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surgeonsincludingtheeditorspreferthepronejackknifepositionthat allowssurgeonsandassistantsroomtooperateoneachsideofthe patient.
SurgicalTechnique
TheHillFergusonretractorisinsertedtosequentiallyassesstheright posterior,rightanterior,andleftlateralcolumns.Theexcisionscanbe
limitedtoonlythepathologicallyenlargedcolumns(1,2,and/or3may beexcised;Fig.1-1).
FIGURE1-1TheHillFergusonretractoris
positionedintheanalcanaltodemonstratetheentire lengthoftheenlargedhemorrhoidalcolumn.
Thelargestofthepathologiccolumnsshouldbeaddressedfirstas excision.Woundclosuremayreducethesizeoftheadjacentcolumnsby
eitherreducingthevolumeofthenextexcisionorobviatingfurther excision.
TheenlargedcolumnshouldbegraspedatitsbasewithaDebakey forcepstoassurethattheanodermwillbetensionfree(Fig.1-2).
FIGURE1-2Thehemorrhoidalcolumnis
compressedatthebasewithaDebakeyforcepsto ensurethattheanodermcanbeapproximated withoutunduetension.Theincisionshouldbeshaped likeanhourglass,withthenarrowedportioncentered attheleveloftheanodermtominimizeexcisionof thistissuetoreducetheriskofstricture.
p.2
p.3
A10scalpelbladeisusedtoincisethehemorrhoidcolumninanhour glassfashionwiththewaistofthehourglasscenteredattheanodermto
minimizeexcisionoftissueatthisleveloftheanalcanal.Wideningthe incisionatthetopofthehemorrhoidalcolumnassuresadequateexcision oftheinternalhemorrhoidalcomplex.Similarly,awiderexcisionofskin reducestheriskofskintagspostoperatively.
Thehemorrhoidalcolumnisthendissectedfromthesurfaceofthe internalsphincterusingMayoscissorsuptothepedicle(Fig.1-3).
FIGURE1-3Thehemorrhoidalpedicleisdissected
offthesurfaceoftheinternalanalsphincteruptothe levelofthepedicle.
p.3
p.4
ThepedicleisgraspedwithalargeKellyclampallowingtransectionof thehemorrhoid.
Thepedicleissutureligatedusing3-0VicrylonaCT2needle.Adeeper suturefixationofthepedicleisrepeatedtoassurefixationofthepedicle
abovetheleveloftheanorectalringtoreducetheriskofrecurrenceof symptomsduetopedicleprolapse(Fig.1-4).
FIGURE1-4Thehemorrhoidalpedicleisdoubly
ligatedwith3-0Vicrylsutureatthetopofthe anorectalringtoreducetheriskofrecurrentprolapse.
ThesameVicrylsutureisusedtoclosetherectalmucosa,anoderm,and perianalskininsequence.Itisonlynecessarytoplaceeverythirdstitch
intotheinternalanalsphinctertohelpreducepain.Thiswillallow adequateclosureofdeadspace(Fig.1-5).
FIGURE1-5Thepediclesutureisusedtoperform
arunningclosureoftheentirelengthofthewound.
POSTOPERATIVEMANAGEMENT
Painremainsthemostchallengingcomponentofpostoperativecare followingexcisionalhemorrhoidectomy.
Theoptimalanalgesicregimenshouldbeginwiththeaccurate infiltrationofbupivacaineintothewoundsandtheperianalskin’
althoughitsusehasbeenvariablysuccessfulinlong-termpain reduction.Liposomalbupivacainehasbeenemployedforthisprocedure inparticular,withsuggestionsofsuperioranalgesia;however,this benefitisgainedatasignificantcostpercase.
NSAIDs(nonsteroidalanti-inflammatorydrugs),especiallyketorolac, havebeenveryefficaciousinmanagingposthemorrhoidectomypain.
Therelativebenefitofpreoperativeoralloadingwithnaprosynthatcan becontinuedpostoperativelyisalsoveryeffectiveandinexpensive.
Thehome-goingoralpaincontrolregimenfornarcoticsparinganalgesia shouldinclude300mggabapentinq8h,acetaminophen650mgq6h,
andnaprosyn500mgq12h. Thepatientcanbeprovidedasmallprescriptionfororalnarcoticsfor
break-throughpainmanagement.
Urinaryretentionisanotherfrequentposthemorrhoidectomy complication.Agentssuchasparasympathomimeticsorα-adrenergic blockingagentsmaybebeneficial.However,theuseofsitzbathsfor comfort,effectiveanalgesia,andthelimitationsofperioperativefluid administrationto500mlmaybeamoreeffectiveapproach.
Bowelmanagementisveryimportanttoavoidfecalimpactionorpain duetoconstipation.Theauthorgenerallyrecommendsanearlyreturnto normaldiet,nightlyuseofanoralmagnesiumlaxativeforseveraldays, anddailypsylliumfibersupplement.

COMPLICATIONS

Delayedhemorrhagefollowingexcisionalhemorrhoidectomyisnot totallypreventablebutfortunatelyoccursinlessthan2%ofcases,and presentationisusuallyfromdays5to10postoperatively.Thepatient shouldbeinstructedtoreturnimmediatelyuponrecognitionwithstrong considerationforreturntotheoperatingroomwithresuturingofthe wounds.Thesituationcanbetemporizedbybladdercathetertamponade usinga60-mlballooncatheterplacedintrarectallyandpulledintothe analcanal.Consistenttensionortractionisrequiredtoslowbloodloss.
Surgicalsiteinfectionisamazinglyrarewiththisoperationbutithas beenreported.Typicallywhenitdoesoccurthewounddehisces,which mayactuallyrelievethesituation.Occasionally,thepatientcandevelopa deeperabscesswiththeriskofdevelopingaperianalabscess/fistulain ano.However,thiscomplicationisalmostinthereportablecasereport range.
ThebestreviewofthetechniquewasthelargereviewoftheFerguson experiencebyGanchrowetalin1971.Thedatashowedthatbleeding and/orhemorrhoidalprolapsewastheprimaryindicationfor hemorrhoidectomy.
80%were3column;and17%3columnwithunderminingofintervening anodermtoclearintermediatehemorrhoidaltissue
Fissurectomywasperformedin21%ofcasesandsphincterotomyin12% ofcases
Earlycomplicationsincluded:minimalbleeding,2%;bleedingwith returntoOR,1.3%;andabscess,0.2%
Latecomplications:fissure,2.7%;analstenosis,1.1%;abscess/fistula,
0.9%

RESULTS

InadditiontotheGanchrowarticlementionedearlier,therehavebeen severalmeta-analysescomparingFergusontechniquetothetwomost commoncompetitors:MilliganMorganandcircularstapledtechniques. Themessageremainsthattheclosedtechniqueiseconomicallyefficient andhighlyeffectiveinthelongtermforsymptomreliefwithalowriskof complications.Comparedwiththeopentechnique,bothshort-term healingandlong-termfunctionalityappearsuperior.Althoughcircular stapledtechniquecanbeeffective,itismoreexpensive,itisassociated withmoresurgicalcomplicationsandahigherrecurrencerate,and reportsofpersistentpainaftertheprocedurehaveresultedinwithdrawal oftheinstrumentfromthemarket.

CONCLUSIONS

TheFergusonclosedhemorrhoidectomyhasstoodthetestoftimeasthe goldstandardforsymptomaticprolapsinghemorrhoidsnotabletobe managedwithnonoperativetechniques.Theoperationcanbeeffectively performedwithscalpel/scissortechniquewithminimalcomplications, bothshortandlongterm.Thereislittleneedtoaddexpensiveenergy technology.Effectivepaincontrolpostoperativelyandbowel managementwillspeedthepatients’recovery.
RECOMMENDEDREFERENCESAND READINGS
BhattiMI,SajidMS,BaigMK.Milligan-Morgan(open)versusFergusonhaemorrhoidectomy
(closed):asystematicreviewandmeta-analysisofpublishedrandomized,controlledtrials.
WorldJSurg2016;40(6):1509–19. FergusonJA,HeatonJR.Closedhemorrhoidectomy.DisColonRectum1959;2:176–9. GanchrowMJ,MazierWP,FriendWG,FergusonJA.Hemorrhoidectomyrevisited:acomputer
analysisof2038cases.DisColonRectum1971;14:128–33. HayssenTK,LuchtefeldMA,SenagoreAJ.Limitedhemorrhoidectomy:resultsandlong-term
follow-up.DisColonRectum1999;42(7):909–14;discussion914–5. HetzerFH,DemartinesN,HandschinAE,ClavienPA.Stapledvsexcisionhemorrhoidectomy:
long-termresultsofaprospectiverandomizedtrial.ArchSurg2002;137(3):337–40. JayaramanS,ColquhounPH,MalthanerRA.Stapledhemorrhoidopexyisassociatedwithahigher
long-termrecurrencerateofinternalhemorrhoidscomparedwithconventionalexcisional
hemorrhoidsurgery.DisColonRectum2007;50(9):1297–305. JóhannssonHO,PåhlmanL,GrafW.Randomizedclinicaltrialoftheeffectsonanalfunctionof
Milligan-MorganversusFergusonhaemorrhoidectomy.BrJSurg2006;93(10):1208–14. LaughlanK,JayneDG,JacksonD,RupprechtF,RibaricG.Stapledhaemorrhoidopexycompared
toMilligan-MorganandFergusonhaemorrhoidectomy:asystematicreview.IntJColorectal
Dis2009;24(3):335–44. MajeedS,NaqviSR,TariqM,AliMA.Comparisonofopenandclosedtechniquesof
haemorrhoidectomyintermsofpost-operativecomplications.JAyubMedCollAbbottabad
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DisColonRectum1981;24:211–4. NisarPJ,AchesonAG,NealKR,ScholefieldJH.Stapledhemorrhoidopexycomparedwith
conventionalhemorrhoidectomy:systematicreviewofrandomized,controlledtrials.DisColon
Rectum2004;47(11):1837–45. SenagoreA,MazierWP,LuchtefeldMA,MacKeiganJM,WengertT.Thetreatmentofadvanced
hemorrhoidaldisease:aprospectiverandomizedcomparisonofcoldscalpelversuscontact
Nd:YAGlaser.DisColonRectum1993;6:1042–9. SenagoreAJ,SingerM,AbcarianH,etal;ProcedureforProlapseandHemorrhoids(PPH)
MulticenterStudyGroup.Aprospective,randomized,controlledmulticentertrialcomparing
stapledhemorrhoidopexyandFergusonhemorrhoidectomy:perioperativeandone-year
results.DisColonRectum2004;47(11):1824–36.Erratumin:DisColonRectum
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