Haemorrhoids are one of the most common anorectal disorders, affecting nearly 4.4% of the global population, with peak prevalence among individuals aged 45 to 65 years (1). They are vascular cushions in the anal canal that, when symptomatic, may cause bleeding, prolapse, pain, and discomfort. Haemorrhoids are classified into internal and external types, with internal haemorrhoids further categorized into Grades I to IV depending on the degree of prolapse (2). While conservative management is suitable for early-stage disease, surgical intervention becomes necessary for Grades II to IV or when complications arise.

Conventional haemorrhoidectomy techniques, including the open Milligan-Morgan and closed Ferguson procedures, are considered the gold standard for advanced disease but are associated with significant postoperative pain, prolonged recovery, and risk of complications such as bleeding, infection, and anal stricture (3,4). These drawbacks have led to the development of newer, less invasive techniques aimed at reducing morbidity while maintaining efficacy.

Chivate’s procedure, a modified technique for haemorrhoid excision, has gained attention for its potential to minimize postoperative pain and shorten recovery time. It involves targeted excision and preservation of mucocutaneous bridges, aiming to reduce nerve damage and tissue trauma (5). However, comparative studies assessing its benefits over conventional approaches remain limited, especially in low-resource settings.

This study aims to evaluate the efficacy of Chivate’s procedure in reducing postoperative pain and associated complications compared to conventional haemorrhoidectomy in patients with Grade II to IV haemorrhoids in a tertiary care center in North Kerala.

This prospective, hospital-based study was conducted at MES Medical College Hospital, Perinthalmanna, Malappuram, Kerala. The study included patients diagnosed with Grade II to IV internal hemorrhoids who were scheduled to undergo either conventional haemorrhoidectomy or Chivate’s procedure.

Study Population

Patients of all age groups and both sexes presenting to the surgical outpatient department with a history of per rectal bleeding or prolapsing mass, and subsequently confirmed to have Grade II, III, or IV haemorrhoids based on clinical examination and routine investigations, were considered for inclusion.

Inclusion Criteria

• Patients with Grade II, III, or IV haemorrhoids.
• Patients of any age or gender who were fit for surgery.
• Patients providing informed consent.

Exclusion Criteria

• Thrombosed haemorrhoids
• Perianal hematoma
• Ulcerated haemorrhoids
• Anal strictures
• Active proctitis
• Suspicious rectal or sigmoid growths

Sampling and Sample Size

A total of 50 patients were recruited using a convenient sampling method.

Surgical Procedure and Group Allocation

The final decision regarding the surgical procedure—either Chivate’s or conventional haemorrhoidectomy—was determined intraoperatively after anaesthesia administration, based on surgeon preference and intraoperative findings.

Data Collection

Postoperative pain was assessed using the Visual Analogue Scale (VAS) on the 1st, 3rd, and 7th postoperative days. Additional variables recorded included duration of hospital stay and incidence of postoperative complications such as bleeding, infection, urinary retention, and constipation.

Statistical Analysis

All collected data were entered into SPSS software for analysis. Continuous variables such as pain scores were compared using the independent samples t-test. A p-value of less than 0.05 was considered statistically significant.

A total of 50 patients were included in the study, with an equal distribution of males and females. The average age of the participants was 39.6 years. Most individuals (52%) had no comorbidities, while 12% had a history of previous surgical interventions such as laser or MIPH procedures. The most frequent presenting complaint was a mass per rectum, observed in 60% of cases. Grade III haemorrhoids were the most common, affecting 72% of participants (Table 1).

Postoperative pain scores assessed using the Visual Analogue Scale (VAS) showed significantly lower values in patients who underwent Chivate’s procedure compared to those who underwent conventional haemorrhoidectomy on postoperative days (POD) 1 and 3 (p < 0.05). By POD 7, the difference in pain scores was not statistically significant (Table 2). A similar trend was observed in the subset of patients with Grade IV haemorrhoids, where Chivate’s group reported lower pain scores on POD 1 and 3 (p < 0.05), but not on POD 7 (Table 3, Graph 1).

Patients undergoing Chivate’s procedure also experienced shorter hospital stays, which was statistically significant (p < 0.05). Although complication rates were higher in the conventional group (20%) compared to the Chivate’s group (4%), this difference was not statistically significant. The complications included postoperative bleeding (40%), infection (20%), urinary retention (20%), and constipation (20%) (Table 4, Graph 2).

Graph 1: Comparison of Postoperative Pain Scores on Days 1, 3, and 7 between Chivate’s Procedure and Conventional Haemorrhoidectomy.

Graph 2: Postoperative Complication Rates for both surgical approaches, including bleeding, infection, urinary retention, and constipation.

Table 1: Demographic and Clinical Characteristics of the Study Population

Table 2: Comparison of Postoperative Pain Scores Between Procedures

Table 3: Pain Score in Grade IV Haemorrhoids by Procedure

Table 4: Hospital Stay and Postoperative Complications

Hemorrhoidal disease, particularly in its advanced stages, often necessitates surgical intervention due to persistent symptoms and recurrence after conservative therapy. While conventional haemorrhoidectomy remains a widely accepted treatment, it is often associated with substantial postoperative pain, delayed recovery, and higher complication rates (1,2). The present study demonstrates that Chivate’s procedure offers significant benefits over conventional haemorrhoidectomy in terms of postoperative pain and hospital stay duration.

The findings indicate that patients undergoing Chivate’s procedure experienced significantly lower pain scores on postoperative days 1 and 3, which is consistent with previous studies advocating for tissue-sparing techniques in haemorrhoid surgery (3,4). The reduced pain could be attributed to the preservation of anoderm and minimal trauma to surrounding tissues, a hallmark of Chivate’s technique (5). On postoperative day 7, the pain scores in both groups were comparable, indicating that initial tissue trauma is the major contributor to early postoperative discomfort (6).

A notable observation in this study was the significantly shorter hospital stay in the Chivate’s group. Reduced need for analgesia and faster mobilization likely contributed to early discharge, which has also been observed in other minimally invasive haemorrhoid surgeries such as Doppler-guided hemorrhoidal artery ligation (7,8). The implications of shorter hospitalization are critical in resource-constrained settings, improving bed turnover and reducing healthcare costs (9).

The rate of postoperative complications, although not statistically significant, was lower in the Chivate’s group. Haemorrhage was the most frequent complication in the conventional group, consistent with the literature suggesting that open haemorrhoidectomy carries a higher bleeding risk due to extensive tissue excision (10). Other complications such as urinary retention and infection were also more prevalent in the conventional group, aligning with earlier findings linking them to more invasive techniques (11,12).

Interestingly, the effectiveness of Chivate’s procedure in managing Grade IV haemorrhoids was noteworthy. Even in these severe cases, the pain was significantly lower on early postoperative days. This reinforces the adaptability of Chivate’s procedure for more complex cases, which had previously been considered a limitation of tissue-sparing approaches (13).

The strengths of this study include a prospective design and standardized pain assessment using VAS at multiple time points. However, limitations include a small sample size and single-center design, which may limit the generalizability of the findings. Longer-term follow-up is also needed to assess recurrence rates, which remain a concern with less invasive procedures (14,15).

In conclusion, Chivate’s procedure appears to be a safer and more patient-friendly alternative to conventional haemorrhoidectomy, especially for patients with Grade II–IV haemorrhoids. It is associated with reduced postoperative pain, shorter hospital stay, and a lower trend in complications, making it particularly suitable for adoption in low-resource healthcare settings.

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