What are the surgical procedures for internal hemorrhoids?

Surgical Procedures for Internal Hemorrhoids

Conventional excisional hemorrhoidectomy is the most effective surgical treatment for internal hemorrhoids, particularly for grade III-IV disease, with the lowest recurrence rate of 2-10%, and should be performed when office-based procedures fail or for symptomatic grade III-IV hemorrhoids. 1, 2

Indications for Surgical Intervention

Surgical hemorrhoidectomy is indicated for: 1

• Failure of medical and office-based therapy (rubber band ligation, sclerotherapy)
• Symptomatic grade III or IV internal hemorrhoids
• Mixed internal and external hemorrhoids
• Concomitant anorectal conditions requiring surgery (fissure, fistula)
• Anemia from hemorrhoidal bleeding 1

Primary Surgical Techniques

Conventional Excisional Hemorrhoidectomy

Open (Milligan-Morgan) Technique: 2

• Excises internal and external components of each hemorrhoid
• Wounds left open in a 3-leaf clover pattern
• Heals secondarily over 4-8 weeks
• No consistent difference in postoperative pain compared to closed technique 2

Closed (Ferguson) Technique: 2

• Excises hemorrhoid components and closes wounds primarily
• Associated with reduced postoperative pain and faster wound healing compared to open technique 2
• Four randomized trials showed no difference in pain versus open technique in three trials 2

Both techniques achieve: 1, 3

• Success rates of 90-98%
• Recurrence rates of only 2-10%
• Most effective for grade III-IV hemorrhoids

Diathermy Hemorrhoidectomy

• Shows no difference in pain scores compared to scissors hemorrhoidectomy 2
• Oral pain medication requirement was less in diathermy groups 2

Stapled Hemorrhoidopexy

Technique: 2

• Performs circular excision of internal hemorrhoids and prolapsing rectal mucosa proximal to the dentate line
• Recommended for circular hemorrhoids
• Significantly less postoperative pain than conventional hemorrhoidectomy

Important caveat: Should be employed with care and only after thorough training due to risk of rare, severe complications 4

Submucosal Hemorrhoidectomy

• Shows decreased pain and more rapid return to work compared to Milligan-Morgan hemorrhoidectomy 2

Alternative Surgical Approaches

Suturing or Banding Technique: 2

• Involves suturing or banding internal hemorrhoids
• Excises external component
• Emergency hemorrhoidectomy is safe for incarcerated, gangrenous hemorrhoids 2

Techniques to Avoid

Anal Dilatation: 1, 2

• Should NEVER be performed
• 52% incontinence rate at 17-year follow-up
• Causes sphincter injuries
• Higher failure rate than operative hemorrhoidectomy

Cryotherapy: 1

• Rarely used due to prolonged pain
• Foul-smelling discharge
• Greater need for additional therapy

Lateral Internal Sphincterotomy: 2

• Randomized studies have not confirmed usefulness as adjunct to hemorrhoid excision
• May increase incontinence

Postoperative Management

Pain Management: 1, 2

• Narcotic analgesics generally required
• Most patients not returning to work for 2-4 weeks
• Sitz baths recommended for inflammation and discomfort 1

Adjunctive Therapy: 5

• Flavonoids (diosmin-hesperidin) can be used as adjunct to standard postoperative care
• Stool softeners essential 1

Complications

Common complications include: 2

• Urinary retention
• Bleeding (secondary bleeding typically occurs 10-14 days post-procedure) 6
• Anal stenosis
• Infection
• Incontinence
• Sphincter defects documented in up to 12% of patients 2

Rare but serious: 6

• Pelvic sepsis
• Fournier's gangrene
• Massive hemorrhage (especially in patients on anticoagulation)

Critical Pitfalls to Avoid

• Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1
• Do not delay definitive treatment when active bleeding has caused anemia 1
• Avoid simple incision and drainage if external thrombosis is present, as this leads to persistent bleeding and higher recurrence 1
• Ensure proper training before performing stapled hemorrhoidopexy due to risk of severe complications 4