In an adult undergoing internal hemorrhoidectomy who has mild urgency, occasional fecal leakage, and altered rectal sensation, how important is the amount of hemorrhoidal tissue removed for overall patient well‑being?

The Amount of Hemorrhoidal Tissue Removed Is Critical to Patient Well-Being

In patients with mild urgency, occasional fecal leakage, and altered rectal sensation after internal hemorrhoidectomy, the extent of tissue excision directly determines functional outcomes—excessive removal causes sphincter injury and incontinence, while inadequate removal leads to recurrence.

Understanding the Functional Role of Hemorrhoidal Tissue

Hemorrhoidal cushions are not merely pathologic structures but serve essential physiologic functions:

• The cushions contribute approximately 15–20% of resting anal pressure and act as a conformable plug to ensure complete anal canal closure 1
• They consist of connective tissue, arteriovenous communications, and subepithelial smooth muscle that suspends the vascular plexus 1
• Removal of these structures permanently eliminates their contribution to continence mechanisms 1

The Direct Link Between Tissue Removal and Incontinence

Sphincter defects occur in up to 12% of patients after hemorrhoidectomy, documented by ultrasonography and manometry, with the extent of tissue excision being the primary determinant 1, 2:

• Excessive retraction and dilation of the anal canal during surgery is the mechanism responsible for sphincter injury and subsequent incontinence 1, 2
• Incontinence rates range from 2–12% after conventional hemorrhoidectomy, directly correlating with the amount of tissue manipulation 1, 2
• Smooth muscle fibers from the internal anal sphincter are detected in hemorrhoidectomy specimens when excessive tissue is removed 1

Stapled Hemorrhoidopexy: A Cautionary Example

The stapled technique illustrates the importance of precise tissue removal:

• Internal sphincter fragmentation occurs in 14% of patients when using standard 37-mm anal dilators 1, 3
• Life-threatening complications (rectal perforation, retroperitoneal sepsis, pelvic sepsis) arise when full-thickness rectal wall is excised rather than mucosa and submucosa only 1, 3
• One randomized trial was suspended when 5 of 22 patients developed persistent pain and fecal urgency lasting up to 15 months 1

Balancing Efficacy Against Functional Preservation

Recurrence Rates by Technique

The amount of tissue removed inversely correlates with recurrence but directly correlates with complications:

• Conventional excisional hemorrhoidectomy achieves the lowest recurrence (2–10%) but requires the most tissue removal and carries the highest complication risk 1, 4
• Rubber band ligation preserves tissue and sphincter function with 70.5–89% success rates, but 20% require repeat procedures 1, 5, 4
• Stapled hemorrhoidopexy removes less tissue and shows comparable recurrence rates to conventional surgery, but long-term efficacy data are lacking 1, 3

Your Patient's Symptoms Are Predictable Consequences

The triad of mild urgency, occasional fecal leakage, and altered rectal sensation reflects:

• Loss of the hemorrhoidal cushions' contribution to anal closure, eliminating 15–20% of resting pressure 1
• Possible sphincter injury from excessive retraction during surgery 1, 2
• Altered sensory feedback from removal of the highly innervated anal transition zone tissue 1

Critical Surgical Principles to Minimize Functional Impairment

Avoid excessive tissue excision and anal canal manipulation 1, 2:

• Limit sphincter dilation and retraction to the minimum necessary for visualization 1, 2
• Never perform lateral internal sphincterotomy as an adjunct—it increases incontinence rates rather than reducing them 1, 2
• Abandon anal dilatation entirely, as it causes sphincter injuries and results in 52% incontinence at 17-year follow-up 1

For stapled procedures, verify intraoperatively that only mucosa and submucosa are excised 1, 3:

• Direct inspection of the staple line is mandatory to prevent full-thickness injury 2, 3
• Use the smallest effective anal dilator to reduce sphincter fragmentation 1, 3

The Irreversible Nature of Tissue Loss

Unlike other surgical complications, the functional consequences of excessive hemorrhoidal tissue removal are permanent:

• The hemorrhoidal cushions cannot regenerate once excised 1
• Sphincter defects documented after hemorrhoidectomy persist on long-term follow-up 1, 2
• Resting anal pressure normalizes after hemorrhoidectomy only when sphincter integrity is preserved 1

Common Pitfalls in Surgical Planning

Do not assume all grade III–IV hemorrhoids require complete excision 1:

• Rubber band ligation achieves 70.5–89% success for selected grade III hemorrhoids with preserved sphincter function 1, 5
• Hemorrhoidal artery ligation may preserve tissue while addressing symptoms in grade II–III disease 6

Recognize that postoperative incontinence is multifactorial 7:

• Prior obstetric injury, perianal infection, or Crohn's disease increase vulnerability to sphincter injury 7
• An isolated single injury is normally not sufficient to cause incontinence—comorbidities amplify the impact of tissue loss 7

Implications for Your Patient

The symptoms described—mild urgency, occasional fecal leakage, and altered sensation—suggest:

• Moderate tissue removal that eliminated the cushions' contribution to continence without causing complete sphincter disruption 1
• Potential for improvement with conservative management (fiber, pelvic floor exercises) since symptoms are mild 1, 4
• Low likelihood of surgical correction, as the tissue loss is permanent and revision surgery carries additional risks 1