What is the best course of action for treating grade 3 hemorrhoids discovered during a sphincterotomy (surgical procedure to cut the anal sphincter) in a patient already under anesthesia?

Management of Grade 3 Hemorrhoids Discovered During Sphincterotomy

Direct Recommendation

Proceed with concurrent hemorrhoidectomy during the same operative session, as the patient is already under anesthesia and grade 3 hemorrhoids represent a clear surgical indication that would otherwise require a separate procedure. 1

Surgical Approach and Rationale

The optimal approach is to perform conventional excisional hemorrhoidectomy (Milligan-Morgan or Ferguson technique) in addition to the planned sphincterotomy. 2, 1 This combined approach is supported by evidence showing:

• Hemorrhoidectomy is specifically indicated for symptomatic grade 3 hemorrhoids, with success rates of 90-98% and recurrence rates of only 2-10% 1
• Performing both procedures simultaneously avoids subjecting the patient to a second anesthetic and operative intervention 1
• The American Gastroenterological Association recognizes that concomitant anorectal conditions requiring surgery justify combined surgical intervention 1

Critical Technical Considerations

If performing lateral internal sphincterotomy with hemorrhoidectomy, limit the sphincterotomy to "minimal cutting" to reduce incontinence risk. 1 The evidence shows:

• Hemorrhoidectomy alone carries up to 12% risk of sphincter defects documented by ultrasonography and manometry 2
• Adding aggressive sphincterotomy increases incontinence rates rather than reducing them 2
• However, one recent study (2021) demonstrated that adding limited lateral internal sphincterotomy to hemorrhoidectomy significantly reduced postoperative pain at 12,24, and 48 hours, with lower rates of postoperative bleeding and urinary retention 3

The key distinction is performing a limited, controlled sphincterotomy rather than excessive sphincter division. 2, 3

Specific Surgical Technique Selection

Choose between open (Milligan-Morgan) or closed (Ferguson) hemorrhoidectomy based on the following:

• Both techniques show comparable efficacy for grade 3 hemorrhoids 4
• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 2
• Avoid stapled hemorrhoidopexy in this setting, as it does not address external hemorrhoid components and the patient was not consented for this specific technique 2

Techniques to Absolutely Avoid

Never perform anal dilatation as an adjunct to either procedure - this causes sphincter injuries and results in 52% incontinence rate at long-term follow-up 2, 1

Do not use cryotherapy - it causes prolonged pain, foul-smelling discharge, and requires more additional therapy 2, 1

Informed Consent Considerations

While the patient consented to sphincterotomy, the discovery of grade 3 hemorrhoids represents a surgical indication that would require treatment regardless. The ethical framework supports proceeding because:

• Grade 3 hemorrhoids are symptomatic by definition (bleeding and/or prolapse) 1
• Leaving them untreated would necessitate a second surgery 1
• The patient is already under anesthesia, avoiding additional anesthetic risk
• Conventional hemorrhoidectomy is the most effective treatment for grade 3 hemorrhoids 2, 1

Document thoroughly in the operative note that grade 3 hemorrhoids were discovered intraoperatively and that proceeding with treatment was in the patient's best interest to avoid a second procedure. Discuss this with the patient immediately postoperatively when they are alert.

Postoperative Management Expectations

Prepare the patient for significant postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks. 2, 4 Key management includes:

• Narcotic analgesics are generally required 2, 4
• Stool softeners and bulk-forming agents (psyllium husk 5-6 teaspoonfuls with 600 mL water daily) to prevent straining 1
• Sitz baths to reduce inflammation and discomfort 1
• Emphasize high-fiber diet and adequate hydration to prevent constipation, which could compromise healing of both surgical sites 1

Common Complications to Monitor

Be vigilant for urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%). 2 Specific concerns with combined procedures:

• Gas incontinence may be transiently higher with lateral internal sphincterotomy but typically resolves 3
• Long-term outcomes show lower rates of anal stenosis and anal fissure when limited sphincterotomy is added 3
• Sphincter defects occur in up to 12% of patients after hemorrhoidectomy, likely due to excessive retraction and dilation 2

Alternative Conservative Approach (Not Recommended Here)

The only scenario where you should not proceed would be if the hemorrhoids are incidentally noted but truly asymptomatic (no bleeding, no prolapse), which would be unusual for grade 3 hemorrhoids. 1 However, grade 3 hemorrhoids by definition involve prolapse with bowel movements, making them symptomatic and warranting treatment. 1