Surgical treatment for hemorrhoids - Hemorrhoidectomy

Hemorrhoidectomy

Open hemorrhoidectomy for surgical treatment of hemorrhoids

The Milligan-Morgan technique (open hemorrhoidectomy) is very common in Europe, but it’s also the most popular surgical method for treatment of hemorrhoids around the world. It was developed in the early 19th century.

The procedure in short: Prior to surgery you need to evacuate your bowels. The operation itself is performed under anesthesia. The type of anesthesia is up to the patient and his surgeon – it could be local, general or regional block. In any case, the anal canal should also be injected with lidocaine or another numbing agent.

The patient is put in lithotomy position and after that, the surgeon will inspect the anal canal. The internal hemorrhoids are grasped with forceps and then retracted outwards producing something that resembles a triangle. The operation involves excision of the hemorrhoidal tissue. The hemorrhoidal mass is excised from the underlying sphincter muscle, which shouldn’t be damaged in any way. The dissection is carried proximally as far as the pedicles. The wounds are then left open and light dressing might be applied. The surgeon will usually excise up to three columns.

The open hemorrhoidectomy is a radical, but very effective operation for the treatment of complicated internal hemorrhoids. Since it’s not a new method, there have been numerous studies to confirm its effectiveness in the short and long-term. The recurrence rate is below 5% if the operation is done correctly. Moreover, recurrence is impossible at the same place, where the hemorrhoidal tissue has been excised. However, the open hemorrhoidectomy has its shortcomings. The most concerning complications are the severe postoperative pain, urinary retention, postoperative bleeding and fecal impaction. Delayed complications, such as hemorrhage, internal infection and anal stenosis are rare, but shouldn’t be underestimated.

Hemorrhoidectomy recovery

For a smoother postoperative course, physicians will prescribe analgesics and might inject an anesthetic agent into the internal sphincter. You might have to take analgesics continuously if it’s indicated by the physician. You should stick to a high-fiber diet and drink plenty of fluids. Supplements, such as psyllium, can be useful in moderate amounts. You should be careful to avoid constipation and diarrhea during the recovery. The first bowel movement after the surgery could be a very painful experience. It’s best to delay it (if possible) for the second or even the third day after surgery. It’s advisable to take a hot bath or even have the bowel movement in hot water. The postoperative recovery might seem like a long journey. The available data shows that in most cases it will take about 20-30 days, before the pain symptoms subsides. The pain is usally is very pronounced during the first week and starts to wear off after that. Complete recovery usually takes 30 to 60 days.

Pain after hemorrhoidectomy can be very intense. The image compares VAS of Pain after Open hemorrhoidectomy and DG-HAL/RAR.
Pain after hemorrhoidectomy can be very intense. The image compares the VAS of pain after Open hemorrhoidectomy and DG-HAL/RAR.

Closed hemorrhoidectomy for surgical treatment of hemorrhoids

This technique is more popular in the US. It was first described by Ferguson in the 50s. The preoperative procedures are the same as for the open hemorrhoidectomy. The operation itself is performed under anesthesia. The patient is put in the jack-knife position. The surgeon will inspect the anal canal and the make an elliptical (or hourglass-shaped) excision which stretches up to the anorectal ring. The technique utilizes full excision of the mucosa and submucosa, without hurting the internal sphincter. The surgeon will remove the hemorrhoidal tissue and then make a three-point stitch at the apex of the wound to close it. Dressing could be applied to the wounds.

The closed hemorrhoidectomy is a radical, but very effective operation for treatment of complicated internal hemorrhoids. Numerous studies there have compared the open and closed hemorrhoidectomy techniques.  Some authors suggest that complete wound healing is achieved faster in closed hemorrhoidectomy. However, most studies show similar results in postoperative pain, the length of hospital stay and the degree of complications.  The recurrence rate after closed hemorrhoidectomy is below 5%. Moreover, recurrence is impossible at the same place, where the hemorrhoidal tissue has been excised. The most concerning complications are severe postoperative pain, urinary retention, postoperative bleeding and fecal impaction. The postoperative course doesn’t differ from the one for open hemorrhoidectomy.

Circumferential hemorrhoidectomy for surgical treatment of hemorrhoids

The Whitehead technique has been described in the 19th century. It was popular in the UK but has fallen out of favor in the recent decades. It’s regarded to be a very complex and difficult operation to perform, especially for inexperienced surgeons. There have been reports that it can lead to a loss of sensation, anal stenosis and mucosal ectropion (Whitehead’s deformity). The operation is best suited for treatment of big circumferential internal hemorrhoids. The Whitehead hemorrhoidectomy is performed under anesthesia. The surgeon will make a circumferential excision of the hemorrhoids and the redundant mucosa above the linea dentata. The excision is complete, which is why it could lead to anal stenosis and incontinence. However, the circumferential hemorrhoidectomy has its strengths in some specific cases, where the Milligan-Morgan hemorrhoidectomy can’t be performed. Studies show that the operation is very effective if done by an experienced surgeon. The postoperative course doesn’t differ from the one for open hemorrhoidectomy.

Alternative operative techniques for treatment of hemorrhoids

Laser hemorrhoidectomy

Due to the problematic postoperative pain, researchers have been investigating several alternative methods of hemorrhoidal excision. Lasers have been utilized with success in patients suffering from rectal carcinomas and the public demand led to the rise of laser hemorrhoidectomy. Many patients mistakenly believe that laser treatment is “modern”, therefore painless. Laser hemorrhoidectomy has been performed for several years, but the limited data from clinical studies is not very promising. Several trials have shown that the laser method doesn’t really offer any benefits in terms of pain management or wound healing. Laser treatment usually utilizes CO2 or Nd:YAG laser. These lasers are relatively expensive and they require additional training from the surgeon to operate.

Other procedures

Ligasure instrument for hemorrhoidectomy by Covidien
Ligasure instrument for hemorrhoidectomy by Covidien. Image is courtesy to Covidien.

Some other modern devices have been examined for the purposes of hemorrhoidectomy. Namely – the LigaSure™  bipolar energy device and the Harmonic® Ultrasonic scalpel. Some surgeons even talk about Ligasure™ hemorrhoidectomy or Harmonic® hemorrhoidectomy. The idea behind these devices is that they offer better control and therefore less thermal injury is caused to the tissue. Nevertheless, clinical trials suggest that there isn’t much difference compared to the classic excisional hemorrhoidectomy in terms of postoperative pain or wound healing. These advanced devices could speed up the operative time, but on the other hand, they will make the operation more costly.

 

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