Closed Hemorrhoidectomy

In 1959, D. Ferguson and J. Heaton introduced an out-patient surgical procedure for the removal of hemorrhoids called closed hemorrhoidectomy. It is typically only conducted on fourth and some large third-degree hemorrhoids.

In contrast with open hemorrhoidectomy or Milligan-Morgan technique, where the internal and external hemorrhoidal tissues are excised and the wounds left open (hence the name), in a closed hemorrhoidectomy, each wound are sutured close.

Things to Expect in Preparation for the Surgery:

• There is not a lot of testing needed prior to the surgery. Older patients may need to submit to an ECG to check for cardiac problems. Anticoagulant testing is also not normally necessary unless the patient is currently taking certain types of medication that would affect the bloods normal ability to coagulate.
  
  
• The patient will be required to fast starting around midnight on the night before the surgery.
  
  
• The patient will also have to give themselves an enema in the morning prior to check in for the surgery.
  
  
• Once the patient is checked in an IV (intravenous line of solution normally composed of saline and dextrose) is established.

Surgical Procedure

Once in the surgery room the patient will be placed into the appropriate position for surgery:

• Both sides of the butt cheeks are pulled apart with an adhesive tape.
• The hips are flexed
• The arms are extended

The patient is then sedated and a local anesthesia prepared. Typically there are five local injections given in the anal region. While the shots are given finger or a special type of retractor known as a Hill-Ferguson retractor is inserted into the anal canal. The anesthesia tends to take affect very quickly. The anal area and the sphincter become relaxed.

The surgical procedure progresses with a survey of the anal canal by inserting a medium-sized Hill-Ferguson retractor into the opening. A plan for removing the affected hemorrhoid established is then established.

The surgery then proceeds:

• A knife is used to make a circular incision around the hemorrhoid (starting at the dentate line and extending well past the anal verge).
  
  
• Scissors are then used to lift the skin from the external sphincter. The mucosa is freed from the internal sphincter cephalad (close to the dentate line). Blood loss during the procedure is small. Normally only sponges are needed to clean the area during the procedure.
  
  
• The incisions will reveal the muscle of the Treitz anchoring the internal sphincter to the mucosa.
  
  
• The mucosa suspensory ligament is divided using the scissors.
  
  
• The proximal part of the internal sphincter is cut free and the hemorrhoid complex is removed.
  
  
• A partial and superficial internal sphincterotomy may be performed at the base of the wound. This can help relieve pain and has other benefits. This, however, is not performed on elderly patients.
  
  
• The wound is closed with sutures. In contrast with open hemorrhoidectomy, no part is left open for drainage. No drainage tubes or hemostatic packs are inserted into the area. Sometimes an external dressing may be applied.

The surgical procedure is usually completed within 2 hours.

Upon completion of the surgery the patient is brought to a recovery area. The patient typically waits in this area for 30 minutes to an hour. During this time they are often offered something to eat, a drink, and possibly some oral pain medication.

After the Surgery

Once home the patient is instructed to follow a regiment of sitz baths and take pain medication as needed. They may also be given medication to help stimulate bowel movements. Typically there are 2 post surgical doctors appointments scheduled for 10 days and 3 weeks after surgery. The wounds should be completely healed within 3 weeks. In most cases, the patient can resume full activities within 1 to 2 weeks.

Complications

As with other types of hemorrhoid surgeries, pain remains the most common complaint. Other complications, and their incidence rate is shown below:

Long-Term Success

Closed hemorrhoidectomy with local anesthesia is the preferred method of hemorrhoid surgery in the United States. When expertly done, this surgical procedure has a high patient satisfaction rate. However, a long-term follow-up shows that within one to seven years, approximately 7.5% of patients require another operation or further treatment for their hemorrhoids.