The Milligan-Morgan hemorrhoidectomy, which is widely practiced in Europe, was originally described in 1937, and its efficacy has been subsequently documented in many series.This technique includes resection of the entire enlarged internal hemorrhoid complex, ligation of the arterial pedicle, and preservation of the intervening anoderm.[33] The distal anoderm and external skin is left open to minimize the risk of infection in the wounds. This technique is safe and effective. However, the fact that the external wounds are left open can be a cause of considerable discomfort and prolonged morbidity.

The closed Ferguson hemorrhoidectomy was proposed as an alternative to the Milligan-Morgan technique and has a similar large body of reported experience. This technique involves an hourglass-shaped (centered at the midportion of the anoderm) excision of the entire internal/external hemorrhoidal complex, preservation of the internal and external anal sphincters, and primary closure of the entire wound. Occasionally, it is necessary to undermine flaps of anoderm and perianal skin to allow removal of intermediate hemorrhoidal tissue while preserving the bridges of anoderm between pedicles. This technical adjustment avoids postoperative strictures.

The Whitehead hemorrhoidectomy, described in 1882, was devised to eradicate the enlarged internal hemorrhoidal tissue in a circumferential fashion and to relocate the prolapse dentate line, which is often a component of prolapsing hemorrhoids. Although this technique was used widely, it was subsequently largely abandoned because of the high rates of mucosal ectropion and anal stricture.The technique has had renewed support, with several authors who documented minimal stricture rates and no occurrences of mucosal ectropion.Despite these promising reports, the Whitehead procedure is technically demanding because of the need to accurately identify the dentate line and relocate it to its proper position

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Urinary retention is a frequent postoperative problem after hemorrhoidectomy, ranging in incidence from 1 to 52%. A variety of strategies have been used to treat the problem, including parasympathomimetics, alpha-adrenergic-blocking agents, and sitz baths.The best approach, however, seems to be prevention that includes limiting perioperative fluid administration to 250 ml, an anesthetic approach that avoids the use of spinal anesthesia, the avoidance of anal packing, and an aggressive oral analgesic regimen.

Early postoperative bleeding (<24 hours) occurs in approximately 1% of patients and represents a technical error that requires return to the operating room for resuturing of the offending wound.Delayed hemorrhage occurs in 0.5 to 4% of cases of excisional hemorrhoidectomy at 5 to 10 days postoperatively.The cause is likely early separation of the ligated pedicle before adequate thrombosis in the feeding artery can occur.In this scenario, the bleeding is usually significant and requires some method for the control of ongoing hemorrhage. Options include return to the operating room for suture ligation or tamponade at the bedside with Foley catheter or anal packing. The subsequent outcome after the control of secondary hemorrhage is generally good with virtually no risk of recurrent bleeding. It may be helpful to irrigate the distal colorectum with posthemorrhage enemas or at the time of intraoperative control of bleeding to avoid confusion when the residual clots pass per anum.

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