Ferguson

Anthony J. Senagore

Indications/Contraindications

The most frequent symptoms leading to surgical intervention for hemorrhoidal suffers are bleeding, protrusion, and anorectal discomfort and pain.

Bleeding typically bright red blood on the toilet paper or dripping into commode.
Occasionally massive bleeding with very large internal hemorrhoids.
Hemorrhoidal prolapse usually with bowel movements that may spontaneously reduce, require manual reduction, or be irreducible depending on stage.
Severe, constant pain is usually related to acute thromboses of internal or external hemorrhoids and associated with a palpable perianal mass.

Examination of the patient with hematochezia requires inspection of the perianal area including anoscopy and either rigid proctoscopy or flexible sigmoidoscopy. Colonoscopy can be undertaken based on patient’s history, age, or suspicious symptomatology. The author prefers examination in the modified Sims’ position (left lateral decubitus with knees drawn toward the chest and the lower legs extended). This position approach allows relative patient comfort, while allowing the clinician to perform all components of the anorectal examination.

A careful digital examination of the anal canal and distal rectum and prostate
Anoscopy to clearly inspect the hemorrhoidal tissue and anal canal with assessment of size, degree of prolapse, and any fragility or bleeding
Proctoscopy or flexible sigmoidoscopy to exclude neoplasia or inflammation
Assessment of the three standard columns (right anterior, right posterior, and left lateral)

Preoperative Planning

The decision to proceed to excisional hemorrhoidectomy requires a mutual decision by the physician and patient that medical and nonexcisional options have either failed or are inappropriate. Surgery is typically employed when the primary symptom is
significant, intractable hemorrhoidal prolapse, or alternatively large external skin tags that impair anal hygiene. Preoperative preparation is generally minimal as the patient population is generally healthy and the procedure is typically ambulatory. If the patient is on therapeutic anticoagulation, this should be managed in conjunction with the managing physician to control the risk of hemorrhage postoperatively

The procedures are usually performed in the operating theater following preoperative sodium phosphate enemas to clear the distal rectum of stool.
The modified Sims’ position is the preferred position by the author for all excisional procedures except for procedure for prolapsing hemorrhoid (PPH) that is optimally performed in lithotomy position.
Anesthetic selection is usually left to the anesthesiologist and patient; however, local anesthesia supplemented by the administration of intravenous narcotics and propofol is highly effective and short acting.
Avoid spinal anesthesia due to risk of urinary retention.
Restrict intraoperative fluids.
Administer preemptive analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) in operating room.

Selection of Excisional Tool

Surgery

Options for excisional hemorrhoidectomy include the following techniques:

Milligan-Morgan hemorrhoidectomy

1. This technique resects the entire enlarged internal hemorrhoid complex; in conjunction with ligation of the arterial pedicle correctly performed the intervening anoderm is preserved, while the distal anoderm and external skin are left open to heal by secondary intention.

Ferguson closed hemorrhoidectomy

2. Proposed as an alternative to the Milligan-Morgan technique with similar experience and efficacy. The technique employs an hourglass-shaped excision of the entire internal/external hemorrhoidal complex centered at the midportion of the anoderm with preservation of the intervening anoderm. Unlike the Milligan-Morgan, the rectal mucosa, anoderm, and perianal skin are closed primarily with an absorbable suture.

Whitehead hemorrhoidectomy

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