How critical is preserving the normal anal cushions during internal hemorrhoidectomy for grade III–IV hemorrhoids to maintain long‑term continence, especially in older patients or those with baseline sphincter weakness?

Preserving Hemorrhoid Tissue Is Critical for Long-Term Continence

Anal cushions are normal anatomical structures that contribute 15–20% of resting anal continence, and their preservation during hemorrhoidectomy is essential—particularly in patients with baseline sphincter weakness—because excisional surgery causes sphincter defects in up to 12% of cases and worsens continence in patients who already have compromised function. 1, 2

Anatomical Foundation: Why Hemorrhoid Tissue Matters

• Anal cushions are normal vascular structures composed of connective tissue surrounding arteriovenous communications, suspended by smooth muscle arising from the conjoined longitudinal muscle layer 3
• These cushions directly contribute 15–20% of baseline resting anal pressure, making them functional components of the continence mechanism rather than pathological tissue 3
• Symptomatic hemorrhoids develop when these normal cushions become abnormally enlarged and their suspensory muscles stretch, leading to prolapse—the pathology is displacement, not the existence of the tissue itself 3

Evidence of Continence Deterioration After Excisional Surgery

The 2012 prospective study of 76 patients undergoing Milligan-Morgan hemorrhoidectomy provides the strongest direct evidence:

• Patients with preoperatively compromised continence (liquid retention <900 mL) experienced significant worsening of both objective continence testing (858 mL pre-op vs 574 mL post-op, P=0.011) and Wexner scores (2.71 vs 3.58, P=0.003) 2
• In contrast, patients with normal baseline continence showed no deterioration, suggesting that tissue preservation is most critical when sphincter function is already marginal 2
• The study concluded that Milligan-Morgan hemorrhoidectomy should be avoided in patients with preoperative compromised continence 2

Mechanism of Continence Impairment

• Excessive retraction and dilation during hemorrhoidectomy causes sphincter injury, with ultrasonography and manometry documenting sphincter defects in up to 12% of patients 1
• Incontinence rates after hemorrhoidectomy range from 2–12%, with the variation largely attributable to surgical technique and extent of tissue removal 1
• Anal dilatation as an adjunct procedure results in a 52% incontinence rate at 17-year follow-up and should never be performed 1, 4

Modern Surgical Philosophy: Fixation Over Excision

Contemporary understanding has shifted toward symptom control rather than radical tissue removal:

• The theory of a sliding anal canal lining and recognition that hemorrhoidal cushions are normal anatomy should guide treatment toward repositioning rather than excision 5
• Techniques that fix cushions back in position (rubber band ligation, stapled hemorrhoidopexy) can be performed with reasonable success rates while preserving tissue 5
• When surgery is required, it should be aimed at symptomatic hemorrhoids only, not prophylactic removal of all cushion tissue 5

Tissue-Sparing Alternatives for High-Risk Patients

For older patients or those with baseline sphincter weakness, prioritize:

• Rubber band ligation for grade I–III hemorrhoids achieves 70.5–89% success rates without tissue excision 4, 6
• Stapled hemorrhoidopexy removes redundant mucosa above the anal canal while preserving the hemorrhoidal tissue itself, with comparable continence outcomes to conventional hemorrhoidectomy 1
• The anal cushion lifting (ACL) method dissects and repositions cushions without excision, reporting zero cases of anal stenosis or persistent pain in 127 patients 7

Critical Pitfalls in Older or High-Risk Patients

• Never perform excisional hemorrhoidectomy in patients with preexisting fecal leakage or incontinence—this is a relative contraindication because additional sphincter manipulation will worsen symptoms 4, 2
• Avoid aggressive dilation or retraction during any anorectal procedure, as this is the primary mechanism of iatrogenic sphincter injury 1
• Do not assume all hemorrhoid tissue is pathological—the goal is to address symptomatic prolapse and bleeding, not to remove normal anatomical structures 3, 5

When Excisional Surgery Is Unavoidable

If hemorrhoidectomy must be performed in at-risk patients:

• Use minimal tissue excision targeting only the most symptomatic columns 5
• Employ closed (Ferguson) technique rather than open (Milligan-Morgan), as it may offer slightly improved outcomes 4
• Perform limited, controlled sphincterotomy if concurrent fissure exists, avoiding excessive sphincter division 4
• Recognize that narcotic analgesics will be required for 2–4 weeks and most patients cannot return to work during this period 1, 4

The evidence strongly supports that hemorrhoidal cushions are functional tissue contributing to continence, and their preservation—especially in older patients or those with baseline sphincter weakness—should be prioritized through tissue-sparing techniques whenever possible. 3, 2, 5