Conventional Hemorrhoidectomy
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20 March 2010
Even with the advent of PPH, conventional hemorrhoidectomy remains to be an essential component of every colorectal surgeon’s armamentarium. In clinical practice, our indications for conventional hemorrhoidectomy include the following: early thrombosed hemorrhoids; single mixed piles; hemorrhoids associated with anal fissures; large circumferential prolapsing hemorrhoids, particularly if irreducible or gangrenous; as well as patient’s preference (usually due to inability to afford PPH).
Generally, conventional hemorrhoidectomy has been categorized into two, specifically the OPEN technique, where the skin and mucosa are left open to heal by secondary intention; and the CLOSED technique, where the resultant defect is closed by absorbable running sutures. A variety of individual techniques fall within these categories. Pain scores and healing rates are generally similar for both techniques, also some data point to a higher wound dehiscence and infection rate with the closed procedure.
In the Colorectal Division of the Philippine General Hospital we perform approximately 350 conventional hemorrhoidectomies a year, 98% of which are done as ambulatory day surgery, 25% under local anesthesia, with an overall complication rate of less than1%. Our residents predominantly use the open Milligan-Morgan technique, with varying modifications, which is relatively easy to learn. Some of our senior consultants use the closed techniques, as well as a variety of flap techniques for large piles.
Hemorrhoid surgery, just as it was taught by master surgeons of previous generations (who did not have the luxury of PPH) remains to be an art more than just a technique. Success is generally measured in terms of post-operative pain scores and aesthetic appearance, low complication rates, as well as patients’ satisfaction. While stapled hemorrhoidectomy has become an important option for many patients, conventional hemorrhoidectomy is still a necessary tool for colorectal surgeons, who must, just as in generations past, master the art of patient selection and operative technique.
