Literature Review on Hemorrhoidectomy

Abstract

The surgical hemorrhoidectomy remains the gold standard for the management of symptomatic grade III and grade IV Hemorrhoids. In 1937, Milligan-Morgan described the surgical hemorrhoidectomy, leaving the wounds open, the term open hemorrhoidectomy came to symbolize the excisional hemorrhoidectomy (Milligan et al., Lancet 233:1119–1124, 1937). In 1959 Ferguson et al., described the technique of modifying the Milligan-Morgan hemorrhoidectomy by closing hemorrhoidectomy wounds, the term closed hemorrhoidectomy came to symbolize the modification of the Milligan-Morgan procedure (Ferguson and Heaton, Dis Colon Rectum 2:176–179, 1959). The “closed” hemorrhoidectomy has become the main technique for hemorrhoidectomy instructed in General Surgery and Colon and Rectal Surgery residencies in the United States. The principal of the surgical hemorrhoidectomy is to completely excise all of the hemorrhoidal tissue, in the three most common quadrants, the right anterior, right posterior and left lateral areas of the anal canal. The most common complaint for patients is postoperative pain, and the disability caused by the pain. This postoperative pain is the driving force in the development or “quest” for the “painless” hemorrhoidectomy. All other procedures are compared to the excisional hemorrhoidectomy, for postoperative pain, disability, bleeding, stricture formation and recurrence. There are multiple modalities that are utilized to diminish post hemorrhoidectomy pain, which I will discuss. There has been development of new technology for “non-excisional” hemorrhoid procedures with the promise to decrease post hemorrhoidectomy pain and disability. The two most commonly used alternatives today is the Procedure for Prolapsed Hemorrhoids (PPH) more commonly known as the “Stapled Hemorrhoidopexy” and the other is the Doppler-Guided Hemorrhoidal Artery Ligation, known as Transanal Hemorrhoidal Dearterialization (THD) with plication of the Hemorrhoids (ligation anopexy or mucopexy) (Yeo and Tan, World J Gastroenterol 20:16,976–16,983, 2014; Lohsiriwat, Tech Coloproctol 12:229–239, 2015).

The standard tools for the surgical hemorrhoidectomy are the scalpel, scissors or electrocautery, however efforts to decrease the amount of intraoperative bleeding, and the associated post-operative pain and disability have led to the development of alternative energy devices to dissect and excise the hemorrhoidal tissue: the LigaSure™, a computer-guided bipolar electrothermy device (BED), and the Harmonic Scalpel™, which is vibratory energy (VE) (Mastakov et al., Tech Coloproctol 2:229–239, 2008; Neinhuijs and de Hingh, Cochrane Database Syst Rev 1:CD 006761, 2009; Chung et al., Dis Colon Rectum 45:784–794, 2002; Armstrong et al., Dis Colon Rectum 44:558–564, 2001). This chapter will discuss the literature leading up to the current management of patients with advanced hemorrhoidal disease and the procedures and the methods utilized to minimize postoperative pain and disability.