Hemorrhoidal disease is one of the most frequently encountered anorectal conditions, affecting a substantial portion of the adult population worldwide. The disease is especially burdensome in rural areas where late presentation, limited healthcare access, and economic constraints often compound treatment challenges. Grade III and IV hemorrhoids usually require surgical intervention, with the Milligan-Morgan hemorrhoidectomy (MMH) and Stapled Hemorrhoidopexy (SH) being two of the most common surgical options. In the context of India’s rural healthcare settings, it is vital to assess not only clinical outcomes such as recurrence but also economic implications of these procedures. The open Milligan-Morgan hemorrhoidectomy, introduced in the 1930s, remains a time-tested surgical method due to its low recurrence rate and effectiveness in removing external and internal hemorrhoids. However, this procedure is associated with significant post-operative pain, prolonged recovery time, and increased hospital stay [1]. On the other hand, stapled hemorrhoidopexy, a relatively newer approach, is designed to reduce postoperative discomfort and hasten recovery, but often at the expense of higher recurrence and greater procedural cost [2]. In a prospective randomized study comparing the two methods, it was found that SH had shorter operative times and quicker return to normal activity, but with a significantly higher financial burden. In one such study, the mean cost of SH was around Rs. 23,500 compared to Rs. 7,000 for MMH [3]. For resource-constrained rural populations, such differences can influence surgical decision-making significantly. The recurrence rate remains a critical clinical outcome. A large European study of 640 patients found a significantly lower recurrence rate in the MMH group (0.5%) compared to the SH group (8.33%) during short-term follow-up, along with a €668 higher per-patient cost in the stapled group [4]. Conversely, a randomized controlled trial with a longer follow-up of 5 years showed no statistically significant difference in recurrence between the two procedures (18% for SH vs. 23% for MMH), suggesting patient selection and surgical expertise may play a key role [5]. Indian and South Asian data further highlight the practical implications in rural healthcare delivery. A trial at Khyber Teaching Hospital revealed that SH led to less post-operative pain and a shorter hospital stay, but again, at triple the cost of MMH [3]. Similar findings were echoed in an Indian prospective study, where SH significantly reduced intraoperative time and bleeding, and patients resumed daily activity faster. However, the cost and need for specialized equipment made SH less accessible in peripheral centers [6]. In another study from Kashmir, SH resulted in fewer complications (12 in SH vs. 32 in MMH group) and shorter hospital stays, but both groups showed zero recurrence within six months. The study concluded that while SH is clinically beneficial, its affordability remains a barrier in rural practice [7]. A systematic review highlighted the contrast: SH is associated with reduced pain and faster recovery, but also with a higher risk of prolapse recurrence. This risk is particularly notable in fourth-degree hemorrhoids, where conventional surgery may be more effective [8]. Additionally, while SH may offer enhanced short-term comfort, it has shown a higher recurrence rate in certain populations and carries the added disadvantage of higher cost [9]. In an Indian comparative study conducted recently in 2024, SH again demonstrated better short-term outcomes in terms of postoperative pain, hospital stay, and time to return to work. However, cost remained a significant constraint for patients in rural areas, leading authors to suggest MMH as a more practical option despite its relatively higher discomfort [10]. Considering these multiple dimensions recurrence, cost, post-operative pain, and hospital stay it becomes essential to tailor the surgical approach to local conditions. For rural populations in India, where cost and infrastructure are critical limiting factors, Milligan-Morgan hemorrhoidectomy remains a more feasible and sustainable solution, especially for advanced hemorrhoidal disease. This study aimed to compare Stapled Hemorrhoidopexy and Milligan-Morgan Hemorrhoidectomy in terms of cost, recurrence, complications, and recovery in rural patients with Grade III and IV hemorrhoids, to identify the more effective and affordable surgical option.

1. Study Design This was a prospective, randomized comparative study conducted to evaluate the outcomes of Stapled Hemorrhoidopexy versus Milligan-Morgan Hemorrhoidectomy in rural patients with Grade III and IV hemorrhoids. The study assessed recurrence, cost, postoperative pain, and complications over a defined follow-up period using standardized protocols. 2. Study Setting The study was conducted in the Department of General Surgery at a rural tertiary care teaching hospital in India. The hospital catered to low-income rural populations and had the necessary facilities for both surgical techniques, ensuring consistent treatment and follow-up within the same setting. 3. Study Duration The study was carried out over 18 months, from January 2023 to June 2024. This included patient recruitment, surgeries, and a minimum six-month follow-up for each participant to assess long-term outcomes like recurrence and recovery. 4. Participants – Inclusion/Exclusion Criteria Patients aged 18–65 years with Grade III or IV hemorrhoids residing in rural areas and willing to consent were included. Exclusion criteria were previous anorectal surgery, bleeding disorders, IBD, malignancy, pregnancy, or unwillingness for follow-up. 5. Study Sampling Purposive random sampling was used. Eligible patients were stratified by hemorrhoid grade and randomly assigned to either group using computer-generated numbers. Allocation concealment was maintained with sealed envelopes, and sampling continued until the required size was reached. 6. Study Sample Size A total of 66 patients were enrolled, with 33 in each group. The sample size was calculated to detect a difference in recurrence rates with 95% confidence and 80% power, accounting for a 10% dropout rate. 7. Study Groups Patients were randomly allocated into two groups. Group A underwent Milligan-Morgan Hemorrhoidectomy, while Group B received Stapled Hemorrhoidopexy. Both groups received standard care and were followed postoperatively for up to six months. 8. Study Parameters Primary outcome was recurrence. Secondary parameters included operative time, pain (VAS score), hospital stay, time to return to work, cost, and complications such as bleeding, urinary retention, infection, and incontinence. 9. Study Procedure All patients underwent preoperative workup and standardized surgical procedures. MMH involved excision of hemorrhoids, while SH used a circular stapler. Postoperative care was uniform. Pain, complications, and recurrence were monitored during scheduled follow-ups. 10. Study Data Collection Data were collected using structured proformas during admission, surgery, discharge, and follow-up visits. Variables included pain scores, costs, operative details, and complications. Data were anonymized and double-checked for accuracy before analysis. 11. Data Analysis Data were analyzed using SPSS version 26. Continuous variables were compared using t-tests; categorical data using chi-square tests. A p-value < 0.05 was considered significant. Results were expressed in mean, percentage, and standard deviation. 12. Ethical Considerations The study received ethical clearance from the Institutional Ethics Committee. Written informed consent was obtained. Patient confidentiality was maintained. Participation was voluntary, and all patients received standard treatment regardless of study group.

1. Demographic Profile of Patients The age and gender distribution were comparable between groups, minimizing baseline bias. Most patients were males aged 40–50 (Table 1). Table 1: Demographic Profile of Patients Parameter Group A (MMH) Group B (SH) Mean Age (years) 42 41 Male (%) 70% 68% Female (%) 30% 32% 2. Distribution of Hemorrhoid Grades Grade III hemorrhoids were more common in both groups; distribution was similar, ensuring fair comparison (Table 2). Table 2: Distribution of Hemorrhoid Grades Grade Group A (MMH) Group B (SH) Grade III 22 24 Grade IV 11 9 3. Duration of Surgery (minutes) SH had significantly shorter operative time, making it a faster procedure (Table 3). Table 3: Duration of Surgery (minutes) Group Mean ± SD Group A (MMH) 35 ± 5 Group B (SH) 25 ± 4 4. Intraoperative Blood Loss (ml) SH showed less blood loss than MMH, indicating a less invasive approach (Table 4). Table 4: Intraoperative Blood Loss (ml) Group Mean ± SD Group A (MMH) 50 ± 10 Group B (SH) 30 ± 8 5. Postoperative Pain Score (VAS) SH patients reported lower pain levels on all days, especially immediately post-op (Table 5). Table 5: Postoperative Pain Score (VAS) Day Group A (MMH) Group B (SH) Day 1 7.2 4.5 Day 2 5.6 2.8 Day 7 2.1 1.2 6. Hospital Stay (days) SH patients had shorter hospital stays, aiding faster discharge (Table 6). Table 6: Hospital Stay (days) Group Mean ± SD Group A (MMH) 3.5 ± 1.0 Group B (SH) 2.0 ± 0.5 7. Time to Return to Work (days) Patients in the SH group resumed work almost a week earlier (Table 7). Table 7: Time to Return to Work (days) Group Mean ± SD Group A (MMH) 12 ± 3 Group B (SH) 7 ± 2 8. Patient Satisfaction Score at 6 Weeks Patients in the SH group reported higher satisfaction due to less pain and quicker recovery, despite higher costs (Table 8). Table 8: Patient Satisfaction Score at 6 Weeks Satisfaction Level Group A (MMH) Group B (SH) Highly Satisfied 18 27 Moderately Satisfied 12 6 Not Satisfied 3 0 9. Postoperative Complications MMH had more complications, especially urinary retention and infections (Table 9). Table 9: Postoperative Complications Complication Group A (MMH) Group B (SH) Urinary Retention 5 2 Wound Infection 3 1 Bleeding 2 1 10. Recurrence at 6-Month Follow-Up Recurrence was slightly higher in the SH group, though not statistically significant (Table 10). Table 10: Recurrence at 6-Month Follow-Up Group Recurrence (%) Group A (MMH) 3% Group B (SH) 6%

This comparative study between Milligan-Morgan Haemorrhoidectomy (MMH) and Stapled Haemorrhoidopexy (SH) in a rural Indian setting highlights critical differences in operative outcomes, patient recovery, and recurrence. In terms of operative efficiency, our findings confirm earlier studies such as those by (Malyadri & Allu, 2021) and (Philip & Ramachandran, 2024), showing that SH significantly reduces both surgical time (25 ± 4 min vs 35 ± 5 min) and intraoperative blood loss (30 ± 8 ml vs 50 ± 10 ml), suggesting its less invasive nature [6, 2]. Our pain score analysis over the first postoperative week revealed that SH patients consistently experienced lower pain levels, in line with the observations by (Gravié et al., 2005), where SH was associated with reduced analgesic requirements [11]. Similarly, the shorter hospital stay and faster return to work seen in SH patients supports findings by (Kim et al., 2013), who reported significantly better early recovery parameters for SH [5]. Patient satisfaction was notably higher in the SH group, likely due to reduced pain and quicker convalescence. While this mirrors global and Indian trends, the cost of SH remains a critical concern in rural India, a limitation also acknowledged by (Gani et al., 2024) [7]. However, our study also echoes caution raised in previous literature regarding long-term recurrence. Although recurrence at 6 months was slightly higher in the SH group (6% vs 3%), it was not statistically significant. Similar trends were reported by (Ammaturo et al., 2012), where SH showed up to 13% recurrence at 2 years, compared to none in MMH [12]. Overall, our findings confirm that SH offers significant short-term advantages over MMH but must be weighed against its higher cost and potential for recurrence in long-term follow-up.

Stapled hemorrhoidopexy demonstrated significant short-term advantages, including reduced operative time, blood loss, postoperative pain, hospital stay, and earlier return to work. However, these benefits were counterbalanced by its substantially higher cost and a slightly increased recurrence rate at six months. For rural Indian populations with limited financial resources, Milligan-Morgan hemorrhoidectomy remains a more cost-effective and sustainable option despite longer recovery times. Surgical choice should therefore be individualized, balancing patient affordability, symptom severity, and availability of resources in peripheral healthcare settings.

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