What are the types of hemorrhoidectomy procedures?

Types of Hemorrhoidectomy

Surgical hemorrhoidectomy can be performed using either open (Milligan-Morgan) or closed (Ferguson) techniques, with both approaches showing comparable efficacy for treating third- and fourth-degree hemorrhoids. 1

Traditional Excisional Techniques

Open Hemorrhoidectomy (Milligan-Morgan)

• Widely used in the United Kingdom, this technique involves excising the internal and external components of each hemorrhoid while leaving the skin open in a 3-leaf clover pattern 1
• The wounds heal secondarily over 4-8 weeks 1
• Randomized trials show no consistent difference in postoperative pain compared to closed techniques, though one trial found increased pain versus submucosal (partially closed) hemorrhoidectomy 1

Closed Hemorrhoidectomy (Ferguson)

• Each hemorrhoid component is excised and the wounds are closed primarily 1
• Primary closure appears superior to the open version with respect to postoperative pain and wound healing 2
• Four randomized trials comparing open versus closed techniques showed no difference in postoperative pain in three trials, with inconsistent differences in healing times 1

Variations in Excision Instruments

Diathermy Hemorrhoidectomy

• Randomized trials show no difference in pain scores between diathermy and scissors hemorrhoidectomy 1
• Oral pain medication requirement was less in the diathermy groups 1
• Closed hemorrhoidectomy with diathermic cutting devices may decrease bleeding and pain 3

Laser Hemorrhoidectomy

• Not recommended: A randomized trial of Nd:YAG laser versus cold scalpel excision found no difference in postoperative pain or analgesic use 1
• Associated with impaired wound healing and higher cost 1
• Has no advantage over conventional techniques and is more costly 1

Ultrasonically Activated Scalpel

• Four randomized controlled trials showed conflicting results with respect to postoperative pain 1
• Closed hemorrhoidectomy with ultrasonic cutting devices may decrease bleeding and pain 3

Bipolar Diathermy (LigaSure)

• Two small randomized trials suggested a possible minor advantage 1
• Pain scores themselves did not differ significantly 1

Newer Hemorrhoidectomy Techniques

Stapled Hemorrhoidopexy (Longo Procedure)

• Performs a circular excision of internal hemorrhoids and prolapsing rectal mucosa proximal to the dentate line 1
• A purse-string suture is placed 3-4 cm above the dentate line and tied around the stapler shaft, then resection and stapling of the mucosa are performed 4
• Associated with significantly less postoperative pain than conventional hemorrhoidectomy 1
• Shorter operation time (5-15 minutes), hospital stay, and faster recovery compared to excisional hemorrhoidectomy 2, 4
• Disadvantage: higher recurrence rate compared to conventional excisional techniques 2
• Particularly advisable for circular hemorrhoids 2
• May be employed in emergency situations of acute anal prolapse 2
• Potential for several postoperative complications 1

Hemorrhoidal Artery Ligation (HAL)

• May be combined with Recto-Anal Repair (HAL/RAR) 2
• Demonstrates better tolerance of the procedure at the expense of a higher recurrence rate 2
• May be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly 3
• Qualifies for treatment of grade III and IV hemorrhoids 2

Submucosal Hemorrhoidectomy

• One randomized trial showed decreased pain and more rapid return to work following submucosal (partially closed) versus Milligan-Morgan hemorrhoidectomy 1

Techniques to Avoid

Anal Dilatation

• Should be abandoned: 52% of patients who underwent anal dilatation had impaired continence at 17-year follow-up 1
• Anal endosonography has shown sphincter injuries associated with this technique 1
• Higher failure rate than operative hemorrhoidectomy in prospective randomized trials 1
• Not recommended given the associated risk of sphincter injury and incontinence 1

Lateral Internal Sphincterotomy

• Has been suggested as an adjunct to hemorrhoid excision, but randomized studies have not confirmed its usefulness 1
• Studies have actually shown an increase in incontinence 1

Alternative Surgical Approaches

Suturing or Banding Technique

• Involves suturing or banding the internal hemorrhoids and excising the external component 1

Emergency Hemorrhoidectomy

• Can be performed safely for incarcerated, gangrenous hemorrhoids with results comparable to elective hemorrhoidectomy 1
• A randomized trial showed both Milligan-Morgan hemorrhoidectomy and incision with rubber band ligation can be performed safely for acute strangulated hemorrhoids, with slightly improved early recovery after incision and ligation 1

Key Clinical Considerations

Postoperative Pain Management

• Postoperative pain remains the major drawback of excisional hemorrhoidectomy 1
• Narcotic analgesics are generally required 1
• Most patients do not return to work for 2-4 weeks following surgery 1

Complication Rates

• Complications are usually minor but occur with significant frequency 1
• Urinary retention (2%-36%), bleeding (0.03%-6%), anal stenosis (0%-6%), infection (0.5%-5.5%), and incontinence (2%-12%) 1
• Sphincter defects documented by ultrasonography and anal manometry in up to 12% of patients after hemorrhoidectomy 1
• Excessive retraction with extensive dilation of the anal canal is probably responsible for sphincter injury and incontinence 1

Efficacy and Recurrence

• Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for third-degree hemorrhoids, with a low recurrence rate of 2-10% 5, 6
• Recurrence following properly performed hemorrhoidectomy is uncommon 1