Special Report
377
LigaSure Hemorrhoidectomy for Symptomatic Hemorrhoids: First Pediatric Experience Ole Grossmann1
Giampiero Soccorso1
Govind Murthi1
1 Department of Paediatric Surgery, Sheffield Children’s Hospital,
Sheffield, United Kingdom
Address for correspondence Ole Grossmann, Department of Paediatric Surgery, Sheffield Children’s Hospital, 118 Cundy Street Walkley, Sheffield, S6 2WN, United Kingdom (e-mail: [email protected]).
Abstract Keywords
► symptomatic hemorrhoids ► children ► LigaSure ► hemorrhoidectomy
Hemorrhoids are uncommon in children. Third and fourth degree symptomatic hemorrhoids may be surgically excised. We describe the first experience of using LigaSure (Covidien, Mansfield, Massachusetts, United States) to perform hemorrhoidectomies in children. LigaSure hemorrhoidectomy has been well described in adults and is found to be superior in patient tolerance as compared with conventional hemorrhoidectomy.
Introduction
Patients and Methods 1
Hemorrhoids are extremely uncommon in children and data regarding incidence is unavailable. Hemorrhoids are more common in children with portal hypertension and incidence has been estimated to be between 4.2 and 33%.2,3 Symptomatic hemorrhoids usually present with a prolapsing mass and pain on defecation, but can also present with bleeding or itching.1 Treatment of hemorrhoids in children is usually nonoperative through dietary modification with increased fiber and fluid intake, together with the use of bulk laxatives as required. Our practice also includes performing a colonoscopy for recurrent or persistent hemorrhoids to look for possible hemangiomatous malformations and an abdominal ultrasound to look for evidence of portal hypertension. Surgical intervention in the form of hemorrhoidectomy is usually reserved for grade three or four internal symptomatic hemorrhoids and the conventional procedures have been well described. Hemorrhoidectomy using the LigaSure vessel sealing system (Covidien, Mansfield, Massachusetts, United States) has more recently been described in the adult literature.4 We report our experience of using LigaSure in children with symptomatic hemorrhoids. To our knowledge the use of the LigaSure in the treatment of symptomatic hemorrhoids in children, has yet not been previously reported in the literature.
received December 16, 2013 accepted after revision April 24, 2014 published online June 11, 2014
Patients Between January 2008 and December 2012, five male children underwent daycare LigaSure hemorrhoidectomy in our department under the care of a single surgeon. The decision to operate was based on the clinical finding of significant internal grade three or four hemorrhoids and persistent symptoms despite adequate treatment of constipation. We retrospectively reviewed the outcome for this procedure; the mean follow-up was 3 months.
LigaSure Vessel Sealing System In our series we used the LigaSure open instrument, which is a bipolar electrothermal device. Through a combination of pressure and thermal energy, the device transforms elastin and collagen to form a permanent seal (equivalent strength to other conventional mechanical methods). It has a built-in feedback mechanism that monitors tissue impedance and therefore only generates the required amount of energy to seal the tissue, reducing tissue desiccation.4,5 Apart for hemorrhoidectomy the LigaSure can be used for other open general surgery procedures, which require electrothermal dissection with minimal thermal spread. The reusable LigaSure standard instrument costs £727.58 with the additional cost of £154.84 for its single use electrode. All prices are inclusive of value added tax.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1382258. ISSN 0939-7248.
Downloaded by: University of Pittsburgh. Copyrighted material.
Eur J Pediatr Surg 2015;25:377–380.
LigaSure Hemorrhoidectomy for Symptomatic Hemorrhoids
Grossmann et al. One patient had previous injection sclerotherapy before representing with recurrent hemorrhoids and then underwent two further LigaSure hemorrhoidectomies for persisting symptoms. The results are summarized in ►Table 1. The mean number of hemorrhoids excised in a single setting was two (ranging from 1 to 4). One patient developed an early postoperative complication of fecal incontinence that resolved spontaneously after 6 weeks. All patients were treated as day cases and discharged the same day with analgesics and a course of laxatives. Patients were reviewed 3 months postoperatively in the outpatient clinic.
Discussion
Fig. 1 Exposure of internal hemorrhoids using a retractor.
Surgical Technique While under a general anesthesia the patient is placed in the lithotomy position. After appropriate cleaning and draping, an Eisenhammer retractor is used to expose the hemorrhoids (►Fig. 1), which are then grasped with a nontraumatic grasper and lifted off the underlying internal anal sphincter (►Fig. 2). The LigaSure is then applied across the base of the hemorrhoid in multiple applications until completely removed from its pedicle. The wound is covered with ointment and no dressing is required.
Results Five children were identified to have undergone the procedure during the study period. The mean age of the children was 4.5 years (range 2.5–7 years). All children presented with a prolapsing mass and pain on defecation. No children were found to have portal hypertension.
Fig. 2 Retraction of the hemorrhoid and application of LigaSure (Covidien, Mansfield, Massachusetts, United States). European Journal of Pediatric Surgery
Vol. 25
No. 4/2015
Hemorrhoids in children can usually be managed nonoperatively but if this fails and patients remain symptomatic, surgical intervention should be considered. Hemorrhoidectomy has been the traditional surgical operation for symptomatic hemorrhoids. As this procedure is often painful various nonsurgical treatments have been developed, such as rubber band ligation, sclerotherapy, photocoagulation, and cryotherapy. However, surgical excision remains the most effective and definitive treatment of third and fourth degree hemorrhoids.4 Hemorrhoidectomy using the LigaSure vessel sealing system has more recently been described in the adult literature4 and several meta-analyses of randomized control trials (RCTs) show a significant benefit for LigaSure hemorrhoidectomy over other conventional techniques (open, closed, diathermy, and stapled). To date there are no reports of this technique in the pediatric literature. In a meta-analysis by Milito et al,6 11 RCTs (850 patients) comparing LigaSure versus conventional hemorrhoidectomy found that LigaSure had a significantly shorter duration of operation (p < 0.001), less postoperative pain (p < 0.001), and improved wound healing and time to normal activities (p < 0.001). The proportion of postoperative bleeding did not significantly differ between the two groups (p ¼ 0.056). Anal stenosis and hemorrhoid relapse were significantly lower in LigaSure group (p ¼ 0.024). No case of flatus or fecal incontinence was reported. In another meta-analysis by Tan et al7 nine RCTs (525 patients) also found improved outcome in the LigaSure group as compared with conventional techniques in terms of operative time (p < 0.001), postoperative pain, convalescence (p < 0.001), and blood loss (p < 0.001). The time was decreased to resume normal activities but was of marginal significance (p ¼ 0.08). There were no statistically significant difference in terms of complications including fecal/flatus incontinence (p ¼ 0.50), anal stenosis (p ¼ 0.93), and urinary retention (p ¼ 0.17). In a larger meta-analysis Mastakov et al8 compared 11 RCTs (1,046 patients) and reported that LigaSure hemorrhoidectomy compared with conventional techniques was shorter (p < 0.001) and the postoperative pain score and
Downloaded by: University of Pittsburgh. Copyrighted material.
378
LigaSure Hemorrhoidectomy for Symptomatic Hemorrhoids
Grossmann et al.
379
Case
Age/sex
Presenting symptom(s)
Previous procedures
Position of LigaSure excision (no. of hemorrhoids)
Postoperative problems
I
6-y-old boy
Rectal bleeding and painful defecation
Injection sclerotherapy
First operation: At 1, 4, 6, 12 o’clock (4). Second operation: At 7, 10 o’clock (2)
None
II
7-y-old boy
Prolapsing mass and discomfort during defecation
None
At 12 o’clock (1)
Transient fecal incontinence—resolved
III
3-y-old boy
Prolapsing mass and pain during defecation
None
At 3, 9 o’clock (2)
None
IV
2.5-y-old boy
Prolapsing mass and pain during defecation
None
At 9, 11 o’clock (2)
None
V
4-y-old boy
Prolapsing mass and pain during defecation
Proctosigmoidoscopy— prominent anal cushions found, no excision done
At 7, 11 o’clock (2)
None
blood loss during the operation were significantly reduced (p ¼ 0.001). After LigaSure hemorrhoidectomy wound healing (p ¼ 0.004) and return to normal activities (p ¼ 0.001) were significantly faster. The overall incidences of complications were not significantly different (p ¼ 0.056). In all of the RCTs LigaSure hemorrhoidectomy was either done under a general, an epidural or a spinal anesthesia. In a Cochrane Database Systematic Review comparing LigaSure versus conventional surgery for hemorrhoid treatment9 12 RCTs (1,142 patients) were meta-analyzed and concluded that LigaSure technique resulted in significantly less immediate postoperative pain without any adverse effect on postoperative complications, convalescence, and incontinence rate; thus, this technique was superior in terms of patient tolerance. In our series, one patient had transient fecal incontinence that may be attributed to anal sphincter stretching. With adequate tissue retraction the hemorrhoidal plexus can be elevated off the underlying anal sphincter to allow safe application of the LigaSure forceps.9–12 There have been no reports in the English literature of major anal sphincter injury following use of the LigaSure. The main advantages of LigaSure over conventional bipolar diathermy include the ability to create a consistent and reliable seal of vessels up to 7 mm without dissection or isolation on a single application of the instrument.4 The disadvantage of LigaSure is that it may possibly be more expensive than other conventional hemorrhoidectomy procedures although it is cheaper than, for example, stapled or hemorrhoidal artery ligation hemorrhoidectomy. Exact cost disadvantages over conventional techniques need yet to be calculated and should also take into consideration operative time, postoperative complications, recurrent symptoms, and time taken for patients return to normal activities. We feel that LigaSure hemorrhoidectomy is a technically easy and safe method of performing hemorrhoidectomy in
children. We also feel this is associated with less bleeding, postoperative pain, quicker return to normal activity, and improved wound healing as compared with conventional methods. As a result, we perform LigaSure hemorrhoidectomy as a primary procedure in symptomatic grade three or four hemorrhoids that have failed to respond to medical treatment. Larger trials in children and further follow-up are required but the use of LigaSure shows potential in the definitive treatment of hemorrhoids in children.
Conflict of Interest None.
References 1 Stites T, Lund DP. Common anorectal problems. Semin Pediatr Surg
2007;16(1):71–78 2 Heaton ND, Davenport M, Howard ER. Symptomatic hemorrhoids
3
4 5
6
7
8
and anorectal varices in children with portal hypertension. J Pediatr Surg 1992;27(7):833–835 Heaton ND, Davenport M, Howard ER. Incidence of haemorrhoids and anorectal varices in children with portal hypertension. Br J Surg 1993;80(5):616–618 Milito G, Cadeddu F. Tips and tricks: haemorrhoidectomy with LigaSure. Tech Coloproctol 2009;13(4):317–320 Thorbeck CV, Montes MF. Haemorrhoidectomy: randomised controlled clinical trial of Ligasure compared with Milligan-Morgan operation. Eur J Surg 2002;168(8-9):482–484 Milito G, Cadeddu F, Muzi MG, Nigro C, Farinon AM. Haemorrhoidectomy with Ligasure vs conventional excisional techniques: meta-analysis of randomized controlled trials. Colorectal Dis 2010;12(2):85–93 Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP. Metaanalysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy. Arch Surg 2007; 142(12):1209–1218, discussion 1218 Mastakov MY, Buettner PG, Ho YH. Updated meta-analysis of randomized controlled trials comparing conventional excisional European Journal of Pediatric Surgery
Vol. 25
No. 4/2015
Downloaded by: University of Pittsburgh. Copyrighted material.
Table 1 Presentation and outcome of children who had LigaSure hemorrhoidectomy
LigaSure Hemorrhoidectomy for Symptomatic Hemorrhoids haemorrhoidectomy with LigaSure for haemorrhoids. Tech Coloproctol 2008;12(3):229–239 9 Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids. Cochrane Database Syst Rev 2009;21(1):CD006761 10 Jayne DG, Botterill I, Ambrose NS, Brennan TG, Guillou PJ, O’Riordain DS. Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy. Br J Surg 2002;89(4):428–432
Grossmann et al. 11 Chen CW, Lai CW, Chang YJ, Chen CM, Hsiao KH. Results of 666
consecutive patients treated with LigaSure hemorrhoidectomy for symptomatic prolapsed hemorrhoids with a minimum follow-up of 2 years. Surgery 2013;153(2):211–218 12 Peters CJ, Botterill I, Ambrose NS, Hick D, Casey J, Jayne DG. Ligasure trademark vs conventional diathermy haemorrhoidectomy: long-term follow-up of a randomised clinical trial. Colorectal Dis 2005;7(4):350–353
Downloaded by: University of Pittsburgh. Copyrighted material.
380
European Journal of Pediatric Surgery
Vol. 25
No. 4/2015
377
LigaSure Hemorrhoidectomy for Symptomatic Hemorrhoids: First Pediatric Experience Ole Grossmann1
Giampiero Soccorso1
Govind Murthi1
1 Department of Paediatric Surgery, Sheffield Children’s Hospital,
Sheffield, United Kingdom
Address for correspondence Ole Grossmann, Department of Paediatric Surgery, Sheffield Children’s Hospital, 118 Cundy Street Walkley, Sheffield, S6 2WN, United Kingdom (e-mail: [email protected]).
Abstract Keywords
► symptomatic hemorrhoids ► children ► LigaSure ► hemorrhoidectomy
Hemorrhoids are uncommon in children. Third and fourth degree symptomatic hemorrhoids may be surgically excised. We describe the first experience of using LigaSure (Covidien, Mansfield, Massachusetts, United States) to perform hemorrhoidectomies in children. LigaSure hemorrhoidectomy has been well described in adults and is found to be superior in patient tolerance as compared with conventional hemorrhoidectomy.
Introduction
Patients and Methods 1
Hemorrhoids are extremely uncommon in children and data regarding incidence is unavailable. Hemorrhoids are more common in children with portal hypertension and incidence has been estimated to be between 4.2 and 33%.2,3 Symptomatic hemorrhoids usually present with a prolapsing mass and pain on defecation, but can also present with bleeding or itching.1 Treatment of hemorrhoids in children is usually nonoperative through dietary modification with increased fiber and fluid intake, together with the use of bulk laxatives as required. Our practice also includes performing a colonoscopy for recurrent or persistent hemorrhoids to look for possible hemangiomatous malformations and an abdominal ultrasound to look for evidence of portal hypertension. Surgical intervention in the form of hemorrhoidectomy is usually reserved for grade three or four internal symptomatic hemorrhoids and the conventional procedures have been well described. Hemorrhoidectomy using the LigaSure vessel sealing system (Covidien, Mansfield, Massachusetts, United States) has more recently been described in the adult literature.4 We report our experience of using LigaSure in children with symptomatic hemorrhoids. To our knowledge the use of the LigaSure in the treatment of symptomatic hemorrhoids in children, has yet not been previously reported in the literature.
received December 16, 2013 accepted after revision April 24, 2014 published online June 11, 2014
Patients Between January 2008 and December 2012, five male children underwent daycare LigaSure hemorrhoidectomy in our department under the care of a single surgeon. The decision to operate was based on the clinical finding of significant internal grade three or four hemorrhoids and persistent symptoms despite adequate treatment of constipation. We retrospectively reviewed the outcome for this procedure; the mean follow-up was 3 months.
LigaSure Vessel Sealing System In our series we used the LigaSure open instrument, which is a bipolar electrothermal device. Through a combination of pressure and thermal energy, the device transforms elastin and collagen to form a permanent seal (equivalent strength to other conventional mechanical methods). It has a built-in feedback mechanism that monitors tissue impedance and therefore only generates the required amount of energy to seal the tissue, reducing tissue desiccation.4,5 Apart for hemorrhoidectomy the LigaSure can be used for other open general surgery procedures, which require electrothermal dissection with minimal thermal spread. The reusable LigaSure standard instrument costs £727.58 with the additional cost of £154.84 for its single use electrode. All prices are inclusive of value added tax.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1382258. ISSN 0939-7248.
Downloaded by: University of Pittsburgh. Copyrighted material.
Eur J Pediatr Surg 2015;25:377–380.
LigaSure Hemorrhoidectomy for Symptomatic Hemorrhoids
Grossmann et al. One patient had previous injection sclerotherapy before representing with recurrent hemorrhoids and then underwent two further LigaSure hemorrhoidectomies for persisting symptoms. The results are summarized in ►Table 1. The mean number of hemorrhoids excised in a single setting was two (ranging from 1 to 4). One patient developed an early postoperative complication of fecal incontinence that resolved spontaneously after 6 weeks. All patients were treated as day cases and discharged the same day with analgesics and a course of laxatives. Patients were reviewed 3 months postoperatively in the outpatient clinic.
Discussion
Fig. 1 Exposure of internal hemorrhoids using a retractor.
Surgical Technique While under a general anesthesia the patient is placed in the lithotomy position. After appropriate cleaning and draping, an Eisenhammer retractor is used to expose the hemorrhoids (►Fig. 1), which are then grasped with a nontraumatic grasper and lifted off the underlying internal anal sphincter (►Fig. 2). The LigaSure is then applied across the base of the hemorrhoid in multiple applications until completely removed from its pedicle. The wound is covered with ointment and no dressing is required.
Results Five children were identified to have undergone the procedure during the study period. The mean age of the children was 4.5 years (range 2.5–7 years). All children presented with a prolapsing mass and pain on defecation. No children were found to have portal hypertension.
Fig. 2 Retraction of the hemorrhoid and application of LigaSure (Covidien, Mansfield, Massachusetts, United States). European Journal of Pediatric Surgery
Vol. 25
No. 4/2015
Hemorrhoids in children can usually be managed nonoperatively but if this fails and patients remain symptomatic, surgical intervention should be considered. Hemorrhoidectomy has been the traditional surgical operation for symptomatic hemorrhoids. As this procedure is often painful various nonsurgical treatments have been developed, such as rubber band ligation, sclerotherapy, photocoagulation, and cryotherapy. However, surgical excision remains the most effective and definitive treatment of third and fourth degree hemorrhoids.4 Hemorrhoidectomy using the LigaSure vessel sealing system has more recently been described in the adult literature4 and several meta-analyses of randomized control trials (RCTs) show a significant benefit for LigaSure hemorrhoidectomy over other conventional techniques (open, closed, diathermy, and stapled). To date there are no reports of this technique in the pediatric literature. In a meta-analysis by Milito et al,6 11 RCTs (850 patients) comparing LigaSure versus conventional hemorrhoidectomy found that LigaSure had a significantly shorter duration of operation (p < 0.001), less postoperative pain (p < 0.001), and improved wound healing and time to normal activities (p < 0.001). The proportion of postoperative bleeding did not significantly differ between the two groups (p ¼ 0.056). Anal stenosis and hemorrhoid relapse were significantly lower in LigaSure group (p ¼ 0.024). No case of flatus or fecal incontinence was reported. In another meta-analysis by Tan et al7 nine RCTs (525 patients) also found improved outcome in the LigaSure group as compared with conventional techniques in terms of operative time (p < 0.001), postoperative pain, convalescence (p < 0.001), and blood loss (p < 0.001). The time was decreased to resume normal activities but was of marginal significance (p ¼ 0.08). There were no statistically significant difference in terms of complications including fecal/flatus incontinence (p ¼ 0.50), anal stenosis (p ¼ 0.93), and urinary retention (p ¼ 0.17). In a larger meta-analysis Mastakov et al8 compared 11 RCTs (1,046 patients) and reported that LigaSure hemorrhoidectomy compared with conventional techniques was shorter (p < 0.001) and the postoperative pain score and
Downloaded by: University of Pittsburgh. Copyrighted material.
378
LigaSure Hemorrhoidectomy for Symptomatic Hemorrhoids
Grossmann et al.
379
Case
Age/sex
Presenting symptom(s)
Previous procedures
Position of LigaSure excision (no. of hemorrhoids)
Postoperative problems
I
6-y-old boy
Rectal bleeding and painful defecation
Injection sclerotherapy
First operation: At 1, 4, 6, 12 o’clock (4). Second operation: At 7, 10 o’clock (2)
None
II
7-y-old boy
Prolapsing mass and discomfort during defecation
None
At 12 o’clock (1)
Transient fecal incontinence—resolved
III
3-y-old boy
Prolapsing mass and pain during defecation
None
At 3, 9 o’clock (2)
None
IV
2.5-y-old boy
Prolapsing mass and pain during defecation
None
At 9, 11 o’clock (2)
None
V
4-y-old boy
Prolapsing mass and pain during defecation
Proctosigmoidoscopy— prominent anal cushions found, no excision done
At 7, 11 o’clock (2)
None
blood loss during the operation were significantly reduced (p ¼ 0.001). After LigaSure hemorrhoidectomy wound healing (p ¼ 0.004) and return to normal activities (p ¼ 0.001) were significantly faster. The overall incidences of complications were not significantly different (p ¼ 0.056). In all of the RCTs LigaSure hemorrhoidectomy was either done under a general, an epidural or a spinal anesthesia. In a Cochrane Database Systematic Review comparing LigaSure versus conventional surgery for hemorrhoid treatment9 12 RCTs (1,142 patients) were meta-analyzed and concluded that LigaSure technique resulted in significantly less immediate postoperative pain without any adverse effect on postoperative complications, convalescence, and incontinence rate; thus, this technique was superior in terms of patient tolerance. In our series, one patient had transient fecal incontinence that may be attributed to anal sphincter stretching. With adequate tissue retraction the hemorrhoidal plexus can be elevated off the underlying anal sphincter to allow safe application of the LigaSure forceps.9–12 There have been no reports in the English literature of major anal sphincter injury following use of the LigaSure. The main advantages of LigaSure over conventional bipolar diathermy include the ability to create a consistent and reliable seal of vessels up to 7 mm without dissection or isolation on a single application of the instrument.4 The disadvantage of LigaSure is that it may possibly be more expensive than other conventional hemorrhoidectomy procedures although it is cheaper than, for example, stapled or hemorrhoidal artery ligation hemorrhoidectomy. Exact cost disadvantages over conventional techniques need yet to be calculated and should also take into consideration operative time, postoperative complications, recurrent symptoms, and time taken for patients return to normal activities. We feel that LigaSure hemorrhoidectomy is a technically easy and safe method of performing hemorrhoidectomy in
children. We also feel this is associated with less bleeding, postoperative pain, quicker return to normal activity, and improved wound healing as compared with conventional methods. As a result, we perform LigaSure hemorrhoidectomy as a primary procedure in symptomatic grade three or four hemorrhoids that have failed to respond to medical treatment. Larger trials in children and further follow-up are required but the use of LigaSure shows potential in the definitive treatment of hemorrhoids in children.
Conflict of Interest None.
References 1 Stites T, Lund DP. Common anorectal problems. Semin Pediatr Surg
2007;16(1):71–78 2 Heaton ND, Davenport M, Howard ER. Symptomatic hemorrhoids
3
4 5
6
7
8
and anorectal varices in children with portal hypertension. J Pediatr Surg 1992;27(7):833–835 Heaton ND, Davenport M, Howard ER. Incidence of haemorrhoids and anorectal varices in children with portal hypertension. Br J Surg 1993;80(5):616–618 Milito G, Cadeddu F. Tips and tricks: haemorrhoidectomy with LigaSure. Tech Coloproctol 2009;13(4):317–320 Thorbeck CV, Montes MF. Haemorrhoidectomy: randomised controlled clinical trial of Ligasure compared with Milligan-Morgan operation. Eur J Surg 2002;168(8-9):482–484 Milito G, Cadeddu F, Muzi MG, Nigro C, Farinon AM. Haemorrhoidectomy with Ligasure vs conventional excisional techniques: meta-analysis of randomized controlled trials. Colorectal Dis 2010;12(2):85–93 Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP. Metaanalysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy. Arch Surg 2007; 142(12):1209–1218, discussion 1218 Mastakov MY, Buettner PG, Ho YH. Updated meta-analysis of randomized controlled trials comparing conventional excisional European Journal of Pediatric Surgery
Vol. 25
No. 4/2015
Downloaded by: University of Pittsburgh. Copyrighted material.
Table 1 Presentation and outcome of children who had LigaSure hemorrhoidectomy
LigaSure Hemorrhoidectomy for Symptomatic Hemorrhoids haemorrhoidectomy with LigaSure for haemorrhoids. Tech Coloproctol 2008;12(3):229–239 9 Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids. Cochrane Database Syst Rev 2009;21(1):CD006761 10 Jayne DG, Botterill I, Ambrose NS, Brennan TG, Guillou PJ, O’Riordain DS. Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy. Br J Surg 2002;89(4):428–432
Grossmann et al. 11 Chen CW, Lai CW, Chang YJ, Chen CM, Hsiao KH. Results of 666
consecutive patients treated with LigaSure hemorrhoidectomy for symptomatic prolapsed hemorrhoids with a minimum follow-up of 2 years. Surgery 2013;153(2):211–218 12 Peters CJ, Botterill I, Ambrose NS, Hick D, Casey J, Jayne DG. Ligasure trademark vs conventional diathermy haemorrhoidectomy: long-term follow-up of a randomised clinical trial. Colorectal Dis 2005;7(4):350–353
Downloaded by: University of Pittsburgh. Copyrighted material.
380
European Journal of Pediatric Surgery
Vol. 25
No. 4/2015
