What are the indications for open versus closed hemorrhoidectomy in adults with symptomatic grade 3 or 4 hemorrhoids who have failed conservative management?

Indications for Open versus Closed Hemorrhoidectomy

Both open (Milligan-Morgan) and closed (Ferguson) hemorrhoidectomy are indicated for the same clinical scenarios—symptomatic grade III-IV hemorrhoids that have failed conservative management—but the closed Ferguson technique should be preferred as it demonstrates superior outcomes with reduced postoperative pain and faster wound healing. 1, 2, 3

Primary Indications for Surgical Hemorrhoidectomy (Either Technique)

Hemorrhoidectomy is indicated when:

• Failure of medical and non-operative therapy after adequate trial (typically 4-8 weeks) 1, 2
• Symptomatic grade III or IV hemorrhoids with persistent bleeding, prolapse, or pain 1, 2, 3
• Mixed internal and external hemorrhoids with extensive symptomatic external component 1, 2
• Hemorrhoidal bleeding causing anemia (hemoglobin drop requiring transfusion consideration) 1
• Irreducible prolapse with tissue compromise or necrosis 2
• Concomitant anorectal conditions requiring surgery (fissure, fistula, skin tags) 1, 4, 5
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids 1

Choosing Between Open and Closed Techniques

The closed Ferguson technique is superior and should be the preferred approach because:

• Primary wound closure results in reduced postoperative pain compared to open technique 2, 3, 6
• Faster wound healing (4-8 weeks for open vs. faster closure with Ferguson) 3, 6
• Comparable efficacy with recurrence rates of only 2-10% for both techniques 1, 7
• One high-quality study of 693 patients demonstrated excellent pain control (VAS 2.47 at day 1.34 at 7 days) and high patient satisfaction with Ferguson technique 7

Open Milligan-Morgan technique may be considered when:

• Surgeon preference or expertise favors this approach 3
• Randomized trials show no consistent difference in postoperative pain in three out of four studies comparing the techniques 3
• However, one trial found increased pain with open versus submucosal hemorrhoidectomy 3

Both Techniques Share the Same Recurrence Rate

• Conventional excisional hemorrhoidectomy (both open and closed) achieves recurrence rates of 2-10%, making it the most definitive treatment for grade III-IV disease 1, 3, 7
• Long-term follow-up demonstrates high patient satisfaction with low recurrence (7 patients at 1 year, 21 patients at 2 years in a cohort of 693) 7

Critical Contraindications and Timing Considerations

Do not perform immediate hemorrhoidectomy when:

• Acute inflammation and edema are present—reduce these first with conservative management to minimize surgical complications 2
• Thrombosed hemorrhoids presenting beyond 72 hours—conservative management is preferred as spontaneous resolution has begun 1, 2
• Immunocompromised patients (AIDS, neutropenia, uncontrolled diabetes) require medical stabilization first due to 5-fold increased risk of necrotizing pelvic sepsis 2
• Pregnancy—defer surgery until postpartum unless tissue necrosis occurs 2

Exception requiring urgent surgery:

• Acutely incarcerated or thrombosed grade IV hemorrhoids with tissue necrosis 2
• Severe pain, high fever, and urinary retention suggesting necrotizing pelvic sepsis 2

Postoperative Expectations

Both techniques require:

• Narcotic analgesics for postoperative pain management 1, 3
• 2-4 weeks before return to work 1, 3
• Complication rates include urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%) 3

Techniques to Absolutely Avoid

• Anal dilatation causes 52% incontinence rate at 17-year follow-up and should be completely abandoned 1, 2, 3
• Simple incision and drainage leads to persistent bleeding and higher recurrence rates 1, 2
• Cryotherapy causes prolonged pain, foul-smelling discharge, and greater need for additional therapy 1, 2

Common Pitfall to Avoid

Never attribute anemia or significant bleeding to hemorrhoids without colonoscopy to rule out proximal colonic pathology, inflammatory bowel disease, or colorectal cancer 1