Surgical Management of Hemorrhoids

Introduction to Hemorrhoidectomy Techniques

The American Gastroenterological Association recommends surgical hemorrhoidectomy for treating third- and fourth-degree hemorrhoids, with both open and closed techniques showing comparable efficacy 1, 2, 3
The American Society of Colon and Rectal Surgeons suggests that open hemorrhoidectomy involves excising the internal and external components of each hemorrhoid while leaving the skin open in a 3-leaf clover pattern, with wounds healing secondarily over 4-8 weeks 1, 2, 3
Randomized trials show no consistent difference in postoperative pain compared to closed techniques, though one trial found increased pain versus submucosal hemorrhoidectomy 1, 3

The European Society of Coloproctology states that closed hemorrhoidectomy involves excising each hemorrhoid component and closing the wounds primarily, with four randomized trials comparing open versus closed techniques showing no difference in postoperative pain in three trials 1, 3
Diathermy hemorrhoidectomy shows no difference in pain scores compared to scissors hemorrhoidectomy, but oral pain medication requirement was less in the diathermy groups 1, 3

The American Society of Colon and Rectal Surgeons recommends stapled hemorrhoidopexy for circular hemorrhoids, which performs a circular excision of internal hemorrhoids and prolapsing rectal mucosa proximal to the dentate line, with significantly less postoperative pain than conventional hemorrhoidectomy 2, 3, 4
Submucosal hemorrhoidectomy shows decreased pain and more rapid return to work following submucosal versus Milligan-Morgan hemorrhoidectomy 1, 3

The American Gastroenterological Association advises against anal dilatation due to impaired continence and sphincter injuries, with a higher failure rate than operative hemorrhoidectomy in prospective randomized trials 1, 2, 3, 4
Lateral internal sphincterotomy has been suggested as an adjunct to hemorrhoid excision but randomized studies have not confirmed its usefulness and may increase incontinence 1

Suturing or banding technique involves suturing or banding the internal hemorrhoids and excising the external component, with emergency hemorrhoidectomy being a safe option for incarcerated, gangrenous hemorrhoids 1, 2, 3

Postoperative pain management is crucial, with narcotic analgesics generally required, and most patients not returning to work for 2-4 weeks following surgery 1, 2
Complication rates are significant, with urinary retention, bleeding, anal stenosis, infection, and incontinence being common, and sphincter defects documented by ultrasonography and anal manometry in up to 12% of patients after hemorrhoidectomy 1
Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for third-degree hemorrhoids, with a low recurrence rate of 2-10% 2, 5