Hemorrhoidectomy
What the Examiner Expects
Surgical excision of hemorrhoidal tissue, most commonly using the Ferguson (closed) or Milligan-Morgan (open) technique. The examiner expects you to classify hemorrhoids by grade (I–IV) and know that most hemorrhoids are managed nonoperatively (dietary fiber, sitz baths, topical treatments, rubber band ligation for grade I–II). Surgical excision is reserved for grade III–IV hemorrhoids, symptomatic mixed hemorrhoids, or failure of office-based treatments. The key technical principle is to preserve adequate mucosal/anoderm bridges between excision sites (operating in the three primary hemorrhoidal positions: left lateral, right anterior, right posterior) to prevent anal stenosis.
Key Examiner Focus Points
- Excisional hemorrhoidectomy for grade III/IV internal or symptomatic external hemorrhoids
- Must preserve adequate mucosal bridges between excision sites to prevent stenosis
- Stapled hemorrhoidopexy (PPH) is an alternative for circumferential prolapse
- Postoperative pain management is critical — multimodal approach
- Urinary retention is the most common immediate complication
Common Curveballs
Patient presents with acutely thrombosed external hemorrhoid — when is it too late for excision?
Excision is most beneficial within 48–72 hours of onset when pain is maximal. After 72 hours, the pain is usually resolving and excision offers less benefit. After 72 hours, manage conservatively with sitz baths, analgesics, and stool softeners. Incision and drainage (rather than excision) has a higher recurrence rate.
After excisional hemorrhoidectomy, the patient develops anal stenosis
This is from excessive tissue excision without preserving mucosal bridges. Mild stenosis: serial dilation in the office. Severe stenosis may require advancement flap anoplasty (V-Y, Y-V, house flap, or diamond flap). This is a preventable complication.
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