Options for hemorrhoidectomy include the techniques of Milligan-Morgan hemorrhoidectomy, closed Ferguson hemorrhoidectomy, Whitehead hemorrhoidectomy, and the stapled hemorrhoidectomy. The procedures are usually performed in the operating room after minimal preoperative preparation of the bowel. Lasers have no role to play in excisional hemorrhoidectomy, and in fact they cause delayed healing, increased pain, and increased cost.Anesthetic management is usually left to the anesthesiologist and patient; however, local anesthesia supplemented by the administration of intravenous narcotics and propofol is very effective. The use of spinal anesthesia, although effective, may increase the risk of postoperative urinary retention.
The decision to excise the hemorrhoidal plexi requires acceptance by the physician and patient that medical and non-excisional options have either failed or are not appropriate. The usual clinical symptoms that lead to excision are frequent prolapsing of the internal hemorrhoids that results in discomfort and anal seepage. Alternatively, the thickened and prolapsing internal/external hemorrhoidal complexes may make anal hygiene difficult for the patient and may make excision preferable. The final indication for excisional hemorrhoidectomy, although debatable, is the development of acutely thrombosed and gangrenous internal hemorrhoids. It is apparent, however, that hemorrhoidectomy can be performed using standard closed hemorrhoidectomy techniques without undue complications. Specifically, the risk of stenosis appears unwarranted if careful technique is used and the maximum amount of anoderm is preserved with skin bridges between excision sites. In the case of limited external hemorrhoidal thromboses, surgical excision is warranted for more rapid pain relief and avoidance of a residual skin tag.External thromboses are usually easily managed in an office setting with local anesthesia