Haemorrhoidectomy

J Graham Williams

Powerpoint File

Surgical excision of haemorrhoids is perhaps one of the oldest surgical operations performed. A variety of techniques of excising symptomatic haemorrhoids have been described, but some, such as the Whitehead circumferential excision of the anal cushions, have been abandoned. Currently, two methods of excisional haemorrhoidectomy are popular: the open excision described by Milligan and Morgan from St Mark’s Hospital (favoured by UK surgeons) and the closed haemorrhoidectomy described by Ferguson (favoured by North American surgeons). A newer variation of these techniques using the Ligasure® coagulator is covered elsewhere. The principle of both methods of haemorrhoidectomy is to remove the swollen haemorrhoid tissue from outside and inside the anal canal, preserving sufficient mucosa and anoderm to maintain function of the anal canal, particularly sealing the anal canal between bowel movements.

Open (Milligan-Morgan) Haemorrhoidectomy

Traditionally, the patient is placed in the lithotomy position and the procedure is performed under a light general anaesthetic. Examination of the anal canal with a proctoscope or Sims anal retractor will confirm the position of the haemorrhoids to be removed. The skin-covered external element of the haemorrhoids to be excised is grasped with an artery forceps and drawn downwards and outwards to expose the lower pole of the mucosal-covered part of the haemorrhoid. The mucosal component of each haemorrhoid is then grasped with a second artery clip and drawn out to expose the whole of the haemorrhoid to be removed. The haemorrhoid to be removed is dealt with by grasping both artery clips attached to the haemorrhoid in the palm of one hand whilst a v-shaped incision is made in the perianal skin, round the lower border of the haemorrhoid. This incision is deepened and extended across the mucocutaneous junction of the anal canal. The haemorrhoidal mass is then carefully separated from the underlying ring of external sphincter muscle at the anal margin and internal sphincter within the anal canal. In this manner a haemorrhoidal pedicle is developed, with its base in the upper anal canal. The sphincter muscles should be in view and preserved throughout this dissection. The anal mucosa on each side of the pedicle is incised to narrow the pedicle, prior to suture ligation. The haemorrhoidal pedicle is transfixed with a heavy absorbable suture and ligated, before being excised with scissors. The procedure is repeated at each of the other haemorrhoid sites. Care is taken throughout the procedure to maintain adequate muco-cutaneous bridges between each of the excision sites. Failure to do this can lead to a large circumferential wound, which will heal with considerable stenosis. The idea is to leave three pear-shaped wounds on the anal margin. More recent developments of this technique have involved new technologies to excise the haemorrhoid. This includes diathermy, lasers and ultrasonic (harmonic) dissectors. None of these alternatives appear to offer any special advantage over conventional excision with a pair of scissors and they add to the cost of the procedure.

The Milligan-Morgan operation is still widely practiced in the UK. Properly performed it produces good results and has stood the test of time.

Closed (Ferguson) Haemorrhoidectomy

The rational behind the Ferguson operation is based on some of the perceived disadvantages of the Milligan-Morgan operation. This includes removing vascular haemorrhoidal tissue with minimal amounts of anoderm, limiting postoperative discharge and speeding up healing by closing the defects in the anal canal and limiting the potential for stenosis, which may complicate healing by second intention of large anal wounds.

The procedure is performed in the prone jack-knife position under general, regional or local anaesthetic supplemented with mild sedation. A selection of anal retractors is necessary to perform the procedure. A Pratt bivalve speculum is useful for identifying the haemorrhoidal complexes to be removed. Excision of the haemorrhoid is performed with either a Fansler operating anoscope or Hill-Ferguson anal retractor of appropriate size.

The retractor is positioned in the anal canal in line with the haemorrhoidal tissue which is to be removed. The anal skin adjacent to the outer margin of the haemorrhoid is grasped with a strong tissue forceps and drawn towards the centre of the anal canal. Dissecting scissors are then used to incise the perianal skin and commence excision of the haemorrhoid, which is achieved by pressing the belly of the scissors outwards onto the internal sphincter which is protected by being kept taught by the presence of the anal retractor. In contrast to the open technique, the excision proceeds to a higher level in the anal canal, beyond the anorectal junction and top of the internal sphincter. The haemorrhoid is simply excised at the apex of the dissection, without developing and suture ligating the pedicle. Bleeding from the edge of the mucosa is controlled initially with cautery. Any residual excess haemorrhoidal tissue beneath the cut edge of the mucosa on each side can be excised to minimise recurrence, but care is taken not to excise any more anoderm. The resulting defect is closed with a running absorbable suture. 3/0 Monocryl® on a small needle works well. Suturing commences at the apex, where the rectal mucosa is fixed to the underlying muscle to prevent further prolapse. The anal mucosa can be fixed to the internal sphincter by including small bites of the muscle, but some authors contend that this increases pain and increases the likelihood of wound separation in the postoperative period. Suturing continues out onto the perianal skin to produce a longitudinal suture line. After the first (and usually largest) haemorrhoid has been excised, the anal canal is re-inspected with the bi-valve retractor to identify the next haemorrhoid to be excised. The procedure is repeated until all haemorrhoids (usually 3) have been dealt with. Invariably, less tissue is removed at each subsequent site and again care is taken to preserve as much anoderm as possible to allow the wounds to be closed without tension.

Parks described a variation of this closed technique, where haemorrhoidal tissue is excised from the submucosal plane after raising mucocutaneous flaps within the anal canal from a longitudinal incision over the haemorrhoid.

Whether to perform an open haemorrhoidectomy or a closed procedure is largely a matter of surgeon preference and training. A number of trails comparing the two techniques have been published (Table), however the results of these trails vary and most trials suffer from small numbers and short follow up.

Summary of Trials Comparing Open and Closed Haemorrhoidectomy
Results show which method of haemorrhoidectomy had a statistically superior outcome for each of the parameters compared.

A recently published Swedish multicentre trail (Jóhannsson et al) randomised 115 patients to undergo open haemorrhoidectomy and 110 patients to closed haemorrhoidectomy. There was no difference in level of pain post surgery nor in rate of complications. Similarly, at one year post surgery, a similar proportion of patients in each group had experienced recurrent haemorrhoidal symptoms (15.6 vs 17.6%). However, closed haemorrhoidectomy was associated with an improvement in incontinence score at one year, which was not observed after Milligan-Morgan operation and patients were more likely to be satisfied after the Ferguson procedure.

Complications of Haemorroidectomy.

• Pain

Both procedures are recognised to be painful, but the degree of pain varies from patient to patient. Closed haemorrhoidectomy is thought to be less painful than open haemorrhoidectomy. A variety of manoeuvres have been employed to reduce postoperative pain. Commencing laxatives prior to operation seems appropriate to prevent postoperative constipation. There was vogue for combining haemorrhoidectomy with sphincter dilatation to limit painful spasm of the internal sphincter. However, this should be avoided as it is likely to increase the risk of incontinence. Newer approaches include the use of GTN ointment and injection of botulinum toxin as well as using antibiotics such as metronidazole. It should not be forgotten that adequate analgesia without inducing constipation is often all that is required.

• Bleeding

Primary bleeding arises from the vascular pedicle or the cut edges of the mucosa. Simple pressure may be all that is required to stop the bleeding. In the lower rectum, this can be applied by inflating a Foley catheter balloon in the rectum with 30-50 cc of water and applying gentle traction to the catheter for an hour or two. Brisker bleeding requires further examination under anaesthetic and suture ligation. The prone jack-knife position is helpful as blood in the rectum runs away from the operative site. Secondary haemorrhage usually arises as a consequence of infection in the haemorrhoidectomy wound and usually manifests between the 7th and 14th days post surgery. Bleeding is often brisk and will require admission to hospital, fluid resuscitation and examination under anaesthetic. Antibiotics should be prescribed and continued for a few days after the haemorrhage ceases.

• Urinary Retention

Retention of urine is more common in male patients than female patients and is thought to arise as a result of reflex spasm of the urinary sphincter in response to pain. Patients with pre-existing symptoms of urinary outflow obstruction are more prone to retention as are patients who receive a caudal anaesthetic to supplement pain relief. Fluid restriction in the perioperative period is thought to reduce the risk of retention.

• Infection

Infection following haemorrhoidectomy is unusual, despite the high bacterial load of the operative field. Submucous abscess with subsequent fistula formation can form after closed haemorrhoidectomy. Rare cases of fulminant infection after haemorrhoidectomy usually involve patients who are immunosuppressed. However, as the consequence of infection can be catastrophic, a high index of suspicion should be maintained in any patient who is unwell and experiencing increasing pain following haemorrhoidectomy.

• Anal fissure

An anal fissure can develop in one of the wounds following haemorrhoidectomy and usually arises from delayed healing of the wound as a consequence of increased tone in the internal sphincter. Topical sphincter relaxing agents should be used in the first instance, but sphincterotomy may be required. Anorectal physiology studies can guide treatment.

• Anal stenosis

Development of anal stenosis reflect excessive removal of anoderm with cicatrisation of the anal canal during healing. Simple dilatation may be all that is required to correct the problem, but advancement flap Anoplasty is sometimes required to correct the stenosis.

• Incontinence

Anal leakage and soiling is common in the early post-operative period, but is thought to resolve as the wounds heal. However, two recent studies have reported late leakage rates of the order of 30% after open and closed haemorrhoidectomy. Postoperative anal leakage may have a number of causes. Ano-rectal physiology studies have shown changes in mucosal sensitivity and anal sphincter pressures following surgery. Furthermore, removal of haemorrhoidal tissue will affect the symmetry and closure of the anal canal. More worryingly, a recent paper reported endoanal ultrasound evidence of damage to the internal and external sphincter of 12 symptomatic patients following haemorrhoidectomy

Further reading:

Abbasakoor F, Nelson M, Beynon J, et al. Anal endosonography in patients with anorectal symptoms after haemorrhoidectomy. Br. J. Surg. 1998;85(11):1522-4.

Arbman G, Krook H, Haapaniemi S. Closed vs. open hemorrhoidectomy--is there any difference? Diseases of the Colon & Rectum 2000;43(1):31-4.

Arroyo A, Perez F, Miranda E, et al. Open versus closed day-case haemorrhoidectomy: is there any difference? Results of a prospective randomised study. International Journal of Colorectal Disease 2004;19(4):370-3.

Carapeti EA, Kamm MA, McDonald PJ, et al. Randomized trial of open versus closed day-case haemorrhoidectomy.]. Br. J. Surg. 1999;86(5):612-3.

Ferguson JA, Heaton JR. Closed Haemorrhoidectomy. Dis. Colon Rectum 1959;2:176.

Gençosmanoglu R, Sad O, Koc D, et al. Hemorrhoidectomy: open or closed technique? A prospective, randomized clinical trial. Diseases of the Colon & Rectum 2002;45(1):70-5.

Guenin MO, Rosenthal R, Kern B, et al. Ferguson Hemorrhoidectomy: Long-Term Results and Patient Satisfaction After Ferguson’s Hemorrhoidectomy. Dis. Colon Rectum 2005;48:1523–1527.

Ho YH, Seow-Choen F, Tan M, et al. Randomized controlled trial of open and closed haemorrhoidectomy. Br. J. Surg. 1997;84(12):1729-30.

Hosch SB, Knoefel WT, Pichlmeier U, et al. Surgical treatment of piles: prospective, reandomised study of Parks vs. Milligan-Morgan hemorrhoidectomy. Dis. Colon Rectum 1998;41:159-164.

Johannsson HG, Graf W, Pahlman L. Long-term Results of Haemorrhoidectomy. European Journal of Surgery 2002;168:485–489.

Johannsson HO, Pahlman L, Graf W. Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy. Br. J. Surg. 2006;93(10):1208-14.

Milligan ETC, Morgan CN, Jones LE, et al. Surgical anatomy of the anal canal, the operative treatment of haemorrhoids. Lancet 1937;ii:1119-1124.

Parks AG. The surgical treatment of haemorrhoids. Br. J. Surg. 1956;43:337-351.

You SY, Kim SH, Chung CS, et al. Open vs. closed hemorrhoidectomy. Diseases of the Colon & Rectum 2005;48(1):108-13.