MILLIGAN MORGAN HEMORRHOIDECTOMY: TECHNICAL DETAILS EVERY COLOPROCTOLOGIST SHOULD KNOW

Introduction The Milligan-Morgan hemorrhoidectomy is an excisional surgical technique described in 1937, used to remove symptomatic internal and external hemorrhoids. Hemorrhoidectomy is indicated in grade II hemorrhoidal disease (HD) when other conservative treatment options have failed and for large HD (Grade III/IV). Throughout the 20th century and even today, excisional methods have solidified as the most effective due to their good control over bleeding and prolapse, and their lower recurrence rates, despite the emergence of several minimally invasive techniques (laser, harmonic scalpels, radiofrequency, PPH, and THD). The main goal of this presentation is to explore and present the key technical details of the traditional open hemorrhoidectomy for the improvement of younger coloproctologists.

Case Presentation A 61-year-old female patient presented with complaints of anal bleeding and prolapse during evacuation efforts for 3 years, associated with anal discomfort and local pruritus. She had previously undergone dietary, pharmacological treatments, and elastic band ligation sessions with slight improvement. On proctological examination, three small anal plicae and three hemorrhoidal nipples were observed. Colonoscopy was unremarkable. No bowel preparation was performed, and antibiotic prophylaxis was used. The patient was positioned in the Lloyd-Davies position after balanced general anesthesia. Bupivacaine infiltration with vasoconstrictor was administered to reduce bleeding from small vessels. The patient underwent hemorrhoidectomy using the open technique under balanced general anesthesia without complications. The cutaneous-hemorrhoidal complex was resected without damaging the sphincter muscle, pedicles were ligated with absorbable 2-0 sutures, hemostasis was carefully achieved, and appropriate cutaneous-mucosal bridges were preserved. The surgical wounds were left open to heal by secondary intention. The same procedure was performed for the three hemorrhoidal nipples.

Results The patient passed stool and was discharged on the first postoperative day without complications.

Conclusion Although the Milligan-Morgan hemorrhoidectomy is an invasive procedure, it is an effective technique for controlling prolapse and bleeding, safe, and with a low recurrence rate. Due to its simpler learning and execution, and low cost, it should be the method of choice in the training of coloproctologists in Brazil.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025