Haemorrhoids s are considered one of the most common a anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population. years. 1 and a peak incidence between 45 and 65 years. (1,2)Hemorrhoids are clusters of vascular tissue, smooth muscle, and connective tissue arranged in 3 columns along the anal canal . Hemorrhoidal disease presents with a prolapsed lump, painless bleeding. discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease: however, it is also associated with hyper-vascularity, and recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. (3,4)Treatment modalities includes conservative treatment (life style modification, oral medications, and topical treatment). office procedures (rubber band ligation, injection sclerotherapy infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy. Cryosurgery, and laser therapy), as well as Surgical procedures including diathermy hemorhoidectomy, LigaSure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy, and Chivate' s procedure. Surgical procedures are effective at eliminating haemorrhoids but may painful. It avoids wound in Sensitive and Perianal and anal areas as a result has the advantage of significantly reducing postoperative pain.(5,6)

Dr shanthikumar chivate(7) modified this technique and termed-as transanal mucorectopexy. This study was planned to directly compare chivate s procedure as a newer procedure with open hemorrhoidectomy as an older established procedure for the treatment of grade 3 to grade 4 hemorrhoids.

It is a prospective observational study conducted in Department of general surgery in patients with III /IV hemorrhoids. Total 60 patients are included in study which is divided as 30 subjects in each group.

Study divided into 2 groups by odd and even numbers odd numbers were assigned 1 as group A Patients were chivate' s procedure and even numbers were as Signed as group B open haemorrhoidectomy for a period of 24 months.

Inclusion Criteria: All Patients coming to surgical OPD with history of per rectal bleeding, confirmed haemorrhoids cases after routine examinations and grade III /IV hemorrhoids.

Exclusion Criteria: Patients with thrombosed piles, perianal hematoma, and ulcerated piles excluded after confirmation, Recto-sigmoid growth 3 Perianal fistula and fissure, anal stricture.

Participants for this study were enrolled by a process of simple sampling of patients who were admitted for Haemorrhoid in SVS medical surgeries college and hospital who met the above pre-specified inclusion and exclusion criteria. Informed consent was obtained from all participants. They were subjected to thorough History taking, Proper pre-op evaluation of past medical comorbidities and surgical history. All. intraoperative and post-operative events were noted. A Random sampling was done and all the complications that were encountered in Open haemorrhidectomy and chivates procedure that came under inclusion criteria were noted.

All patients were examined for following parameters: Presenting complaints . PR examination, Contributory Laboratory Findings, Intraoperative findings and Postoperative complications

During and after the surgical procedure patients were evaluated for early complications, period of hospital stay and time for return to work. After the discharge patients were followed up bimonthly up to 6 months and then at 6 months interval for delayed complications.

 The collected data will be entered systematically into the Microsoft excel software. Frequency distribution and percentage values will be tabulated. descriptive statistics will be calculated to the mean SD, Prevalence rate will be calculated. Appropriate statistical test will be applied according to study variables and hypothesis if necessary.  The statistical test of significance will be tested at p<0.05 (at 95% CI). The research data analysis will be carried out with the help of SPSS statistics version.23 and Graph pad prism 9.

Table 1: Age, sex distribution and Haemorrhoid types among two groups

Total of 60 patients were included in this study, 30 in each group. The mean age of the participants are 42.23 years majority of which belongs to 35-44 years (50%) the age distribution of the participants in both the groups were compared and found to be insignificant (P>0.05).Most of the cases were males, 41 (68.34%).

In open haemorrhoidectomy group 9 (30%) were female and 21 (70%) were male, whereas in Chivate' s procedure group 10 (33%) were female and 20 (66.7%) male. The slight difference in sex distribution in both the groups was found to be statistically insignificant (p=0.57). As per as the grade of haemorrhoids was considered in open haemorrhoidectomy group 13 (43.4%) were grade III and 17 (56.7%) were grade-IV where in other group 11 (36.7%) were grade-III and 19(63.4%) grade-IV. This difference was not statistically significant (p>0.05)(Table-1).

Figure-1: Duration of surgery in present study

The mean duration of operation time in open haemorrhoidectomy group was 32.1 (±2.41) minutes and for Chivate' s procedure group 40.11 (±4.81) minutes is more and statistically significant.

Table-2: Surgery related complications and indicators between 2 groups.

Operative blood loss,  wound healing time, and wound infection decreased significantly in the Chivate' s procedure group compared with the open haemorrhoidectomy group (P < .001)

Table-3: Comparison of Early complications in two procedure

*significance

In our study post-operative pain, VAS score 3 or more was 73.3% in open haemorrhoidectomy group and only 13.3% in Chivate' s procedure which was significant.

Patients complained of fever, bleeding and urinary retention are  Statistically significant (p<0.05)

Table-4: Comparison of post-operative duration of hospital stay and return to work between two operations.

Duration of hospital stay was 3.5 (±0.8) days in open group and 1.5 (±0.3) in Chivate' s procedure. Return work is early in Chivate' s procedure than open groups which is significant.

Table-5: Comparison of delayed complications between the two operations

With one year period of follow up only 8 patients in open haemorrhoidectomy group developed delayed complications. Bleeding was seen in 3 patients. Incontinence in 1 patient anal stenosis and recurrence in 2 patient each. None of these complications were seen in Chivate' s procedure (Table-5).

In this study we've extensively studied and analysed the two surgical procedures: Open haemorrhoidectomy and Chivate' s procedure. Both the procedures were performed in two groups of 30 patients each with almost similar age, sex and grade of haemorrhoids (grade-III and IV)

In our study, mean duration of operation time in open haemorrhoidectomy group was 32.1 (±2.41) minutes and for Chivate' s procedure group 40.11 (±4.81) minutes is more and statistically significant.. Mastakov et al(8) found the similar result of mean operative duration of around 27.4 minutes for open hemorrhoidectomy group on 27 patients. Bhagwat VM et al (9) (2017) found similar results of 49.80 minutes operative duration for 50 patients for open hemorrhoidectomy group, which is similar to our study.

In our study Operative blood loss,  wound healing time, and wound infection decreased significantly in the Chivate' s procedure group compared with the open haemorrhoidectomy group (P < .001). Postoperative bleeding showed decreased significantly in the Chivate' s procedure group compared with the open haemorrhoidectomy group (P < .001). Mean blood loss in Chivate' s procedure group 78.8 ± 26.1 and 99.5 ± 34.1 ml in open hemorrhoidectomy group. Thus, Chivate' s procedure is better than open hemorrhoidectomy in bleeding as it has less intraoperative bleeding and also less chances of postoperative bleeding. In open hemorrhoidectomy, the etiology has been held to be early separation of the ligated pedicle before adequate thrombosis in the feeding artery can occur . Options include return to the operating theatre for Chivate' s procedure or tamponade at the bedside by foley catheter or anal packing. As there is no such thing present in Chivate' s procedure, there is less incidence of bleeding intraoperatively as well as postoperatively. This observation is similar to Adil saker (10)study , in which 56 % incidence of postoperative bleeding in open hemorrhoidectomy group.  Mastakov at el(8) done study on 45 patients in which, postoperative bleeding was present in 77.7 % patients of open hemorrhoidectomy, which is similar to our study.

In our study post-operative pain, VAS score 3 or more was 73.3% in open haemorrhoidectomy group and only 13.3% in Chivate' s procedure which was significant. The pain is more due to extensive dissection in open haemorrhoidectomy group, which is the most common drawback of this procedure. Our observation was similar to different studies in which 80% of the patients had moderate to severe postoperative pain(11,12). Our observation is similar to Adil Shaker study (10) in which from 190 patients, 80.1 % patients had moderate to severe pain postoperatively.

Patients complained of fever, bleeding and urinary retention  are statistically significant (p<0.05). Bhagvat VM et al (9) observed study on 50 patients of open hemorrhoidectomy and found 16.6 % incidence of postoperative 33 urinary retention. Neeralagi CS et al (13) found 23.33 % incidence of urinary retention in open hemorrhoidectomy group and this result is similar to our study. In a study carried out by Chik B et al(14) the incidence of urinary retention 38 following open haemorrhoidectomy was 15.2%.

Duration of hospital stay was 3.5 (±0.8) days in open group and 1.5 (±0.3) in Chivate' s procedure.  The patients undergoing Chivate' s procedure were able to return to work in 4.8 days was much earlier than the open haemorrhoidectomy group 12.4 days

Chivate' s procedure requires less hospitalization than open hemorrhoidectomy and thus patient can peruse his routine work early than open hemorrhoidectomy. Shantikumar Chivate (7) performed a study in which, he observed that the milligon morgan procedure is very painful requiring 3-5 days hospitalization and sedation. As Chivate' s procedure is less  painful procedure, it requires less hospitalization . Neeralagi CS et al (13) stated that the mean hospital stay for open hemorrhoidectomy on 120 patients, is 4.1 days and this result is similar to our study.

We studied the advantage and disadvantages of open haemorrhoidectomy and trans anal Chivate' s procedure in 60 patients over a period of 24 months without compromising the safety of the patients and we found the advantages and disadvantages of both the techniques. Chivate' s procedure though take little bit more operative time resulted in less post-operative pain , less requirement of analgesia, less post-operative complications, less period of hospital stay and early return to work resulting in less financial loss. Thus the trans anal Chivate' s procedure can be recommended as a safe, cost effective alternative procedure to open haemorrhoidectomy and can be performed at any rural setup after an adequate training.

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