The treatment of early hemorrhoidal disease can be conservative through dietary changes, stool regulation, sclerotherapy, and the use of rubber band ligation. If conservative measures are unsuccessful and third- or fourth-degree hemorrhoidal disease with subjectively impairing symptoms occurs, surgical therapy is required. Annually, about 50,000 people in Germany undergo surgery for hemorrhoidal disease, which accounts for only 5% of all patients treated for hemorrhoids. The disadvantages of common surgical methods include a work incapacity of 2 to 4 weeks and intense postoperative pain.
If a resective procedure (mono- or multisegmental) is indicated, the following options are generally available:
- open hemorrhoidectomy according to Milligan-Morgan (MM),
- closed hemorrhoidectomy according to Ferguson (FG),
- subanodermal/submucosal hemorrhoidectomy according to Parks (PA),
- reconstructive hemorrhoidectomy according to Fansler-Arnold (FA).
E. T. C. Milligan and C. N. Morgan from the United Kingdom first performed the open segment excision named after them around 1935 and reported on it in 1937 [1]. The MM procedure is the most frequently performed procedure in the surgical treatment of hemorrhoidal disease, also in Germany [2 - 5].
Most surgeries are performed under general or regional anesthesia. Some authors also mention performing it under local anesthesia, sometimes with sedation [6, 7, 8]. The procedure is usually performed on an inpatient basis with an average stay of 3 days [9, 10]. With appropriate patient selection, the procedure can also be performed on an outpatient basis [6, 7]. The operation time varies from 10 to 40 minutes, with an average of 30 minutes [9, 10]. The duration of work incapacity varies from 7 to 30 days, with a median of 18.6 days [11].
Postoperative pain is understandably of great importance to the patient. It seems that the extent of the procedure (1, 2, or 3 pedicles) has no impact on the duration and intensity of the pain [12].
The frequency of postoperative partial incontinence ranges from 0 to 28% according to studies, although predominantly transient [13, 14]. Johannson determined an operation-related incontinence rate of 9.5% [15]. Another study found no differences between incontinence before and after an MM hemorrhoidectomy [16]. However, there is a possibility that a pre-existing continence disorder may intensify after an MM operation.
Where specified, the success rates of the operation vary depending on the follow-up between 67% and 100% [9, 13, 15, 17, 18, 19]. Recurrences are reported between 0% and 7.6%, with one study indicating 12% [8, 9, 17 - 22]. In less than 2% of recorded cases, a repeat operation due to hemorrhoids was necessary.
The rates of postoperative complications vary between 0 and 25% and mostly involve urinary retention and bleeding [18, 23]. In a small group of 25 patients, 5 patients (20%) experienced bleeding, of which only one (4%) required surgical therapy [24]. In studies with a larger number of patients, the number of bleedings is usually 1 to 2%. Postoperative stenoses or strictures occur with a frequency of up to 6%, while in a single weak RCT, it was reported at 20% [8, 20]. Stool incontinence due to sphincter injury as a long-term complication is rare at 4.5% [25].
The use of radiofrequency (bipolar sealing instruments) leads to a shorter operation time, less bleeding, fewer anoderm resections, and less postoperative pain due to reduced thermal spread [26]. However, the effect of reduced pain is only noticeable between the 7th and 14th postoperative day and does not occur thereafter [27].
The effectiveness of stapled hemorrhoidopexy as a non-resective and thus pexing procedure has been investigated in numerous studies. Watson et al. showed in 2016 that pain after hemorrhoidopexy is less in the short-term postoperative course (6 weeks) than after hemorrhoidectomy [28]. However, hemorrhoidectomy was favored in terms of recurrence rates, complaints, reoperations, and quality of life. The authors of a recent meta-analysis come to similar conclusions [29]. In a 2015 review study that examined the treatment of 7827 patients with third- or fourth-degree hemorrhoids, it was found that stapled hemorrhoidopexy causes more recurrences than conventional hemorrhoidectomy [30]. Other meta-analyses also show that the stapler procedure has a higher recurrence rate [31]. According to the German guideline "Hemorrhoidal Disease," stapled hemorrhoidopexy can be offered as a possible procedure for third-degree hemorrhoidal disease. Due to the increased recurrence rate compared to conventional operations, the stapler technique should not be used for fourth-degree hemorrhoidal disease [25].
In some studies, "the MM" was combined with other procedures such as anal dilation or sphincterotomy. Although Mortensen found no significant differences in postoperative manometry between patients with or without anal dilation, three patients from the dilation group had mild incontinence after one year [32]. Galizia reports that the combination of MM with sphincterotomy reduced resting and squeezing pressures, and Mathai ended his study because the additional sphincterotomy led to high incontinence rates [8, 18]. Due to increased incontinence rates, segment excision according to Milligan-Morgan should therefore not be combined with sphincterotomy.