Amount of Tissue Removed in Single-Column Hemorrhoidectomy
In a single-column hemorrhoidectomy, the surgeon excises one hemorrhoidal complex (typically 2–4 cm in length and 1–2 cm in width at the base), removing the redundant mucosa, submucosa, hemorrhoidal plexus, and associated vascular pedicles while preserving intervening anoderm and mucosa bridges to prevent anal stenosis.
Anatomical Extent of Tissue Excision
A single hemorrhoidal column extends from approximately 2 cm above the dentate line proximally to the anal verge distally, encompassing the internal hemorrhoidal plexus and any associated external component. 1
The excised specimen includes mucosa, submucosa, the hemorrhoidal vascular plexus, and the terminal branches of the superior rectal artery that supply that specific column. 1
The width of excision at the base typically measures 1–2 cm, narrowing to an apex proximally where the vascular pedicle is ligated. 1
Muscle fibers from the internal anal sphincter are frequently present in hemorrhoidectomy specimens (this is a normal anatomical finding, not a complication), reflecting the intimate relationship between hemorrhoidal tissue and the underlying sphincter. 2
Critical Technical Principles to Prevent Complications
Adequate mucosal bridges (at least 1 cm of intact mucosa) must be preserved between excised columns to prevent circumferential scarring and subsequent anal stenosis, which occurs in 0–6% of cases when this principle is violated. 1, 2
The excision must be performed at least 2 cm proximal to the dentate line to avoid injury to the somatic sensory nerve fibers below the anal transition zone, which would cause severe postoperative pain. 1
Excessive tissue retraction or anal dilation during the procedure increases the risk of sphincter defects (documented in up to 12% of patients when these maneuvers are performed), so gentle tissue handling is mandatory. 1
Comparison with Multi-Column Excision
Traditional three-column hemorrhoidectomy removes three separate hemorrhoidal complexes (right anterior, right posterior, and left lateral positions), resulting in significantly more tissue removal and longer operative time. 3
Limited (one- or two-column) hemorrhoidectomy achieves 96% initial symptom relief with only 2.9% of patients requiring additional interventional therapy at 8-year follow-up, demonstrating that focused excision of symptomatic columns is sufficient in most cases. 3
There is no significant difference in recurrence rates between limited hemorrhoidectomy (34% recurrent symptoms) and three-column excision (29% recurrent symptoms), and fewer than 2% of limited-hemorrhoidectomy patients require further procedural intervention. 3
Specimen Characteristics and Histology
The excised tissue typically weighs 5–15 grams per column (though this varies with hemorrhoid grade and size) and consists of vascular tissue, connective tissue, and overlying mucosa. 2
Histological examination routinely demonstrates dilated vascular channels, fibrosis, and smooth muscle fibers; the presence of internal sphincter muscle fibers in the specimen is a normal anatomical finding and does not indicate surgical error. 2
Tailoring Excision to Hemorrhoid Grade and Anatomy
For grade III hemorrhoids with a dominant symptomatic column, single-column excision addresses the primary pathology while minimizing postoperative morbidity compared with routine three-column excision. 3, 4
When hemorrhoids are circumferential or involve multiple symptomatic columns, single-column excision is insufficient; the surgeon must excise all symptomatic columns while maintaining mucosal bridges. 4
Stapled hemorrhoidopexy removes a circumferential strip of mucosa 3–4 cm above the dentate line (approximately 2–3 cm in height and the full circumference of the anal canal), representing a fundamentally different tissue-removal pattern than column-specific excision. 5, 6
Common Pitfalls in Tissue Excision
Removing insufficient tissue (failing to ligate the vascular pedicle high enough) leads to persistent bleeding and early recurrence. 1
Excising too much tissue or creating inadequate mucosal bridges results in anal stenosis (0–6% incidence), which may require subsequent anoplasty. 1, 2
Extending the excision below the dentate line into the anoderm causes severe postoperative pain because somatic sensory nerves are present in this region. 1