Mucocutaneous Bridge Preservation During Three-Pedicle Milligan-Morgan Hemorrhoidectomy for Acutely Thrombosed Mixed Hemorrhoids: A Surgical Case Report

Introduction: Excisional hemorrhoidectomy remains a major surgical option for advanced hemorrhoidal disease, particularly in patients with bulky mixed internal-external hemorrhoids and thrombosed piles. One of the most important technical principles of open hemorrhoidectomy is preservation of mucocutaneous bridges in order to reduce the risk of postoperative anal stenosis. Case presentation: We report the case of a 45-year-old woman with a past surgical history of ovarian cyst surgery 7 years earlier, who underwent surgery for symptomatic mixed hemorrhoidal disease with marked thrombosis. Under regional anesthesia, operative exploration of the anal verge and anal canal demonstrated mixed internal and external hemorrhoids with three major hemorrhoidal piles: a large thrombosed pile at the 3 o’clock position and two additional large piles at the 8 and 11 o’clock positions. A three-pedicle Milligan-Morgan hemorrhoidectomy was performed. Because organized clots extended between the external components of the resected piles, limited interpedicular mini-excisions with suture-assisted clot extraction were added while deliberately preserving the intervening mucocutaneous bridges. Clinical discussion: This case illustrates a practical refinement of conventional open hemorrhoidectomy in the setting of thrombosed mixed hemorrhoids. Adequate treatment of thrombosed external components must be balanced against strict preservation of viable anoderm and mucosal bridges. In this patient, targeted interpedicular clot evacuation allowed treatment of thrombotic extensions without converting the operation into a circumferential excision pattern. Conclusion: In acutely thrombosed mixed hemorrhoids requiring excisional surgery, preservation of mucocutaneous bridges should remain a non-negotiable operative principle. Selective interpedicular clot extraction may be added when necessary, provided that bridge integrity is maintained to minimize the risk of postoperative anal stenosis.