OT notes · General Surgery

Open haemorrhoidectomy (Milligan-Morgan)

Usual anaesthesia
Spinal (saddle or low spinal); general in selected patients
Position
Lithotomy; prone jack-knife in some units
Setting
elective

Operative note template for open (Milligan-Morgan) excisional haemorrhoidectomy, with a filled example for grade III internal haemorrhoids with external components at the three primary positions.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • pain after surgery, worst at defaecation
  • reactionary bleeding, and secondary bleeding at 10 to 14 days
  • retention of urine
  • anal stenosis
  • minor leakage of flatus or stool (sphincter injury)
  • wound infection and slow healing
  • recurrence and residual skin tags

Pre-operative details for this operation

  1. Grade and site of haemorrhoidsGrade IIGrade IIIGrade IVstate the position convention used: quadrant (left lateral, right anterior, right posterior) or clock with patient position
  2. External component / skin tagsPresentAbsent
  3. Associated lesions excludedfissure, fistula, rectal prolapse; proctoscopy / sigmoidoscopy / colonoscopy findings as per age and risk
  4. Hb and anticoagulants / antiplateletsvalue; drugs stopped, when
  5. Bowel preparationEnema givenNot given

Anaesthesia and position

  1. AnaesthesiaSpinalGeneralLocal with sedation
  2. PositionLithotomyProne jack-knife
  3. Perianal skin shaved and preparedantiseptic used

Operative findings

  1. Digital rectal examination and proctoscopy under anaesthesiasphincter tone, any mass, fissure, internal opening
  2. Pile massesnumber, position, size, internal and external components, thrombosis
  3. Secondary pilesNonePresent (positions)
  4. Other findingsNoneFissureSkin tagsPolyp

Procedure (steps)

  1. Anal dilatationNot doneDone (reason)
  2. Submucosal injection of dilute adrenalineGivenNot givenstrength and volume
  3. Artery forceps on skin and mucosal parts of each pilepiles held and incisions marked to keep bridges
  4. V-shaped skin incision at base of external componentScissorsDiathermy
  5. Pile dissected off internal sphincter up to pedicleinternal sphincter seen and kept intact
  6. Pedicle handlingTransfixed and ligatedDivided with diathermy / energy devicesuture material and size
  7. Piles excisednumber and positions
  8. Skin and mucosal bridges preservednumber of bridges; anal canal admits how many fingers at the end
  9. HaemostasisDiathermySuture ligatureBipolar

Closure, drains and dressing

  1. WoundsLeft open (Milligan-Morgan)Partly closed
  2. Local anaesthetic infiltrationdrug, volume
  3. Anal packNoneAbsorbable haemostatic packGauze pack (removal time)
  4. Dressinggreased gauze pad, T-bandage

Specimens and implants

  1. Pile masses sent for HPEYes, labelled by positionYes, together

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Watch for bleedingsoakage of dressing, pulse, BP; inform surgeon if bleeding
  2. Urinenote time of first void; catheterise if not passed and bladder palpable
  3. Pack removaltime, if a pack was placed
  4. Sitz bathwarm water, how often, from when
  5. Stool softener / laxativedrug and dose; aim for soft stool early
  6. Diethigh fibre, plenty of fluids
  7. Analgesiadrug, dose, frequency
  8. Follow-upwound check and HPE report; check for stenosis at review

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. A.S., 42 years, with bleeding per rectum and prolapse needing manual reduction for 2 years. Grade III internal haemorrhoids with external components at left lateral, right anterior and right posterior positions. Colonoscopy normal.

Case details

Date: 22/04/2026. Elective. OT 2.

In OT 08:30. Spinal given 08:40. Incision 08:55. Procedure completed 09:40.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: symptomatic grade III haemorrhoids, bleeding and prolapse, not controlled by fibre, laxatives and sitz baths for 6 months.

Hb 12.1 g/dl. No anticoagulant or antiplatelet drugs. Colonoscopy (March 2026): normal up to caecum.

Enema given the night before and on the morning of surgery.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient, brother as witness.

WHO checklist sign in and time out done. Prophylactic antibiotic as per unit policy: drug, dose and time recorded on the anaesthesia chart.

Anaesthesia and position

Spinal anaesthesia. Lithotomy position. Perianal skin shaved, painted with povidone-iodine and draped. Positions below are described by quadrant.

Findings

DRE: normal tone, no mass. Proctoscopy: three primary piles at left lateral, right anterior and right posterior positions, each with an external skin component. Largest at left lateral. No fissure, no internal opening, no polyp.

Procedure

No anal dilatation done.

Dilute adrenaline 1:400,000 injected in the submucosal plane under each pile.

Artery forceps applied to the skin and mucosal parts of each pile. Incisions marked to leave skin and mucosal bridges between them.

Left lateral pile first: V-shaped incision at the base of the external part with diathermy, carried across the anal verge. Pile dissected off the internal sphincter up to its pedicle. Internal sphincter fibres seen and kept intact.

Pedicle transfixed and ligated with polyglactin 910 (Vicryl) 2-0, pile excised distal to the ligature.

Right anterior and right posterior piles excised the same way.

Three skin and mucosal bridges preserved. Anal canal admits two fingers easily at the end.

Haemostasis with diathermy. Wounds left open.

Closure

Wound edges infiltrated with bupivacaine with adrenaline.

No anal pack. Greased gauze dressing and T-bandage applied.

Specimens and implants

Three pile masses in formalin, labelled left lateral, right anterior and right posterior, sent for HPE. No implants.

End of procedure

Estimated blood loss 40 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to post-operative ward in stable condition. Pulse 80/min, BP 126/80 mmHg.

Post-op orders

Pulse, BP half-hourly for 2 hours, then 4-hourly. Check dressing for soakage every hour for 4 hours.

Note time of first voiding. If not passed urine by 6 hours and bladder palpable, inform resident on duty.

Oral liquids after 4 hours, then high-fibre diet with plenty of fluids.

Stool softener from tonight and analgesia as per ward protocol.

Warm sitz bath for 20 minutes, 2 to 3 times a day, from POD 1.

Review in surgery OPD after 1 week with HPE report.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 22/04/2026, 10:00.

Must document for this operation

  • Number and positions of piles excised, with the position convention used. Clock positions change with patient position, so the next surgeon or a pathologist can misread them.
  • That skin and mucosal bridges were kept and the calibre of the anal canal at the end. Anal stenosis is a known complication and this is the record that the risk was guarded against.
  • Whether the internal sphincter was seen and kept intact, and whether anal dilatation was done. If the patient later has leakage of flatus or stool (incontinence), the note shows how the sphincter was handled.
  • How the pedicles were secured and whether a pack was left. Nurses must remove any pack on time, and a bleed needs to be traced to a pedicle.
  • Pile masses sent for histopathology (HPE), labelled. An unexpected cancer or other lesion is sometimes found in the tissue.
  • Colon evaluation done before surgery. Bleeding per rectum must not be blamed on piles without excluding a bowel cancer.

Common mistakes in these notes

  • Writing 'haemorrhoidectomy done' without the positions or number of piles.
  • Using clock positions without stating the patient position.
  • Not recording whether a pack was placed, so it is left in too long.
  • Leaving out the state of the internal sphincter.
  • Not noting the first voiding time after surgery.

Sources

  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 15, Surgery of the anus and perineum: General technique; Haemorrhoids; Milligan-Morgan haemorrhoidectomy, pp. 307-312.
  • Bhat SR. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 25, Anorectal Surgeries: Treatment of haemorrhoids; Open operative methods (Milligan-Morgan), pp. 1016, 1020-1022.
  • Scott-Conner CEH, Dawson DL, eds. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2015, Ch 122, Hemorrhoid Management (Kaiser AM): Excisional hemorrhoidectomy, pp. 656-661.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

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