Intra-Operative

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Intra-operative analgesia

To ensure an adequate analgesic effect in the immediate postoperative period, it may be necessary to administer analgesic medication prior to the postoperative period, e.g. conventional NSAIDs, COX-2-selective inhibitors, paracetamol

PROSPECT Recommendations

  • Injection of botulinum toxin is not recommended (Grade D, LoE 4), due to inconsistent procedure-specific evidence for analgesic benefit in the postoperative period

Clinical Practice

  • The injection of botulinum toxin for pain after haemorrhoid surgery is not performed routinely in clinical practice

Transferable Evidence

  • None cited

Haemorrhoid surgery-specific evidence

  • Two out of two studies demonstrated a decrease in pain scores with Botox injection compared with placebo injection Davies 2003 Click here for more information
  • One study out of two showed a decrease in rescue analgesic consumption with Botox compared with placebo Patti 2005 Click here for more information
  • In one study out of one, the time to complete healing of wounds was significantly shorter with Botox compared with placebo (p<0.001;
  • In one study out of one, the time to return to work was significantly shorter in a Botox group versus a placebo group (p<0.05;
  • The time to first defecation was similar in groups receiving either Botox or placebo in two out of two studies (
  • In one study out of one, the incidence of anal incontinence was similar with Botox and placebo (
  • In one study out of one, the incidence of urinary retention was similar with Botox and placebo (
  • In two studies out of two, there was no significant difference in the length of hospital stay with Botox and placebo (
  • Study details Davies 2003 Click here for more information

PROSPECT Recommendations

  • Stapled haemorrhoid surgery is recommended (Grade A) based on reduced pain compared with other surgical techniques (procedure-specific evidence, LoE 1)
  • The choice of haemorrhoid operative techniques may depend on factors other than postoperative pain alone

Clinical Practice

  • The choice of haemorrhoid operative technique may depend on factors other than postoperative pain alone

Transferable Evidence

  • None cited

Haemorrhoid surgery-specific evidence

  • Closed versus open haemorrhoidectomy
  • Closed versus closed haemorrhoidectomy

PROSPECT Recommendations

  • No recommendation can be made regarding the choice of haemorrhoid dissection technique based on their effect on postoperative pain alone

Clinical Practice

  • None cited

Transferable Evidence

  • None cited

Haemorrhoid surgery-specific evidence

  • Summary of studies Click here for more information
  • Diathermy dissection versus conventional scissors dissection
  • Harmonic Scalpel™ dissection versus conventional scissors dissection
  • Dissection with radiofrequency bistoury versus conventional scissors dissection
  • Diathermy dissection versus Harmonic Scalpel™ dissection
  • LigaSure™ diathermy dissection versus conventional diathermy dissection
  • Cold scalpel dissection versus laser dissection

PROSPECT Recommendations

  • Lateral sphincterotomy as an adjunct to haemorrhoid surgery is not recommended for analgesia (Grade D, LoE 4) due to limited and inconsistent procedure-specific evidence
  • The use of an anal dilator as an adjunct to haemorrhoid surgery is not recommended for analgesia (Grade D, LoE 4) based on limited procedure-specific evidence

Clinical Practice

  • None cited

Transferable Evidence

  • None cited

Haemorrhoid surgery-specific evidence

  • Open haemorrhoidectomy, with or without lateral sphincterotomy
  • Closed haemorrhoidectomy, with or without lateral sphincterotomy
  • Diathermy haemorrhoidectomy, with or without lateral sphincterotomy
  • Anal dilator versus no treatment