Internal haemorrhoid surgery

• Internal haemorrhoid surgery is usually necessary in cases of grade 3 and 4 haemorrhoids.
• There are numerous conservative treatments for the treatment of haemorrhoids, but the only definitive solution for severe cases is the internal haemorrhoid operation.
• Haemorrhoidectomy can be performed using two types of surgical techniques, an open type and a closed type.

Haemorrhoids are dilatations of a group of small veins and arteries that form the vascular plexuses of the anus and rectum. Haemorrhoids are like varicose veins of the small arteries and veins that supply the anal canal at its most superficial part.

From an anatomical point of view there are three possible locations where we can find internal haemorrhoids within the anal canal (part of the intestine that runs between the anus and the rectum) as there are three vascular plexuses in these three locations: right plexus, left plexus, middle posterior plexus (this location is usually found in the posterior part of the anal canal, the one closest to the back if we understand the anal canal as a spherical tube).

Basically, and referring to all the classifications in the scientific literature, we can divide haemorrhoids into two different types depending on their origin: internal haemorrhoids and external haemorrhoids.

• External haemorrhoids are those that are formed from an external haemorrhoidal vascular plexus, are usually formed by perianal tissue on their surface and have a large number of sensitive fibres.
• Internal haemorrhoids are those formed from the internal haemorrhoidal plexus inside the canal.

Internal haemorrhoids can be classified according to their severity and symptoms. To do this, they are divided into four different degrees:

• Grade 1 internal haemorrhoids: in this case they do not go beyond the end of the anal canal.
• Grade 2 internal haemorrhoids: these are those that can prolapse during defecation or with major valsalva manoeuvres towards the outside but which shrink on their own, returning to the inside of the anal canal.
• Grade 3 internal haemorrhoids: these are internal haemorrhoids that prolapse during defecation or with valsalva manoeuvres but which cannot be reduced spontaneously but require manual reduction by the patient.
• Grade 4 internal haemorrhoids: these are internal haemorrhoids that prolapse and cannot be reduced again either spontaneously or by manual reduction by the patient or the healthcare professional.

It is in grades 3 and 4 that the need for internal haemorrhoid surgery is much more likely, as the pain and discomfort caused by these haemorrhoids cannot be relieved by conservative methods in the vast majority of cases.

The usual form of presentation of internal haemorrhoids, as well as external haemorrhoids, is usually the presence of rectal bleeding, generally in small quantities, red in colour and observable by the patient after wiping, appearing on the paper or wipe, as well as pain or the sensation of discomfort during or immediately after defecation.

The presence of rectal bleeding associated with the diagnosis of internal haemorrhoids is usually caused by a small ulceration of the varicose vein that forms from the venous and arterial plexus as explained above. 

Sometimes it is due to a small incision in the varicose vein due to straining during defecation and prolapse through the anal canal of the haemorrhoid. 

The bleeding is usually small, bright red in colour (which helps us to differentiate between recent bleeding near the anus and more chronic bleeding from higher parts of the intestine, which will be much darker, almost black, with a more pasty consistency and the presence of clots).

Occasionally, especially in chronic and prolonged haemorrhoids, the patient may experience an itching sensation (known as pruritus in medical terms) at the margin of the anus and a feeling of heaviness that is accentuated by movement and while the patient is seated.

It is possible that a patient who suffers frequently from haemorrhoids or who suffers from grade 4 internal haemorrhoids may experience a sudden episode of pain from a particular strain and become very dark in colour. This could be related to the presence of a thrombosed haemorrhoid.

This is a relatively common complication in patients suffering from haemorrhoids. Currently, the best treatment is usually to try to manually reduce the haemorrhoid, although it is often difficult for the patient to do so due to the pain associated with it.

The presence of internal haemorrhoids causing pain, itching, rectal bleeding or a feeling of heaviness is closely related to chronic constipation.

It has been observed that almost 75% of all people who suffer or have suffered a process of rectal pain and/or bleeding due to the presence of internal or external haemorrhoids are associated with a specific episode of moderate-severe constipation or a chronic process of constipation with the need to exert severe intra-abdominal pressure for defecatory effort. 

This is an important consideration, since acting on this bowel rhythm problem will help us to both prevent and treat this type of pathology.

As can be seen from the symptoms mentioned above, as well as from what was said in the previous section on the degrees of internal haemorrhoids, the operation for internal haemorrhoids is in many cases a necessity. 

It is true that there are numerous treatments for haemorrhoids, many of them conservative and useful for grade 1 or 2 internal haemorrhoids, but if the patient has grade 3 or 4 internal haemorrhoids, it is very likely that if the problem is to be solved definitively, internal haemorrhoid surgery will be necessary. 

In the following banner you can find out more about haemorrhoids.

In order to make the diagnosis and find out whether it may subsequently be necessary to carry out an operation for internal haemorrhoids, the patient who is affected by haemorrhoids generally goes to see a primary care specialist or a specialist in proctology or general surgery because of the presence of rectal bleeding or pain during defecation.

This clinic will indicate the presence of haemorrhoids of at least grade 2, 3 or 4 as one of the first possibilities to be taken into account. The diagnosis of internal haemorrhoids is also made during the consultation itself, with the patient lying on the examination table in the genupectoral position so that the doctor can observe the haemorrhoids as they protrude out of the anal canal.

As we have already mentioned on several occasions, in the event that the doctor considers the haemorrhoids to be severe, grade 3 or 4, together with the patient's testimony about their quality of life, they will recommend whether or not an internal haemorrhoid operation should be carried out.

Internal haemorrhoid surgery consists of the removal of the varicose haemorrhoidal veins that cause what are commonly known as piles. The internal haemorrhoid surgery is known as haemorrhoidectomy and can be performed using two types of surgical techniques: the open type or Milligan-Morgan or the closed type or Ferguson technique.

Operation for open type internal haemorrhoids or Milligan-Morgan internal haemorrhoids

This technique involves dissection of the vascular haemorrhoidal plexus, which is removed from the anus using surgical forceps and an electric scalpel to ligate the pedicle, which is the final part of the vascular plexus that joins it to the anal canal. In this case, the wound is not sutured, and this is done in the second instance.

Operation for closed type internal haemorrhoids or Ferguson technique

In this case, the surgical technique is exactly the same as in the case of the Milligan-Morgan technique, the main difference being that after the removal of the haemorrhoidal varicose vein, the final wound is sutured so that it closes inside the anal canal.

In both cases, regional anaesthesia and sedation are used, and the hospital stay after the internal haemorrhoid operation is only 1 day. It is a simple surgery and the patient can return to their daily activities after 2-3 days. It is also normal after haemorrhoid surgery to have discomfort or slight bleeding in the days that follow, until the wound heals definitively.