During a lateral splenectomy, how should intraoperative grade III hemorrhoidal bleeding be managed?

Management of Grade III Hemorrhoids Discovered During Lateral Sphincterotomy

You should proceed with concurrent hemorrhoidectomy during the same operative session, using either the Ferguson (closed) or Milligan-Morgan (open) excisional technique, while limiting your sphincterotomy to minimal cutting to reduce incontinence risk. 1

Rationale for Combined Surgical Intervention

Grade III hemorrhoids with active bleeding represent disease that exceeds the threshold for conservative or office-based management and requires definitive surgical treatment. 1 The American Gastroenterological Association explicitly recognizes that concomitant anorectal conditions requiring surgery justify combined surgical intervention, and conventional excisional hemorrhoidectomy achieves success rates of 90-98% with recurrence rates of only 2-10% for grade III hemorrhoids. 1

Proceeding with sphincterotomy alone while ignoring grade III bleeding hemorrhoids would leave the patient with ongoing bleeding and prolapse requiring a second procedure—this is a critical pitfall to avoid. 1

Surgical Technique Selection

• Ferguson (closed) hemorrhoidectomy involves excising hemorrhoid components and closing wounds primarily, and may offer slightly improved wound healing compared to the open technique with comparable efficacy. 1

• Milligan-Morgan (open) hemorrhoidectomy is equally effective, with no significant difference in outcomes between the two approaches. 1

• Both techniques provide the most definitive treatment with the lowest recurrence rate (2-10%) for this degree of hemorrhoidal disease. 1

Critical Technical Considerations to Minimize Incontinence

Perform a limited, controlled sphincterotomy rather than excessive sphincter division. 1 This is crucial because:

• Hemorrhoidectomy alone carries up to 12% risk of sphincter defects documented by ultrasonography and manometry. 1

• Adding aggressive sphincterotomy increases incontinence rates rather than reducing them. 1

• The combination of both procedures demands meticulous technique to preserve sphincter function. 1

Techniques You Must Absolutely Avoid

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

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

• Avoid stapled hemorrhoidopexy in this setting—it does not address external hemorrhoid components and the patient was not consented for this specific technique. 1

Expected Complications and Monitoring

Be vigilant for these complications after combined procedures: 1

• Urinary retention (2-36%)
• Bleeding (0.03-6%)
• Anal stenosis (0-6%)
• Infection (0.5-5.5%)
• Incontinence (2-12%)
• Sphincter defects occur in up to 12% of patients after hemorrhoidectomy

Postoperative Management

• Narcotic analgesics are generally required for postoperative pain management, with most patients not returning to work for 2-4 weeks following surgery. 1

• Emphasize high-fiber diet and adequate hydration postoperatively to prevent constipation and straining, which could compromise healing of both surgical sites. 1

• Stool softeners, sitz baths, and topical lidocaine provide additional comfort. 1

Alternative Approach (If Reconsidering Surgery)

If the anal fissure indication for sphincterotomy is acute (<8 weeks duration) rather than chronic, you could consider canceling the sphincterotomy and treating both conditions conservatively with: 1

• High-fiber diet (25-30 g daily)
• Topical 0.3% nifedipine with 1.5% lidocaine every 12 hours for two weeks (92% resolution rate for thrombosed hemorrhoids)
• Stool softeners
• Adequate hydration

However, if the fissure is chronic (>8 weeks) and has failed conservative therapy, proceeding with combined surgical treatment as planned is the appropriate definitive approach. 1