Open haemorrhoidectomy revisited: the study of 25 cases

ABSTRACT

Background: Haemorrhoids continue to be the commonest benign anorectal condition

presenting with bleeding and constipation. The presentation may vary depending on the
grade of haemorrhoids. Deciding the best therapeutic option is the biggest challenge faced
by the attending surgeon in an era where newer therapeutic technologies for treatment
continue to evolve. Therefore, revisiting the traditional surgical option of excision and
ligation technique for grossly symptomatic piles was evaluated taking into consideration
the cost of the procedure. Twenty five consecutive patients of symptomatic grade III and
IV haemorrhoids were selected for the study to determine the outcome of the traditional
open method (Milligan Morgan technique).

Methods: Twenty five patients after having been checked for fitness for anaesthesia underwent
the open method of haemorrhoidectomy under spinal anaesthesia. On admission to hospital
a detailed proforma which contained demographic details, and comorbidities was completed.
All 25 patients underwent the same procedure by ligation excision technique. Details of
operative findings including post-operative outcomes were studied prospectively.

Results were evaluated.

Results: Of the 25 patients, one patient developed bleeding in the immediate post-operative
period which required relook surgery and undermining of the oozing stump. Four patients
required catheterisation for urinary retention. A six month follow up did not reveal recurrence
or any sort of discomfort while passing stools.

Conclusions: Open haemorrhoidectomy (Milligan Morgan) continues to be the most optimum

method for treatment of symptomatic piles grade III and IV.

Keywords: Complications, Haemorrhoids, Open, Surgical, Treatment.

INTRODUCTION

Symptomatic haemorrhoids are one of the common conditions which bring a patient to
consult a surgeon. In majority of cases a self-diagnosis is made by the patient and seeks
treatment from quacks or traditional medicine practitioners until the condition becomes
serious and unbearable. Over the counter medications are invariably used for this condition
by patients themselves. Haemorrhoids enlarge as a result of pressures exerted from the
haemorrhoidal arteries, portal veins and systemic veins through an arteriovenous shunt
system at the level of the haemorrhoids.1 This shunt accounts for the bleeding to be
bright red in colour. Common symptoms are pain, bleeding or prolapse usually associated
with constipation. A variety of hypothesis have been postulated for the aetiology of
haemorrhoids.1,2 Based on each hypothesis newer methods of treatment have evolved into
practice. The cure rates of these methods are variable. Few of these methods have
unnecessarily added to the cost of treatment without distinct therapeutic benefit. As a result,
no single method can be considered as the gold standard of treatment.1,3 Deciding the best
therapeutic option is based on the degree of the haemorrhoid. Usually grade III and grade
IV haemorrhoids require surgical intervention. Doppler guided haemorrhoidal artery
ligation, stapler haemorrhoidectomy and the traditional open method of ligation and excision
are the main options available. The cost involved in newer options limits their use in the
developing world. The closed method for haemorrhoidectomy is more painful and has a
chance of anal stenosis. Therefore, revisiting the traditional Milligan Morgan method was
essential to recreate awareness of this safer, efficient and permanent option for the cure of
haemorrhoids.

METHODS

Total 25 patients diagnosed as symptomatic haemorrhoids (grade III and IV) in period
from January 2017 to June 2017 were included in the study.

Inclusion criteria

Symptomatic haemorrhoids either bleeding or prolapsing.

Exclusion criteria
• Pregnant women with symptomatic piles

• Haemorrhoids with suspicion of a growth

• Recurrent haemorrhoids.

On admission to hospital a detailed proforma was completed which contained

demographic details, symptomatology and physical examination findings. Physical
examination including abdomen examination, digital rectal examination and proctoscopy
done in the clinic. Due to non-availability of flexible sigmoidoscopy, this was not performed.
Investigations were carried out to evaluate fitness for the procedure.

All patients underwent open haemorrhoidectomy by Milligan-Morgan technique under

spinal anaesthesia performed by the first author (KV). A simple enema was given in the
morning of the day of surgery. Preoperative antibiotics were given. A combination of
cephalosporin, aminoglycoside and metronidazole were given in the morning. The
procedure was started with the lowest haemorrhoid at 7 o’clock position followed by the one
at 3 o’clock position and finally by the one at 11 o’clock position. A V-shaped incision
was made by the scalpel in the mucocutaneous junction around the base of the haemorrhoid
followed by scissors dissection in the sub mucous space to strip the entire haemorrhoid
from its bed. The dissection was carried cranially up to the pedicle, which was ligated
with strong vicryl (No 1-0) and the distal part excised. Other haemorrhoids were similarly
treated, leaving a skin bridge in-between to avoid stenosis. The wound was left open and
a haemostatic gel foam roll left in the anal canal. Post-operative complications were
evaluated. These included bleeding, retention of urine and pain. Patients were followed up
for 6 months period from the date of the surgery for recurrence of symptoms and anal
stenosis.

RESULTS

Twenty-five patients who underwent haemorrhoidectomy by the open method of ligation and
excision. (Milligan Morgan procedure) were studied. Twenty were male and five were female
patients (Table 1).

Table 1: Sex distribution of patients.

Twenty two patients had grade III haemorrhoids and three had grade IV haemorrhoids
(Table 2).

Table 2: Grade of the haemorrhoid.

Five patients had comorbidities that is a combination of diabetes and hypertension. One
patient who had co morbidities developed persistent oozing or reactionary haemorrhage in
the early postoperative period. This necessitated a relook surgery. The patient underwent
evaluation under general anaesthesia. One of the ligated stumps at 3 o’clock position was
found to be oozing. The oozing stump was under run with a vicryl stitch. The bleed was
controlled. Four patients developed acute urinary retention requiring urinary catheterization
(Table 3).

Table 3: Postoperative complications.

The urinary catheter was removed after for 48hours. The patients who developed complications
of reactionary haemorrhage and acute retention of urine were discharged on the fifth post-
operative day. Otherwise the rest of the patients were discharged on the third postoperative
day after ensuring smooth passage of stools. They were asked to follow up on the seventh
post-operative day for a digital rectal examination to look for narrowing of anal opening.

None of the patients in the study had any evidence of anal narrowing. Thereafter they were
called after 6 weeks, 12 weeks and 24 weeks for digital rectal examination and proctoscopy
to look for narrowing or recurrence. Anal stenosis was not seen in any of the twenty five
patients. All patients were asymptomatic with no recurrence of symptoms. Thus, a six
month follow up did not reveal anal stenosis, recurrence or any sort of discomfort while
passing stools.

DISCUSSION

Haemorrhoids are best defined as “enlargement and distal displacement of the anal cushions.”
The abnormal dilatation and dislocation of the underlying vessels together with damage to
the supporting tissue. The major supporting cushions are at 3 o'clock, left lateral, 7 o'clock,
right posterior, 11 o’clock right anterior position. Chronic straining is the main reason for
pushing these cushions in a downwards direction. Since these cushions contain a lot of blood
vessels, erosion of the overlying mucosa leads to bleeding associated with each act of
defecation. Many a times the bleeding may be chronic or so torrential so as to cause either
anaemia or a shocked state.4 Therefore addressing the bleeding issue is of utmost
importance. In a certain group of patients bleeding may be mild but there may significant
sudden alteration of bowel habits. These are patients in whom one should suspect a malignant
cause. Such patients require detailed investigations either flexible sigmoidoscopy or preferably a
complete colonoscopy. It is a safe procedure to carry out endoscopic evaluation of all
piles patients especially those associated with altered bowel habits with weight loss.4,5
However younger age group patients suffering from chronic constipation for a long time who
eventually develop bleeding and prolapse may not require an endoscopic evaluation.
Therefore, careful evaluation and selection of patients is of utmost importance. The onus
therefore lies on the surgeon to carefully study the symptoms and signs before selecting
the patient for surgery.6

Complications of untreated haemorrhoids include chronic bleeding, prolapse, thrombosis and

sepsis. All these require admission to hospital. Comorbidities need to be identified and
controlled prior to surgery.7

Since there’s a deficit in the supporting mechanisms of the cushions, excising the prolapsing
part constitutes the mainstay of surgical intervention. The excision however should extend to
the base of the pedicle. This will ensure sub mucous fibrosis and better anchorage of the
submucosa to the underlying tissue. Two surgical methods help in addressing the
problem. The newer method involves use of circular stapler specially designed for prolapsed
haemorrhoids. Short term results with stapler haemorrhoidectomy are more gratifying.7-9
However long-term results are not promising as a result of increased incidence of
recurrence and anal stenosis. Since the stapler is an industry driven product developed in the
modern era with aggressive advertisements, patients fall prey and insist on undergoing
this procedure.9,10

The open technique of haemorrhoidectomy addresses both these issues extremely well i.e.
removal of redundant anal cushions followed by fibrosis and anchoring of the mucosa to
the underlying connective tissue. Since the procedure involves only primary haemorrhoids,
the intervening mucosa continues to be intact reducing the chances of stenosis. The main
complication of open method is bleeding.11-13 This can be prevented by adequate infiltration
of mucosa before dissection. One needs to go as high as possible up to the root of the pedicle
before applying trans fixation ligature with a strong absorbable suture material. A
meticulous second look before packing with a gel foam cone is essential to prevent
reactionary haemorrhage in the form of continuous oozing. Non-constipating analgesics,
antibiotics and stool softeners are necessary for first five days after surgery. A sietz bath
twice daily for first five days adds immensely to the comfort of the patient. If all these
protocols are followed meticulously, the likelihood of secondary haemorrhage is significantly
reduced. In the present study only one patient developed bleeding which required relook
surgery which was controlled immediately by under running of the stump. Pain is a
common accompaniment of most anorectal procedures. Infiltration with a local anaesthetic
along with oral analgesia significantly reduces the chances of post op retention of urine.

Catheterization for 24 hours relieves distressful symptoms. Patients should be asked to

follow up on the seventh post-operative day. Digital rectal examination should be
performed to look for any narrowing. There was no evidence of narrowing in any of the
patients in the present study. Patients should then be called after 6 weeks, 12 weeks and
24 weeks for revaluation. In the event of suspected impending anal stenosis detected at
any of the follow up visits, the traditional method of training the patient with the use of St.
Mark’s anal dilator is the best option. Though this method is hardly being adopted by
surgeons in modern day practice, it still holds the promise and avoids the chances of
developing anal stenosis at a later stage.8 In the context of the developing world where cost is
an important determinant of the treatment option, the open method not only addresses the
treatment of the disease but also reduces the healthcare cost of the treatment with a long
lasting cure.

CONCLUSION

In India, where cost is an important determinant in making surgical choices, the open
method is the best as it is not only cheaper but gives excellent long-lasting cure rates.

ACKNOWLEDGEMENTS
Authors would like to thank Dr. Surekha Patil, Dean, D. Y. Patil University, School of
Medicine, Navi Mumbai, India, for allowing them to publish this study and Mr. Parth
Vagholkar for his help in typesetting the manuscript.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee.