Haemorrhoidectomy Techniques
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Direct answer
Ligate the pedicle, excise the pile, leave the wounds open to granulate — that is Milligan–Morgan open haemorrhoidectomy, still the gold standard for prolapsing disease, with the Ferguson variation simply suturing the defect closed. Stapled haemorrhoidopexy (Longo, PPH) circumferentially staples redundant rectal mucosa above the dentate line, hurting less for circumferential prolapse but recurring more, with rare catastrophic complications; Doppler-guided haemorrhoidal artery ligation (HALO/THD) ligates feeding arteries without excision. Goligher's grading drives selection: grades I–II get fibre, flavonoids, banding or sclerotherapy, and grades III–IV get surgery. Every band and every injection goes above the dentate line, where mucosa is insensate — the single most examinable anatomical rule in the topic.
What you must remember
- Goligher grades: I — bleed without prolapse; II — prolapse with spontaneous reduction; III — prolapse needing manual reduction; IV — irreducible; surgery belongs to III–IV.
- Milligan–Morgan (open): pedicles ligated at the classical positions (left lateral, right anterior, right posterior — 3, 7 and 11 o'clock), tissue excised, wounds left open, anocutaneous bridges preserved to prevent stenosis.
- Ferguson (closed): identical excision with the mucocutaneous defect sutured — marginally faster healing at comparable recurrence.
- Stapled haemorrhoidopexy: less pain and earlier return, but higher recurrence plus rare severe complications — chronic pain and urgency, rectovaginal fistula, even rectal perforation; best suited to circumferential grade III prolapse.
- HALO/THD: Doppler-guided arterial ligation with mucopexy — minimal pain, higher recurrence than excision, suits grade II–III.
- Office treatments: rubber band ligation (one to two quadrants per session) and injection of 5 percent phenol in almond oil submucosally above the dentate line.
- Complication set: pain and urinary retention (commonest early problems, retention especially in men after spinal anaesthesia), secondary haemorrhage around day 7–10, stricture from lost bridges, incontinence from internal sphincter injury.
- Historical traps still examined: Lord's forceful four-finger dilatation (abandoned — incontinence) and Whitehead's radical circumferential excision (abandoned — ectropion and wet anus); the micronised purified flavonoid fraction remains a mainstay of Indian grade I–II management.
Working through a grade IV case
A 45-year-old labourer has had irreducible prolapsed piles for five days — oedematous, with patchy dark discolouration. Emergency haemorrhoidectomy is acceptable and definitive in experienced hands, because the tissue planes remain definable even in oedema; the alternative of reduction and delayed surgery trades a real chance of necrosis for comfort. Open Milligan–Morgan proceeds: three pedicles ligated with absorbable ties, mucocutaneous bridges preserved, wounds left open, and analgesia planned — NSAIDs, sitz baths, stool softeners, glyceryl trinitrate ointment for sphincter spasm. He is warned about day 7–10 secondary bleeding: brisk bleeding then means examination under anaesthesia and suture, not watchful waiting. The contrasts are easy marks: a 30-year-old with grade II bleeding gets fibre, flavonoids and banding of the dominant pile; a desk-bound professional with circumferential grade III prolapse who must return to work fast may reasonably choose stapled haemorrhoidopexy, accepting the recurrence trade.
Where students slip
Grade-driven selection is the most fluffed answer: candidates offer excisional surgery for grade II (banding and fibre are correct) and banding for grade IV (excision is correct). The anatomical slip follows — bands or phenol placed below the dentate line, into sensate squamous epithelium, causing severe pain; the rule is absolute that office procedures sit above it. Old MCQs still ask about Lord's procedure and Whitehead's operation, so the abandoned operations are worth more marks per minute than the modern refinements, and "secondary haemorrhage at day 7–10" has been a repeat answer for decades.
Frequently asked questions
Which Goligher grades need operative haemorrhoidectomy?
Grades III (manual reduction required) and IV (irreducible); grades I–II respond to fibre, flavonoids, banding or sclerotherapy.
How do Milligan–Morgan and Ferguson operations differ?
Both ligate and excise the pedicle; Milligan–Morgan leaves the wounds open to granulate while Ferguson closes the mucocutaneous defect with sutures.
Why must bands and phenol injections be placed above the dentate line?
The mucosa above the dentate line is insensate; below it lies highly sensitive squamous epithelium, where banding or injection causes severe pain.
What are the trade-offs of stapled haemorrhoidopexy?
Less pain and faster recovery than excision, offset by higher recurrence and rare serious complications including chronic pain, urgency, rectovaginal fistula and perforation.
When does secondary haemorrhage occur after haemorrhoidectomy?
Around day 5–10, when the ligature sloughs; brisk bleeding then warrants examination under anaesthesia with suture ligation.