Seminars in Colon and Rectal Surgery 24 (2013) 86–90

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Seminars in Colon and Rectal Surgery

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Operative management of hemorrhoids

Nitin Mishra, MDa, Jason F. Hall, MD, MPH, FACSb,c,n
a
Division of Colon and Rectal Surgery, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Edison, NJ
b
Department of Colon and Rectal Surgery, Lahey Clinic, 41 Mall Rd, Burlington, MA
c
Tufts University School of Medicine, Boston, MA

abs tr act

Complaints attributable to hemorrhoidal disease are common. The majority of hemorrhoidal presenta-
tions can be managed with non-operative treatments; however, in some circumstances procedural
intervention is required. Surgical hemorrhoidectomy is usually reserved for patients who are refractory
to office procedures or who are unable to tolerate office procedures. This work reviews the most
commonly used techniques for the operative palliation of hemorrhoidal complaints.
& 2013 Elsevier Inc. All rights reserved.

1. Operative management of hemorrhoids 2. Excisional hemorrhoidectomy

Complaints attributable to hemorrhoidal disease are common. Excisional hemorrhoidectomy can be broadly classified as
The majority of hemorrhoidal presentations can be managed with follows:
non-operative treatments; however, in some circumstances pro-
cedural intervention is required. The mainstay of non-operative (1) Closed or Ferguson type.
hemorrhoidal treatment is increase in fiber and water consump- (2) Open or Milligan–Morgan type.
tion. The primary goal of this approach is to decrease straining (3) Circumferential, amputative, or Whitehead type.
with bowel movements and thus reduce the intraabdominal (4) Other modifications e.g. Park’s submucosal reconstructive
pressure transmitted to the hemorrhoidal vessels. Patients with hemorrhoidectomy.
second-degree hemorrhoids can be offered a trial of non-
operative management although a number of them will fail and Either open or closed hemorrhoidectomy can be performed with
require procedural intervention. Office-based techniques for man- a variety of surgical devices including surgical scalpel, scissors,
agement of hemorrhoids will be covered in another article. Third- monopolar cauterization, bipolar energy, and ultrasonic devices.3–5
and fourth-degree hemorrhoids generally require operative In general, there appears to be no definitive advantage of one over
intervention. the other, although the complete anorectal surgeon would be
Surgical hemorrhoidectomy should be reserved for patients advised to gain familiarity with all of the techniques.6,7 As such,
who are refractory to office procedures, who are unable to individual patient factors and preferences need to be carefully
tolerate office procedures, who have large external hemorrhoids, weighed and considered before a decision for operative therapy.
or who have combined internal and external hemorrhoids with
significant prolapse (grades III and IV).1 Patients with concom- 2. 1. Our general approach to all anal cases
itant anorectal pathology requiring operative intervention may
elect for a simultaneous hemorrhoidectomy. Coagulopathic We generally use the same preparation for all of our anorectal
patients requiring definitive control of bleeding are also candi- cases. We find that having a consistent approach allows for easier
dates for operative therapy.2 integration of the operating room staff and easy availability of all
Surgical treatments falls into three categories: excisional the necessary tools.
hemorrhoidectomy, stapled hemorrhoidopexy and Doppler- Preoperative preparation: All our patients self-administer an
guided transanal devascularization.2 enema prior to the surgery. No formal mechanical bowel prepa-
ration or antibiotic prophylaxis is required.
Anesthesia: We favor the use of local anesthesia and sedation.
In our typical routine, the patient is sedated with propofol and/or
n
Corresponding author at: Department of Colon and Rectal Surgery, Lahey
midazolam. Once appropriately sedated a circumferential anal
Clinic, 41 Mall Rd, Burlington, MA canal block is performed with a 1:1 mix of 1% lidocaine and 25%
E-mail address: [email protected] (J.F. Hall). bupivacaine with epinephrine. Sedation with local anesthesia is

1043-1489/$ - see front matter & 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.scrs.2013.02.006
 N. Mishra, J.F. Hall / Seminars in Colon and Rectal Surgery 24 (2013) 86–90 87

safe and can facilitate recovery and discharge.8 Depending on the 2. 3. Open hemorrhoidectomy
discretion of the anesthesiologist, regional or general anesthesia
can be performed as well. Described by Milligan–Morgan. This technique is more prev-
Patient position: As with any surgical procedure, exposure is alent in the UK.1,10
critical. Proper positioning of the patient is the key to good
exposure and a successful outcome. We prefer the prone-jack
knife position with the buttocks retracted laterally with tape for Steps of the procedure
better exposure. Lithotomy or lateral decubitus can also be See ‘‘general approach to all anal cases’’ above.
chosen based on surgeon experience and comfort level. The steps of an open hemorrhoidectomy are essentially the
Preparation and draping: The perianal area is cleaned with same as a closed hemorrhoidectomy except that the surgical
betadine solution. We use four sterile paper towels and a single wound is not sutured close but left open to heal by secondary
impervious sterile or drape is used with a large window fashioned intention. This technique is commonly used by surgeons perform-
for adequate exposure. ing the tissue excision with vessel-sealing energy devices.
Assessment: The entire anal canal is assessed using an appro-
priate size Hill–Ferguson retractor to examine for additional or
unexpected anorectal pathology. We frequently evaluate the 2. 4. Circumferential, amputative, or Whitehead type11
rectum with a rigid or flexible endoscope to exclude alternative
pathologies, if not done preoperatively. See ‘‘general approach to all anal cases’’ above
There have been several modifications of the Whitehead proce-
dure. These modifications were aimed to reduce complications by
2. 2. Closed or Ferguson type making technical alterations to the procedure while maintaining the
core principle of circumferential hemorrhoidectomy. The prominent
Described by Ferguson, this technique is the most common modifications were described by Burchell et al., Barrios, Khubchan-
form of hemorrhoidectomy in the US.1,9 dani, Rand and Buie.12–16 Wolff published a major series of the Buie
modification of the Whitehead technique in 1988.17 The procedure
Steps specific to closed hemorrhoidectomy is not commonly performed because of the potential long-term
Retraction: A hemostat is used to tent up the hemorrhoid at the complications, especially anal ectropion.
anal verge. Care must be taken not to grab excess tissue as this The procedure consists of developing a rectangular or trape-
may incorporate the underlying sphincter complex. zoidal flap in the distal aspect of the anal canal; this is similar to
Transfixation: Using an absorbable 3–0 stitch we transfix the the anal advancement flap. A similar rectangle, or trapezoid,
hemorrhoid bundle at its most proximal end. This stitch is tagged section incorporating the hemorrhoidal tissue is also incised
for future use for the closure of the wound. (Many surgeons prefer cephalad to the flap. This section of hemorrhoidal tissue is
to transfix at the end of dissection.) excised, and the flap is rotated and advanced up into the anal
Incision: The entire hemorrhoid complex is held on traction canal and sutured to the internal sphincter and mucosa above.
with the hemostat and is outlined using a curvilinear incision One can do this in a circumferential fashion with four flaps
from the proximal end (close to the transfixation stitch) to the (anterior, posterior, right, and left) or by leaving a skin bridge
distal skin edge. It is important to have a long smooth incision for anteriorly or posteriorly between hemorrhoidal groups. This
proper closure and to avoid ‘‘dog ears’’. The incision can be made differs slightly from the procedures described by Burchell et al.,
using a knife or electrocautery. and Barrios and Khubchandani, in that the anoderm is advanced
Dissection: It is of utmost importance to dissect the hemor- further into the anal canal up to or just above the location of the
rhoid free from the underlying sphincter muscles. Also, any former dentate line and is sutured in that position (Figure 1).
hemorrhoidal tissue must be removed to avoid recurrence. The
critical element is to stay in the submucosal plane while elevating
the hemorrhoidal tissues off of the internal sphincter. If one is too
deep, sphincter injury can occur. If one is too superficial then
bleeding ensues. An important technique is to ‘‘sweep’’ the
muscle fibers down off the hemorrhoidal tissue. If properly
dissected, one can clearly see healthy sphincter muscle at the
base of the dissection and the entire hemorrhoidal pedicle is
dissected off it. Dissection can be done by electrocautery, scalpel,
scissors, harmonic scalpel, ligasure etc but the basic principle
remains the same. It is easy to damage the suture used to transfix
the hemorrhoid when one is close to the end of the dissection.
Accordingly, an alternative technique places a clamp at the base
of the hemorrhoid to control the vessels and the ligating suture
after complete hemorrhoid excision.
Ligation and amputation: The same stitch used for transfixation is
used to doubly ligate the hemorrhoid pedicle. The pedicle is ampu-
tated close to the stitch. The free end of the stitch is cut long so that it
can be easily identified in case of post-operative hemorrhage.
Closure: The same stitch is used to close the wound. Up to the Fig. 1. Steps in modified Whitehead hemorrhoidectomy. (A) Prolapsed internal
anal verge we use 3-point inter-locking stitches i.e. small bites of hemorrhoid. (B) Raising of anodermal flap and clearing the flap of external
the underlying muscle is taken to obliterate the dead space. On hemorrhoid. (C) Rectangular anodermal flap has been raised and rectangle of
internal hemorrhoidal tissue is removed. (D) Anodermal flap is advanced into the
the skin we use simple running stitch (same suture) and leave a anal canal and anchored to internal sphincter and mucosa reforming the dentate
small defect (about 5 mm) at the apex of the skin closure. line. (E) Complete 4-flap procedure with anodermal edges coapted. (Adapted with
Post op dressing: Dry gauze and mesh panties. permission from Wolff and Culp.17)
88 N. Mishra, J.F. Hall / Seminars in Colon and Rectal Surgery 24 (2013) 86–90

2. 5. Outcomes of excisional hemorrhoidectomy

In a meta-analysis of 18 randomized prospective studies

comparing hemorrhoidectomy with office-based procedures,
hemorrhoidectomy was the most effective treatment for patients
with grade III hemorrhoids. Other authors have demonstrated
that when compared to rubber band ligation excisional hemor-
rhoidectomy is more effective at achieving complete remission of
hemorrhoidal symptoms.18 Excisional hemorrhoidectomy
patients were 80% less likely to require retreatment. Excisional
hemorrhoidectomy was associated with higher rates of anal
stenosis and post-operative hemorrhage. An outcome that may
be useful to discuss with patients during preoperative counseling
was the increased incidence of incontinence to flatus following
excisional hemorrhoidectomy although this result did not reach
statistical significance.18 When excisional hemorrhoidectomy is
compared to stapled hemorrhoidopexy, excisional hemorrhoidec-
tomy has a lower recurrence rate (0 vs. 25%). Patients who
underwent excisional hemorrhoidectomy also experienced higher
pain levels although they reported higher overall satisfaction
levels than patients who underwent stapled hemorrhoidopexy.19
In a recent meta-analysis of 12 studies with 1142 patients, the
use of a bipolar energy device was found to be faster and to provide Fig. 2. Stapled anoplasty (procedure for prolapse and hemorrhoids). (A) Retracting
less post-operative pain in comparison with conventional hemor- anoscope and dilator inserted. (B) Monofilament purse-string suture (8 bites)
rhoidectomy.5 Additional studies particularly addressing increased placed using operating anoscope approximately 3–4 cm above anal verge.
(C) Stapler inserted through purse-string. Purse-string suture tied and ends of
cost during surgery are needed to further define the relative place of
suture manipulated through stapler. (D) Retracting on suture pulls anorectal
each of these modalities for operative intervention.1 mucosa into stapler. (E) Stapler closed and fired. (F) Completed procedure.
The open and closed approaches of excisional hemorrhoidec- (Reprinted from Singer et al2 with kind permission from Springer Science and
tomy were compared in a prospective randomized controlled trial Business Media B.V.)
of patients with grade III and IV disease.20 The study found that
the patients who underwent the closed technique had less pain be certain that it has not been incorporated. The staple is then
along with better wound healing; this finding has also been fired. The stapler head is then opened and stapler removed
confirmed by others.21 (Figure 2).

3. 2. Outcomes of stapled hemorrhoidopexy

3. Stapled hemorrhoidopexy
Although effective for internal prolapsing disease, it may not
Transanal stapled excision was first described in 1997 for adequately address external hemorrhoids. A recent meta-analysis
rectal mucosal prolapse, subsequently it was used for hemorrhoi- comparing stapled hemorrhoidopexy with conventional exci-
dopexy in 1998.22 This technique has been promoted as a less sional hemorrhoidectomy demonstrated a higher long-term
painful alternative to excisional hemorrhoidectomy. It is primar- recurrence rate in patients undergoing stapled hemorrhoido-
ily used for patients who complain of bleeding and/or prolapsing pexy.25 Early cohort and smaller nonrandomized trials reported
internal hemorrhoids who are found to have relatively confluent/ stapled hemorrhoidopexy to be associated with less pain and
circumferential disease on anoscopy. Its use is somewhat limited faster recovery in comparison with conventional hemorrhoidec-
by the fact that it does not address external disease but is more tomy. An early meta-analysis including 1077 patients came to
useful for symptomatic hemorrhoidal bleeding. similar conclusions.26 However, a more recent Cochrane review of
six randomized trials with 628 patients all having follow-up
3. 1. Steps of the procedure greater than 1 year demonstrated no significant differences
between stapled hemorrhoidopexy and conventional hemorrhoi-
See ‘‘general approach to all anal cases’’ above. dectomy in terms of pain, pruritus, and urgency, with higher long-
The procedure is performed by applying counter-traction to term recurrences following the stapled technique.27 Although
the anoderm skin to facilitate insertion of a circular anal dilator. stapled hemorrhoidopexy is associated with several unique com-
The circular anal dilator is sutured to the skin with a heavy stitch plications (i.e. rectovaginal fistula, staple line bleeding, and
at four quadrants to secure it in place. The external hemorrhoidal chronic pain), overall complication rates are similar to conven-
component must be reduced as much as possible. A submucosal tional excisional hemorrhoidectomy. A meta-analysis of almost
purse-string suture is placed 2–4 cm above the dentate line. If the 2000 patients found the complication rates to be 20.2% for stapled
staple line is any closer, the patients are liable to experience more hemorrhoidopexy vs. 25.2% for conventional hemorrhoidectomy
pain.23,24 It is also theoretically possible to cause injury to the (P ¼ 0.06).28 In general, the stapled procedure is not effective for
internal sphincter if full thickness stitches are applied while large external or thrombosed hemorrhoids, although limited data
placing the initial purse-string suture. The fully opened stapler have demonstrated some success.1,29
head is inserted through the purse-string. This is then secured
under direct visualization. The suture ends are then pulled 4. Doppler-guided transanal hemorrhoid devascularization
through lateral stapler channels by using suture threader. The (THD)
stapler is then aligned along the axis of the anal canal, which is
closed while maintaining moderate tension on the purse-string This technique was first described in 1995 by Morinaga et al.
suture. In women, the posterior vaginal wall should be checked to from Japan.30 The central concept of this procedure involves
 N. Mishra, J.F. Hall / Seminars in Colon and Rectal Surgery 24 (2013) 86–90 89

ligation of the feeding vessel of each hemorrhoidal column with- References

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