Surgical Treatment of Hemorrhoids: From Milligan-Morgan to Modern Techniques
Surgical treatment of hemorrhoids—Milligan-Morgan
When conservative treatments such as fiber supplements, laxatives, and local anesthetic ointments are no longer sufficient, or if the patient experiences repeated bleeding from the intestine and painful prolapse, surgical treatment of hemorrhoids becomes necessary.
The choice of surgical strategy depends on the severity of the hemorrhoids (grade I-IV) and the patient's individual profile.
Small hemorrhoids can be treated using the Milligan-Morgan method under local anesthesia.
Indications for surgery
Surgical treatment of hemorrhoids is primarily considered in the following cases:
- Grade III and IV hemorrhoids: Where the tissue prolapses (falls out) and either needs to be pushed back into place manually or is fixed outside the anal canal.
- Refractory bleeding: Persistent bleeding from the intestine that causes anemia or significantly reduced quality of life and where other treatments do not produce the desired results.
The gold standard: Milligan-Morgan (open hemorrhoidectomy)
The Milligan-Morgan technique, developed in 1937, is still considered the "gold standard" due to its extreme effectiveness and low recurrence rate (risk of relapse).
The procedure
The surgeon dissects the three primary hemorrhoidal bundles and ligates the supplying arteries. The diseased tissue is then removed, and the wound is left open (excision ad modum Milligan-Morgan). This ensures drainage and minimizes the risk of deep infections.
Advantages:
- Lowest risk of recurrence compared to less invasive methods.
- Highly effective for both internal and external components.
Disadvantages:
- Significant postoperative pain (due to wounds in the pain-sensitive part of the anal canal).
- Longer healing time (typically 4–6 weeks).
Alternative Surgical Methods
To reduce postoperative pain, techniques have been developed that operate above the "toothed line" (linea dentata), where the nerve supply is less sensitive.
1. Ferguson (Closed hemorrhoidectomy)
Similar to Milligan-Morgan, but here the mucosa is sutured together after removal of the tissue.
- Benefit: Faster wound healing.
- Disadvantage: Increased risk of wound rupture and infection (abscess).
2. Stapler hemorrhoidopexy (ad modum Longo)
Here, a circular stapler is used to remove a ring of mucous membrane above the hemorrhoids themselves, which "lifts" them into place and interrupts the blood supply.
- Advantage: Significantly less pain and a quick return to work.
- Disadvantage: Higher risk of recurrence and specific complications such as rectal perforation (albeit rare).
3. THD / HAL (Transanal Hemorrhoidal Dearterialization)
An ultrasound-guided technique in which the arteries supplying the hemorrhoids are located and ligated.
- Advantage: Minimally invasive, no skin wounds, very little pain.
- Disadvantage: Less effective for very large, fixed grade IV hemorrhoids.
Comparison of advantages and disadvantages
| Methodology | Pain level | Risk of recurrence | Healing time |
| Milligan-Morgan | High | Very low | 4-6 weeks |
| Longo (Stapler) | Low/Medium | Medium | 1-2 weeks |
| THD/HAL | Low | Medium | < 1 uge |
Postoperative care after Milligan-Morgan surgery
After an open hemorrhoidectomy, the goal is to ensure pain control, keep stools soft, and promote wound healing in the open area.
1. Pain management (analgesics)
Pain is the main challenge after treating hemorrhoids with this method.
- Combination therapy: A fixed regimen of paracetamol (Panodil) and NSAID (e.g., Ibumetin) is typically used to cover the basic pain.
- Stronger painkillers: Opioids (e.g., tramadol or oxycodone) may be necessary for the first 3–5 days.
- Caution: Opioids cause constipation, which can make the first bowel movement very painful.
- Local anesthetic ointment: Applying lidocaine gel before and after bowel movements may provide short-term relief.
2. Bowel Regulation and Diet
It is crucial that the first bowel movement (typically 1-3 days after surgery) is soft.
- Laxatives: Patients are routinely given osmotic laxatives (e.g., Magnesia or Movicol) to avoid constipation and straining.
- Diet: A high-fiber diet (vegetables, whole grains) combined with plenty of fluids (2-3 liters daily) is essential.
- Habit: Avoid sitting on the toilet for too long, as this increases pressure on the operated areas.
3. Hygiene and Wound Care
Since Milligan-Morgan wounds are left open, cleanliness is important to prevent infection.
- Sitz baths: It is often recommended to take lukewarm sitz baths (or rinse with a shower) 2-3 times a day and always after a bowel movement. This cleans the wound and can have a relaxing effect on the sphincter, which reduces spasms and pain.
- Bandaging: A simple absorbent bandage (gauze pad) is used to absorb wound fluid, which is normal during the first few weeks.
4. When should you seek medical attention?
Although a small amount of fresh bleeding from the intestine is normal during the first few bowel movements, the patient should seek medical attention if:
- Heavy or persistent bleeding.
- Fever or increasing swelling and redness (signs of infection).
- Inability to urinate (urinary retention is a known but temporary side effect).
Sources (PubMed-based)
- Brown S.R. (2017). Hemorrhoids: An update on management. Therapeutic Advances in Chronic Disease. PMID: 28670481
- Lohsiriwat V. (2012). Hemorrhoids: From basic pathophysiology to clinical management. World Journal of Gastroenterology. PMID: 22611310
- Salfi R., et al. (2020). Milligan-Morgan hemorrhoidectomy: still the gold standard? Reviews on Recent Clinical Trials. PMID: 32204732
- Watson A.J., et al. (2016). Hemorrhoidal artery ligation versus rubber band ligation for the management of third-degree hemorrhoids (HubBLe): a multicenter, open-label, randomized controlled trial. The Lancet. PMID: 27233860
- Burch J., et al. (2008). Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review. Health Technology Assessment. PMID: 18331705
- · Joshi G.P., et al. (2010). Techniques for managing postoperative pain after hemorrhoidectomy. Current Opinion in Anaesthesiology. PMID: 20644415
- · Gallo G., et al. (2020). Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease. Techniques in Coloproctology. PMID: 32036511
- · Moesgaard F., et al. (1982). High-fiber diet reduces the recurrence of hemorrhoids: a randomized trial. Diseases of the Colon & Rectum. PMID: 6754359
- · Sjödahl R., et al. (2015). Postoperative pain and quality of life after hemorrhoidectomy. International Journal of Colorectal Disease. PMID: 25433653