have been evaluated. Lateral internal sphincterotomy during hemorrhoidectomy may lower anal stenosis and fissure rates, but the balance between pain relief and incontinence risk plays a critical role in clinical decisions. The routine application of this procedure remains contentious, necessitating further prospective studies to compare outcomes related to pain, urinary retention, bleeding, wound healing, and complications, aiming to enhance surgical management and patient outcomes. Aim of the study is to compare post-operative outcomes in patients undergoing open hemorrhoidectomy with and without lateral internal anal sphincterotomy. Objectives include assessing post-operative pain, incidence of urinary retention, post-operative bleeding, wound healing time, and duration of hospital stay in both groups.

Methods

The Prospective analytical study conducted at Department of Surgery, Prasad Institute of Medical Sciences, Lucknow (U.P) after written consent and ethical clearance approved by institute focused on patients aged 18-60 with Grade III or IV hemorrhoidal disease, who failed at least 8 weeks of conservative management and were fit for spinal anesthesia. A total of 50 patients were enrolled and diagnosed through clinical history, digital rectal examination, and proctoscopic evaluation. Patients with conditions such as anal fissure, previous anal surgery, or severe systemic illnesses were excluded. They were randomized into two groups for further analysis. Group A comprised 25 patients who underwent Open Hemorrhoidectomy (OH) alone, while Group B included 25 patients who underwent Open Hemorrhoidectomy with Lateral Internal Anal Sphincterotomy (OH + LIS).

This clinical study, conducted over one year, compared two surgical approaches for hemorrhoid treatment in a tertiary hospital. Standard preoperative assessments included blood tests, continence scoring, bowel preparation, and prophylactic antibiotics. Open Hemorrhoidectomy was performed under spinal anesthesia using the Milligan–Morgan Technique, emphasizing precise dissection and hemorroidal tissue excision. Open Hemorrhoidectomy with Lateral Internal Anal Sphincterotomy involved a controlled incision, carefully preserving tissue. Postoperative care was uniform across both groups, focusing on pain management and dietary guidance. The primary outcome measured was postoperative pain at 24 hours, 48 hours, and 7 days; secondary outcomes included urinary retention, postoperative bleeding, wound healing time, anal stenosis, anal incontinence, and return to daily activities. Follow-ups were scheduled for patient assessment until complete wound healing.

Data were analyzed using Microsoft Excel and SPSS version 24. Continuous variables were reported as mean ± standard deviation, while categorical variables were reported as frequency and percentage. Student’s t-test was utilized for comparing continuous variables, and Chi-square test was employed for categorical variables.

Results

Total 50 patients were included in the study, with 25 patients each in Group A (Open Hemorrhoidectomy) and Group B (Open Hemorrhoidectomy with Lateral Internal Anal Sphincterotomy). The mean age was 44.84 ± 9.72 years for Group A and 45.36 ± 10.14 years for Group B, with no significant age distribution difference (p = 0.861). Male participants comprised 70% of the study, with a similar gender distribution between groups (p = 0.758). Severity of hemorrhoids showed 62% of patients had Grade III and 38% had Grade IV, with no significant difference in hemorrhoid grades (p = 0.771). The average duration of symptoms before surgery was 10.6 ± 4.5 months in Group A and 10.9 ± 4.2 months in Group B, indicating no significant difference (p = 0.824), thus reflecting comparable baseline characteristics across both groups (Table 1).

The study found comparable presenting symptoms between two patient groups, with bleeding per rectum (94%), prolapse (86%), pain during defecation (74%), constipation (58%), pruritus ani (34%), and mucous discharge (22%) reported, showing no statistically significant differences (all p > 0.05). Thus, the baseline clinical presentations before surgery were similar for both groups (Table 2).

*Patients could have more than one presenting symptom.

Postoperative pain was evaluated using the Visual Analogue Scale (VAS) at 24 hours, 48 hours, and on postoperative day 7. Group B (Open Hemorrhoidectomy with Lateral Internal Anal Sphincterotomy) reported significantly lower pain scores than Group A (Open Hemorrhoidectomy alone) across all time points: at 24 hours, VAS scores were 7.56 ± 0.92 in Group A vs. 5.64 ± 0.83 in Group B (p < 0.001); at 48 hours, scores were 5.20 ± 0.88 for Group A and 3.72 ± 0.79 for Group B (p < 0.001); by day 7, scores were 2.52 ± 0.71 for Group A and 1.56 ± 0.58 for Group B (p < 0.001). Wound healing time was similar, with Group A healing at 28.8 ± 4.3 days and Group B at 27.5 ± 3.9 days (p = 0.286). However, the hospital stay was significantly shorter in Group B (2.88 ± 0.53 days) compared to Group A (3.72 ± 0.68 days, p < 0.001). Overall, the addition of lateral internal anal sphincterotomy to open hemorrhoidectomy led to reduced pain and shorter hospital stays without compromising wound healing (Table 3).

Postoperative complications were assessed in two study groups after surgery. Urinary retention was more prevalent in Group A (24%) than in Group B (8%), with a statistically significant difference (p = 0.041), indicating that lateral internal anal sphincterotomy (LIS) reduces urinary retention. Postoperative bleeding occurred in 12% of Group A and 8% of Group B, with no significant difference (p = 0.637). Wound infections affected 8% of Group A and 4% of Group B, also without significance (p = 0.551). Anal stenosis was noted in 8% of the open hemorrhoidectomy group, while none occurred in the OH + LIS group (p = 0.149). Transient incontinence was present in 4% of Group B with no cases in Group A (p = 0.312). Thus, LIS significantly lowers urinary retention but does not affect other complications significantly (Table 4).

Open Hemorrhoidectomy (OH) combined with Lateral Internal Anal Sphincterotomy (OH + LIS) yielded superior postoperative outcomes compared to OH alone. Patients in the OH + LIS group reported lower postoperative pain (VAS score: 5.64 ± 0.83 vs. 7.56 ± 0.92, p < 0.001) and had shorter hospital stays (2.88 ± 0.53 days vs. 3.72 ± 0.68 days, p < 0.001). Although wound healing time was marginally better in the OH + LIS group (27.5 ± 3.9 days vs. 28.8 ± 4.3 days), this difference was not statistically significant (p = 0.286). Furthermore, urinary retention was less common in the OH + LIS group (8% vs. 24%, p = 0.041), while rates of postoperative bleeding were similar (12% vs. 8%, p = 0.637). Anal stenosis occurred in the OH group (8%), and transient incontinence was documented in one OH + LIS patient (4%), but these differences were not statistically significant (p = 0.149 and p = 0.312, respectively). Overall, adding LIS to OH improved pain control and reduced urinary complications without significantly increasing overall complications (Table 5).

Discussion

The prospective analytical study assessed 50 patients with Grade III and IV hemorrhoids, divided equally between Open Hemorrhoidectomy (OH) alone and Open Hemorrhoidectomy with Lateral Internal Anal Sphincterotomy (OH + LIS). Baseline demographic characteristics were similar in both groups, allowing for a focused evaluation on the surgical interventions. The mean age of patients was 45.10 ± 9.89 years, with the majority (38%) in the 41–50 age range, aligning with epidemiological trends indicating that symptomatic hemorrhoidal disease predominantly impacts individuals in their fourth and fifth decades of life. Supporting studies identified a similar distribution, with chronic constipation, straining during defecation, sedentary lifestyles, and occupational factors contributing to this condition [1,10-14]. Furthermore, 70% of participants were male, consistent with findings from multiple other studies that reported a male predominance in hemorrhoid surgery cases. This male dominance may be attributed to certain lifestyle factors and differences in healthcare-seeking behavior.

The analysis of hemorrhoid cases indicates that Grade III hemorrhoids represent 62% of cases, while Grade IV hemorrhoids make up 38%. This distribution aligns with prior findings, as Grade III hemorrhoids are the predominant type managed surgically. Their reducible yet symptomatic nature makes them suitable for excisional hemorrhoidectomy. Multiple studies, including those by Vijayaraghavalu et al. (2021), Wang et al. (2018), Shah and Manda (2023), Saxena et al. (2024), Suresh et al. (2025), and Agrawal et al. (2025), also underscore the prevalence of Grade III hemorrhoids among patients receiving open hemorrhoidectomy, with or without lateral internal sphincterotomy [1,4,10-12,14].

The study found that the mean duration of symptoms before surgery was 10.8 ± 4.3 months, with nearly half of the patients experiencing symptoms for 6–12 months. Factors for delayed presentation included self-medication, embarrassment, fear of surgery, and delayed referrals. Baseline characteristics showed no significant differences between study groups regarding age, gender, hemorrhoid grade, or symptom duration, supporting the validity of postoperative outcome comparisons. The demographic profile aligns with existing literature, indicating that symptomatic Grade III and IV hemorrhoids mostly affect middle-aged adults, particularly males. The comparable baseline characteristics bolster the evaluation of postoperative complications between the groups [3].

In this study, rectal bleeding was the most prevalent symptom, reported in 94% of patients, followed by prolapse (86%), pain during defecation (74%), constipation (58%), pruritus ani (34%), and mucous discharge (22%). These findings align with typical presentations of advanced Grade III and IV hemorrhoids, where bleeding and prolapse are key symptoms leading to surgical treatment. No significant differences were observed between the Open Hemorrhoidectomy (OH) and OH with Lateral Internal Anal Sphincterotomy (OH + LIS) groups regarding symptom frequencies, indicating that both groups were comparable before surgery. This enhances the validity of comparing postoperative outcomes, as corroborated by previous studies that reported similar symptomatic profiles and findings related to hemorrhoidectomy. Overall, this reinforces the consistency of patient presentations and the reliability of the study's comparisons regarding postoperative results [4,10-14].

Postoperative pain is a critical factor in recovery after open hemorrhoidectomy. A study found that patients who had Open Hemorrhoidectomy with Lateral Internal Anal Sphincterotomy (OH + LIS) reported significantly lower pain scores compared to those who had Open Hemorrhoidectomy (OH) alone at various intervals post-surgery (24 hours, 48 hours, and day 7), with statistical significance (p < 0.001). This suggests that sphincter spasm contributes to pain, and LIS effectively alleviates it. While the study's mean wound healing times were similar between groups, the OH + LIS group had a significantly shorter hospital stay (2.88 days vs. 3.72 days; p < 0.001). Overall, adding LIS enhances pain control and accelerates recovery without hindering wound healing, reinforcing its use in select patients undergoing hemorrhoidectomy [1,4,510-13].

Postoperative complications after hemorrhoidectomy significantly impact recovery. This study found urinary retention most common, occurring less in those undergoing Open Hemorrhoidectomy with Lateral Internal Anal Sphincterotomy (OH + LIS) than in Open Hemorrhoidectomy (OH) alone (8% vs. 24%, p = 0.041). Reduced postoperative pain and reflex anal sphincter spasm likely contribute to this difference. Other complications, such as bleeding (12% in OH vs. 8% in OH + LIS) and infection (8% vs. 4%), showed no significant differences. Anal stenosis occurred solely in the OH group (8%), while transient incontinence was low in the OH + LIS group (4%). Overall, adding lateral internal sphincterotomy may improve recovery by lowering urinary retention without increasing major complications, demonstrating its safety and effectiveness as an adjunct in selected patients [4,10-14].

The present study demonstrated that the addition of Lateral Internal Anal Sphincterotomy (LIS) to Open Hemorrhoidectomy (OH) resulted in superior postoperative outcomes compared with OH alone. Patients in the OH + LIS group experienced significantly lower postoperative pain, shorter hospital stay, and a reduced incidence of urinary retention without increasing the risk of major postoperative complications. These findings support the concept that internal anal sphincter spasm is a major contributor to postoperative pain following hemorrhoidectomy and that controlled sphincterotomy effectively alleviates this spasm [2].

The mean postoperative Visual Analogue Scale (VAS) score at 24 hours was significantly lower in the OH + LIS group (5.64 ± 0.83) than in the OH group (7.56 ± 0.92; p < 0.001). Similar reductions in postoperative pain have been reported by Kanellos et al.,[5] Wang et al.,[4] Vijayaraghavalu et al.,[1] Shah and Manda [10], Saxena et al.,[11] Yadaw et al.,[13] Suresh et al.,[12] and Agrawal et al.,[14] all of whom concluded that concomitant LIS provides superior postoperative analgesia and improves patient comfort. Although Khubchandani did not demonstrate a significant benefit in pain reduction, most contemporary studies support the routine addition of LIS in selected patients undergoing open hemorrhoidectomy [8].

Hospital stay was significantly shorter in the OH + LIS group (2.88 ± 0.53 days) than in the OH group (3.72 ± 0.68 days; p < 0.001), reflecting faster postoperative recovery due to improved pain control. Similar observations were reported by Vijayaraghavalu et al., Saxena et al, Suresh et al., and Yadaw et al., who found that patients receiving concomitant LIS achieved earlier ambulation and discharge [1,11-13].

The mean wound healing time was slightly shorter in the OH + LIS group, although the difference was not statistically significant (p = 0.286). This finding is consistent with those of Wang et al., Vijayaraghavalu et al., and Shah and Manda, who demonstrated that adding LIS does not adversely affect wound healing [1,4,10].

Urinary retention was significantly less frequent in the OH + LIS group (8% vs. 24%; p = 0.041), probably because reduced postoperative pain and sphincter spasm facilitate early voiding. Comparable findings have been recent studies by Wang et al., Vijayaraghavalu et al., Saxena et al., and Yadaw et al.,[1,4,11,13] In contrast, postoperative bleeding, anal stenosis, and transient incontinence were comparable between the two groups and did not differ significantly, indicating that LIS does not increase postoperative morbidity when performed appropriately. Similar conclusions have been done by various studies [4,5,10,12,14].

Overall, the findings of the present study are in close agreement with the current literature, demonstrating that the addition of lateral internal anal sphincterotomy to open hemorrhoidectomy significantly improves postoperative recovery by reducing pain, shortening hospital stay, and decreasing urinary retention while maintaining an acceptable safety profile. These results support the selective use of LIS as an effective adjunct to conventional open hemorrhoidectomy in patients with advanced hemorrhoidal disease.

Based on the study's findings, lateral internal anal sphincterotomy (LIS) is recommended as an adjunct to open hemorrhoidectomy for selected patients with Grade III and IV hemorrhoids, particularly those at risk of severe postoperative pain and urinary retention. LIS significantly reduces postoperative pain, hospital stays, and urinary retention without increasing major complications. However, careful surgical technique is vital to minimize transient incontinence risk. Future research should involve larger sample sizes, multicenter participation, and extended follow-up to evaluate long-term outcomes such as continence, recurrence rates, quality of life, and patient satisfaction. Limitations of the current study include a small sample size and brief follow-up duration, necessitating validation through larger trials. Overall, the study supports LIS as a safe and effective option for improving postoperative comfort and outcomes in eligible patients, providing essential guidance for surgical practices in managing advanced hemorrhoidal conditions.

Conclusion

Both Open Hemorrhoidectomy (OH) alone and with Lateral Internal Anal Sphincterotomy (OH + LIS) were compared in 50 patients with Grade III and IV hemorrhoids. Both groups were similar in baseline characteristics, allowing a valid assessment of postoperative outcomes. The OH + LIS group had significantly lower pain scores at multiple postoperative intervals (p < 0.001) and a shorter hospital stay (2.88 vs. 3.72 days; p < 0.001). Additionally, this group showed a lower rate of postoperative urinary retention (8% vs. 24%; p = 0.041). Differences in wound healing and other complications were not statistically significant. Overall, adding lateral internal anal sphincterotomy to open hemorrhoidectomy is a safe and effective approach, enhancing postoperative recovery without increasing complications.

Declarations

Data Availability

All Study data are available from the corresponding author on reasonable request.

Author’s contribution

All authors have equal contribution.

Funding

None

Conflicting Interest

The author(s) declared no conflicts of interest.

Acknowledgements

None