Indian Journal of Colo-Rectal Surgery

: 2021  |  Volume : 4  |  Issue : 2  |  Page : 52--53

Bloodless open excisional hemorrhoidectomy for grade 4th degree hemorrhoids: How i do it?

Preetej Macwan 
 Sanjeevnani Hospital, Mahavir Marg, Anand, Gujarat, India

Correspondence Address:
Dr. Preetej Macwan
Sanjeevnani Hospital, Mahavir Marg, Anand, Gujarat

How to cite this article:
Macwan P. Bloodless open excisional hemorrhoidectomy for grade 4th degree hemorrhoids: How i do it?.Indian J Colo-Rectal Surg 2021;4:52-53

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Macwan P. Bloodless open excisional hemorrhoidectomy for grade 4th degree hemorrhoids: How i do it?. Indian J Colo-Rectal Surg [serial online] 2021 [cited 2022 Jan 18 ];4:52-53
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Hemorrhoids are hypertrophied normal vascular cushions located inside the anus that normally seals the anal opening and prevent leakage of gas or stools. Hemorrhoids occur when these cushions become enlarged due to engorgement of blood vessels and laxity of the surrounding connective tissue.[1] External hemorrhoids are congested external perianal vascular plexus covered by perianal skin, while internal hemorrhoids originate from the subepithelial plexus of the anal canal above the dentate line. Internal hemorrhoids may be classified into four degrees.[2]

The treatment options for symptomatic hemorrhoids vary from conservative medical management, nonsurgical treatments to various surgical techniques depending on the grade of hemorrhoids. The nonsurgical options include rubber band ligation, injection sclerotherapy, cryotherapy, infrared coagulation, laser therapy, and diathermy coagulation.[3] Most nonoperative procedures are reserved for first- and second-degree hemorrhoids. Operative options are clamp and cautery hemorrhoidectomy, open hemorrhoidectomy, closed hemorrhoidectomy, submucosal hemorrhoidectomy, whitehead circumferential hemorrhoidectomy, stapled hemorrhoidopexy, radiofrequency ablation and suture fixation hemorrhoidopexy, pile suture' method, the bipolar diathermy hemorrhoidectomy, and the LigaSure hemorrhoidectomy. Operative hemorrhoidectomies are reserved mainly for third- and fourth-degree hemorrhoids [Figure 1].[4]{Figure 1}

The best possible treatment of third- and fourth-degree hemorrhoids is hemorrhoidectomy. Milligan Morgan's hemorrhoidectomy is the most commonly used and is widely considered the most effective surgical technique for treating hemorrhoids.[5]

We aim at describing the step-wise technique and postoperative care for open excisional hemorrhoidectomy as it is still the gold standard surgery in spite of tremendous advancements in hemorrhoid surgery.

 Surgical technique

All surgeries are performed under regional spinal anesthesia and in the lithotomy position. Then, digital rectal examination is done. The 3 o'clock pile mass is first held with artery forceps and retracted gently. The incision is marked at the anocutaneous junction with the pure cut electrocautery mode, with simultaneous use of handheld electrocautery pencils cutting and coagulation modes; meticulous dissection is carried out to keep the operative field clean and dry to identify the internal sphincter complex. Dissection is carried out up to the hemorrhoidal vessel pedicle. A polyglactin suture material over a 2/0 curved round-bodied needle was used to transfix the pedicle. Another similar bite is taken distal to the first knot and transfixed doubly. The pile mass is then excised distally with the use of cutting electrocautery. Similar steps are undertaken for the 7 and 11 o'clock pile mass. Care is taken to leave behind healthy tissue in between the three-pile mass to reduce postoperative stricture formation [Figure 2] and [Figure 3].{Figure 2}{Figure 3}

The total duration of surgery is around 20–30 min with a total blood loss of 5–7 ml.

Postoperatively, the patient is shifted to the ward and treated with intravenous fluids, analgesics, antibiotics, and laxatives. On the 1st postoperative day morning, the patient receives a good warm sitz bath for around 20 min. They are counseled to apply topical ointments in the squatting position during straining. The patient is discharged with oral antibiotics and analgesics on the 2nd postoperative day and counseled to continue warm sitz bath at home.


The importance of open hemorrhoidectomy cannot be underestimated. This surgery still remains a good option in terms of excellent results, less recurrence, and cost-effectiveness as there is no need for any advanced equipment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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2Nisar PJ, Scholefield JH. Managing haemorrhoids. BMJ 2003;327:847-51.
3MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum 1995;38:687-94.
4Agbo SP. Surgical management of hemorrhoids. J Surg Tech Case Rep 2011;3:68-75. [doi: 10.4103/2006-8808.92797].
5Hulme-Moir M, Bartolo DC. Hemorrhoids. Gastroenterol Clin North Am 2001;30:183-97.