Grade IV hemorrhoidal disease represents the most advanced form of hemorrhoids and is frequently associated with severe prolapse, chronic inflammation, and a high risk of bleeding. Although minimally invasive techniques have gained popularity, excisional hemorrhoidectomy remains the most effective treatment for advanced disease. We report a case highlighting the role of pedicle ligation prior to Milligan-Morgan hemorrhoidectomy in improving surgical safety. A 32-year-old man with no significant medical history presented with symptomatic, irreducible grade IV hemorrhoids refractory to conservative treatment. Open excisional hemorrhoidectomy using the Milligan-Morgan technique was performed following the systematic ligation of the hemorrhoidal pedicles. The procedure was completed without intraoperative complications. Postoperative recovery was uneventful, with excellent clinical and functional outcomes. In advanced hemorrhoidal disease, the risk of intraoperative bleeding is increased due to marked vascular congestion and chronic inflammation. Pedicle ligation prior to excision may enhance hemostasis, improve operative field exposure, and reduce perioperative complications. This strategy is particularly relevant in grade IV hemorrhoids, where minimally invasive techniques have shown higher recurrence rates. Pedicle ligation before Milligan-Morgan hemorrhoidectomy is a safe and effective strategy in the management of grade IV hemorrhoids and may improve surgical outcomes in selected patients.
Hamada et al. (Fri,) studied this question.