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5 Nonsurgical Management ofHemorrhoids
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Hemorrhoidectomy: TheGold
Standard
“The Lord will smite thee with the botch of Egypt, and with the emerods, and with the
scab, and with the itch.”
Moses
6
Key Concepts
• The principle behind hemorrhoidectomy is
ligation and excision.
• Hemorrhoidectomy is deemed the gold standard in the surgical management of
hemorrhoids.
• Grades 3 and 4, thrombosed, strangulated, and
interno-external hemorrhoids are the indications for hemorrhoidectomy.
• Salmon proposed an excision with a high ligation procedure in which the pile mass was
separated at the mucocutaneous junction and
extended beyond the anorectal ring.
• Milligan Morgan is a modication of Miles’
technique. The upper end of excision is limited to the anorectal ring, and the lower end
includes a part of the perianal skin.
6.1 Introduction
The word “ectomy” means surgical removal [1].
Hemorrhoidectomy means the surgical removal
of hemorrhoids. The conventional MilliganMorgan hemorrhoidectomy is globally consid-
ered a “Gold standard” for large, strangulated, or
circumferential hemorrhoids [2, 3]. Different
hemorrhoidectomy techniques have been developed over time. A brief description of the surgical
procedures for hemorrhoids is discussed to
understand the principle behind each technique.
6.2 Historical Background
Hemorrhoids are amongst the oldest diseases
mentioned in the literature. The ancient era substantiates excision and ligation as one of the procedures for hemorrhoids. The modern era symbolizes
a few outstanding surgeons; Salmon was the rst
to introduce anal stretching to treat hemorrhoids
[4, 5]. He next conducted a hemorrhoid tissue
excision procedure, which provided the basis for
open hemorrhoidectomy [4, 5]. His technique was
described by Allingham in 1888 [6]. However, the
major innovation transpired in 1937 with the
Milligan-Morgan hemorrhoidectomy [7]. It is a
widely accepted procedure for treating hemorrhoids. Over the years, colorectal surgeons have
gradually modied the technique to perfection.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
K. Gupta, Lasers in Proctology, https://doi.org/10.1007/978-981-19-5825-0_6
71
72
6 Hemorrhoidectomy: TheGold Standard
6.3 Indications
ofHemorrhoidectomy
• Grade 2 hemorrhoids (failure of medical management/ofce procedures)
• Grade 3 and 4 hemorrhoids
• Thrombosed internal hemorrhoids
• Strangulated hemorrhoids
• Interno-external hemorrhoids
6.4 Principle
ofHemorrhoidectomy
The principle of hemorrhoidectomy is “ligation
and excision.” The pedicle ligation of hemorrhoids stops blood ow from the superior hemorrhoidal artery (SHA) branches to the anal
cushions [8]. Ligation is followed by excision of
the swollen and prolapsed anal cushions, known
as “Hemorrhoids.” Hemorrhoidectomy aims to
preserve skin bridges (anoderm) between excised
hemorrhoids to avoid anal stricture [9].
technique is well mentioned in Allingham’s textbook “The diagnosis and the treatment of the rectum,” published in 1888.
6.6.1.1 Technique
The pile mass was separated by starting the incision at the mucocutaneous junction and continued on either side of the hemorrhoid tissue.
Ligation was done, and the hemorrhoid tissue
was excised about 7.5cm from the anal verge,
proximal to the anorectal ring [6, 10].
6.6.1.2 Pitfalls ofSalmon’s Technique
The disadvantage of this technique was the creation of extensive raw areas leading to brosis
and anal canal stenosis, the incidence being up to
20% [10].
Modication ofSalmon’s Open
Hemorrhoidectomy
Many surgeons modied the technique because
Salmon’s hemorrhoidectomy was associated with
a large granulation area in the anal canal. These
modications included:
6.5 Modications
inHemorrhoidectomy Over
theYears
• Open hemorrhoidectomy (Milligan Morgan)
• Closed hemorrhoidectomy (Ferguson)
• Circumferential hemorrhoidectomy (Whitehead)
• Submucosal hemorrhoidectomy (Park)
• Anal dilatation (Lord)
• Thermal devices for hemorrhoidectomy
• Laser hemorrhoidectomy (CO2 Laser)
• Radiofrequency ablation
6.6 Evolution
ofHemorrhoidectomy
6.6.1 Excision andHigh Ligation
Salmon rst introduced this technique in 1836
for hemorrhoids [10]. The technique was considered the safest and best operation for most cases
of hemorrhoids [6]. Description of Salmon’s
• Miles technique
• Milligan-Morgan’s technique
6.6.2 Miles’ Hemorrhoidectomy
(Excision withLow Ligation)
In 1919, Mile evolved a new technique of hemorrhoidectomy with low ligation up to the anorectal
ring [10]. The principle was the removal of hemorrhoidal tissue and healing by secondary
intention.
In this technique, the upper end of the excision
was extended up to the anorectal ring and not
proximal to the anorectal ring, as in Salmon’s
technique. However, the lower incision was at the
mucocutaneous junction, similar to Salmon’s
technique.
6.6.2.1 Pitfalls oftheMiles’ Technique
In Miles’ technique, the lower level of excision
was also limited to the mucocutaneous junction,
similar to Salmon’s technique, which resulted in
6.6 Evolution ofHemorrhoidectomy
73
the formation of skin tags. The incidence reported
was 34% [10].
6.6.3 Milligan-Morgan’s Hemorrhoidectomy
In 1937, Milligan and Morgan modied Miles’
technique, popularly known as Milligan Morgan’s
hemorrhoidectomy, which is considered the gold
standard [7]. In this technique, the upper end of
the excision was up to the anorectal ring, and the
lower incision included the perianal skin to avoid
postoperative skin tags.
6.6.3.1 Technique
The patient is placed in a lithotomy position
under spinal anesthesia. Artery forceps is applied
on the perianal skin at 3, 7 and 11 o’clock, and
gentle traction is given to visualize the internal
hemorrhoids. The incisions are so marked that
sufcient bridges of intervening anoderm
between the excised hemorrhoidal tissue are preserved. Dissection is started from the largest
hemorrhoid, or if of similar size, then the one on
the left lateral position.
A V-shaped incision starting at the distalmost external component is extended proximally in an elliptical manner. The hemorrhoidal
tissue from the submucosal plane is raised and
separated from the internal sphincter by blunt
and sharp dissection, converging at the pedicle.
The pedicle is securely ligated at the apex of the
hemorrhoidal mass by an absorbable 2-0 polyglactin suture, and nally, the hemorrhoid tissue
is excised [7].
Alternatively, an hourglass or dumbbellshaped incision is taken around the hemorrhoidal mass to ensure that maximal anoderm is
retained and dissection is completed as above.
In this technique of excisional hemorrhoidectomy, after excision and ligation of the pedicle,
the incision is kept open to heal by secondary
intention, which may heal within 4–6 weeks.
All the three hemorrhoids are excised similarly,
ensuring adequate anoderm and mucosal tissue
are retained between the excised hemorrhoids
[7].
6.6.3.2 Pitfalls ofMilligan-Morgan
Hemorrhoidectomy
• Bleeding (Early and delayed)
• Pain
• Mucosal stenosis or anal canal stenosis
• Prolonged healing time [11]
In a study by J Watts etal. on healing after hemorrhoidectomy, the proportion of patients showing
unhealed wounds 6 weeks after hemorrhoidectomy was 4% [10]. The incidence of stenosis and
brosis after the procedure was 1% [10].
6.6.4 Ferguson’s Closed
Hemorrhoidectomy
Ferguson, in 1959, described this technique
[12]. As with Milligan Morgan, the treatment
involves complete excision of the pile mass,
including the perianal skin. The excision is
continued superiorly up to the anorectal ring.
An interrupted fine catgut stitch was used to
close the wound from the anorectal ring to the
perianal skin [12], leaving a small margin for
draining the collection (Fig. 6.1a–c).
Nowadays, instead of catgut, polyglactin 3-0
suture is used.
6.6.4.1 Advantages ofFerguson’s Over
Milligan Morgan
Ferguson’s technique outperforms Milligan
Morgan in postoperative pain, bleeding, wound
healing, and early mobilization. In Milligan
Morgan’s excisional hemorroidectomy, large
wound areas are created, causing pain and
in anal stenosis.
Abdul Razaque Shaikh et al., on comparing
the Milligan-Morgan and Ferguson methods for
hemorrhoidectomy, found that it takes longer to
recover after Milligan Morgan than Ferguson
[14]. Arabman etal. suggested faster wound healing in Ferguson’s [15].
One of the signicant complications of hemorrhoidectomy is postoperative pain caused by
internal sphincter spasms due to trauma, inammation, and sensitive anoderm [16, 17]. A meta-
74
ab
6 Hemorrhoidectomy: TheGold Standard
c
Fig. 6.1 (a–c) Ferguson’s technique. (a) Pedicle ligation
with excision of hemorrhoidal mass. (b) Continuous
suturing of the raw area leaving about 5 mm of open
analysis of randomized controlled studies
concluded that Ferguson’s technique outperforms
open hemorrhoidectomy in postoperative bleeding risk, pain, and wound recovery time [18]. A
wound at the end for drainage purposes. (c) Final wound
as seen at the end of procedure
ring with a circular incision. The whole section of
dilated hemorrhoidal masses and the surrounding
mucosa are excised, and the proximal end is
sutured to the skin below [4].
comparative study of both techniques is mentioned in Table6.1.
6.6.5.1 Pitfalls ofWhitehead
Hemorrhoidectomy
Whitehead’s study, published in 1887, found no
6.6.5 Whitehead Hemorrhoidectomy
incidences of ectropion or stenosis [21].
However, studies reported various complica-
tions after the procedure [22], as mentioned in
In 1882, Walter Whitehead recommended removing the entire pile-bearing mucous membrane
Table6.2. This procedure is almost abandoned
now.
6.6 Evolution ofHemorrhoidectomy
Table 6.1 Comparative study of Milligan Morgan and Ferguson
Journal Postoperative pain Anal stenosis Retention of urine Bleeding Recurrence
Journal of
Medical
Science
Borse [19] Ferguson’s-48% Ferguson’s-0%
Pak J Med
Sci
Shaikh A R
[14]
Nepal Med
Coll J
Pokharel N
[20]
Milligan
Morgan-77%
Milligan
Morgan-lower
Ferguson’smoderate
Milligan
Morgan-7.8
Ferguson’s-4.9
Milligan
Morgan-0%
Milligan Morgan- Milligan
Morgan-11.81%
Ferguson’s-2.91% Ferguson’s-3.88% Ferguson’s- Ferguson’s-0.97%
Milligan
Morgan-3.63%
Milligan
Morgan-3.63%
75
Table 6.2 Complication after Whitehead
hemorrhoidectomy
Stenosis Up to 8.8%
Extreme pain Up to 50%
Anal incontinence 2–12%
Fecal impaction 0.3%
Urinary retention 2–50%
Fistula or abscess formation 1.1%
Postoperative or
intraoperative bleeding
Ectropion or wet anus The exact incidence not
Wound healing
complications
Infection [21, 22] 0.5–5.5%
0.03–6%
mentioned
1–2%
6.6.6 Submucosal
Hemorrhoidectomy (Park’s
Procedure)
Though hemorrhoidectomy was considered the
gold standard for treating hemorrhoids, postoperative pain remained one of the signicant consequences of the surgery. According to Park,
severe anal canal scarring, the endoanal tube
insertion, and the inclusion of the ber of the
internal anal sphincter in the pedicle stitch
caused anal stenosis and postoperative pain
[23]. To reduce such complications, Park devel-
oped submucosal hemorrhoidectomy in 1950
[24].
Because of its complexity and length, considerable blood loss, and danger of incontinence, the
submucosal reconstructive hemorrhoidectomy
procedure [25] has never been popular. The
results are mentioned in Table6.3.
6.6.7 Rise andFall ofLord’s
Procedure
Lord etal. in 1968 suggested anal dilatation [26]
based on the assumption that internal hemorrhoids result from circular constricting bands in
the anal canal or lower rectal wall. These interfere with normal defecation, and subsequently,
the intrarectal pressure rises during the act of
defecation, leading to venous congestion and
hemorrhoid formation.
6.6.7.1 Principle
The procedure is based on the etiopathogenesis
theory that hemorrhoids occur due to increased
anal tone.
6.6.7.2 Indications
• Second-degree hemorrhoids
• Anal ssure
6.6.7.3 Technique
Under general anesthesia, the constricting bands
are broken down by vigorously stretching the
anal canal and lower rectum by inserting four ngers of both hands into the lumen and dilating in
all directions [26]. The dilatation achieved during
surgery is preserved using bulk-forming laxatives
and an anal dilator of 4cm diameter.
However, this procedure fell to disgrace due to
a high incontinence rate (52%) [27].
76
Table 6.3 Results of submucosal hemorrhoidectomy
Journal Recurrence Anal skin tag Anal stenosis Gas incontinence
Epub
Rosa G [25]
Surgical treatment of hemorrhoids
Milito etal. [23]
Table 6.4 Comparative study of bipolar diathermy with ultrasonic scalpel
Bipolar diathermy
Type of device VAS score on postoperative rst day Urinary retention Wound edema Reactive hemorrhage
Bipolar
diathermy
Ultrasonic
scalpel
1.6% 1.6% 1% 0.8%
7% 6.5% 1.6% 3.2%
2 [28] 6.7% 16.7% No
3 [28] 16.7% 20.0% One patient
6 Hemorrhoidectomy: TheGold Standard
6.7 Thermal Devices
inHemorrhoidectomy
The most common complication of hemorrhoidectomy is postoperative pain. Surgeons
have been looking for a procedure associated
with minimal pain and less morbidity for a
while. Replacement of scissors and the introduction of thermal coagulating devices for
hemorrhoidectomy are advancements in this
eld. Various thermal coagulating devices like
bipolar diathermy, ligasure, and harmonic scalpel are used.
6.7.1 Bipolar Diathermy
inHemorrhoidectomy
The diathermy forceps get energy from a bipolar
electrothermal device [28]. There is localized
coagulation with minor heat spread, causing less
postoperative pain [28].
6.7.1.1 Indication
• Second- to fourth-degree hemorrhoids
6.7.1.2 Technique
With bipolar diathermy, the anal cushions are
excised without ligature of the vascular pedicles
[28]. A V-shaped incision is made in the skin
along the hemorrhoid base up to the pedicle, followed by excision.
6.7.1.3 Results
A comparative study of bipolar and ultrasonic
scalpels [28] concluded that bipolar diathermy
hemorrhoidectomy is quick, bloodless, and less
painful than ultrasonic scalpels (Table6.4).
6.7.2 Ligasure
inHemorrhoidectomy
Ligasure is an advanced variant of bipolar diathermy [29], an electrosurgical instrument. It is
represented as a “vessel sealing system” because
of its high efciency in achieving hemostasis.
The energy is provided primarily to the tissue
gripped inside the handpiece’s jaws, with negligible thermal or electrical energy spreading to
surrounding tissues [29]. The vascularized tissue
gripped between the jaws is decreased into a thin
wafer seal. A computer-controlled feedback loop
immediately terminates the energy ow [29]. The
arteries and tissues are coagulated with minimum
charring compared to standard diathermy [25].
6.7.2.1 Indications
Second- to fourth-degree hemorrhoids
6.7.2.2 Technique
With a scalpel, a V-shaped incision is made
between the hemorrhoid junction and the perianal skin, followed by the hemorrhoidal bundles’
dissection from the underlying sphincter muscle
6.9 Radiofrequency Ablation
77
[30]. The ligasure is placed on the dissected hemorrhoids and activated to seal the mucosal surface
and division of the pedicle [30].
6.7.2.3 Results
A comparative study between Ligasure and other
electrosurgical devices reported fewer parenteral
analgesic injections and a lower pain score after
hemorrhoidectomy [31].
6.7.3 Harmonic Scalpel
inHemorrhoidectomy
Harmonic scalpel, rst presented in 1992, utilizes
ultrasound radiation to coagulate and cut soft tissue while causing minimum heat damage to the
adjacent tissue [32].
Since heat damage to the adjacent tissue is
minimal, using a harmonic scalpel causes less
postoperative pain. The harmonic scalpel seals
bleeding from the vessels during surgery by protein denaturation [33].
Advantages ofThermal Devices
Using thermal devices in hemorrhoidectomy
reduces pain and bleeding.
Results
S.Y. Kwok etal. observed a lower postoperative
pain score in their research in the ligasure group
compared to the harmonic scalpel [34].
A comparison study of a harmonic scalpel and
ligasure hemorrhoidectomy undertaken by Kee
Thai Kiu etal. showed no difference in postoperative pain [35].
heat is transmitted into nearby tissues, allowing
the precise cutting of hemorrhoids [36].
6.8.2 Technique
Under spinal anesthesia, the patient is placed in
the lithotomy position. The hemorrhoid is
grasped by tissue forceps, 2–3 mm from the
mucocutaneous junction, and pulled downwards
to bring the internal hemorrhoids into prominence outside the anal verge. A hemostat is used
on a hemorrhoid pedicle. With CO2 laser radiation, a V-shaped incision is made in the skin and
extended into the mucosa, covering hemorrhoids.
The laser beam is aimed perpendicularly and
directly at the hemorrhoid surface. The laser
handpiece is held around 2–3cm away from tissues to ensure optimum visibility.
6.8.3 Advantages
• Hemostasis
• Tissue vaporization
• Bactericidal
• Preventing thermal lesions to neighboring
tissue
• Decreased postoperative pain [37]
A carbon dioxide laser is reported to have a
precise cutting property, but the coagulation ability is relatively low. The diode laser provides far
less postsurgical discomfort with reduced pain.
6.8 Carbon Dioxide Laser Hemorrhoidectomy
Hemorrhoids may be vaporized or excised with
the use of a CO2 laser. It seals tiny blood vessels,
resulting in a bloodless eld and minimum postoperative pain [36, 37].
6.8.1 Principle
Water on the soft tissue surface absorbs the CO2
laser energy, resulting in tissue vaporization. The
6.9 Radiofrequency Ablation
6.9.1 Principle
Radiofrequency ablation obliterates vascular
channels and shrinks the anorectal cushions [38].
6.9.2 Technique
A radiofrequency device and a probe are used to
deliver radiation (RFA) at a frequency of 4MHz to
the hemorrhoidal tissue. The probe tip is introduced at 5 to 10mm depth into the hemorrhoid
78
6 Hemorrhoidectomy: TheGold Standard
tissue and at an angle of 30° to the tissue surface.
The submucosal layer is slanted away from the
hemorrhoidal tissue. RFA is given to the surrounding hemorrhoidal tissue until a whitish discoloration appears, after which the energy is directed to
the internal tissue surface to enhance tissue desiccation [38, 39]. An individual hemorrhoidal tissue
may receive a maximum of 3000MHz at 25W
power. A saline-soaked swab is administered to
the hemorrhoidal tissue immediately. The radiofrequency probe is used to induce coagulation in
the incidence of any bleeding [38, 39].
6.9.3 Advantages
ofRadiofrequency Ablation
• Less pain
• Low recurrence
6.10 Complications ofExcisional
Hemorrhoidectomy
The commonest postoperative complications are
• Bleeding (0.03–6%)
• Pain (20–40%) [40]
• Sepsis (0.5–5.5%)
• Acute urinary retention (2–36%)
• Anal stricture (0–6%)
• Wound breakdown
• Fecal incontinence (2–12%)
• Skin tags
• Anal ssures
6.11 Management ofCommonest
Complications After
Hemorrhoidectomy
The bleeding after hemorrhoidectomy can be
immediate or delayed. Immediate bleeding is
reported within 24 to 48h following surgery and
is most likely caused from the vascular pedicle
[41]. Delayed bleeding is described as bleeding
that occurs more than 2 weeks after surgery and
is usually caused by local trauma or infection
[42].
Management
Immediate bleeding is attributed to improper
ligation of the pedicle. Cauterization or suture
ligation to maintain pressure is usually adequate.
Stopping the bleeding with a local anesthetic and
epinephrine injection is also possible. Typically,
a piece of vaseline gauze or a nger is used as a
tamponade. Since the patient’s sphincter tone
often acts as a tamponade, postoperative bleeding
from the arteries in the anal canal is episodic
[41]. Tamponade may be performed by inating a
Foley catheter with 30 to 40mL water in the anal
canal. Direct visualization of the operative site
with suture ligation is the most effective treatment. Sometimes, it is not easy to ligate the pedicle due to edema. A transanal suture with
interlocking taking both mucosa and submucosa
can immediately stop the bleeding. The interlocking helps to prevent the purse-string effect.
The sutures should be taken both above and
below the bleeding pedicle.
There is an incidence of delayed postoperative
bleeding in 0.9% to 10% of cases [42]. The most
common causes of delayed bleeding are infection
in the pedicle or suture erosion which requires
proper management with antibiotics and hemostatics. NSAIDs (nonsteroid anti-inammatory
drugs) are commonly used in postoperative pain
management that may increase the incidence of
bleeding.
6.11.1 Bleeding
One of the consequences of hemorrhoidectomy is
bleeding. Clinically signicant bleeding of 0.3 to
6% has been observed for conventional hemorrhoidectomy and up to 2% with the thermal
device [41].
6.11.2 Postoperative Pain
Another consequence of the hemorrhoidectomy procedure is pain. Earlier lateral internal
sphincterotomy or anal dilatation was performed along with hemorrhoidectomy to
reduce postoperative pain but was later recom-