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 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
