ISSN (Print) : 2348–263X

ISSN (Online) : 2348-2648

MVP Journal of Medical Sciences, Vol 3(1), 7-10, January 2016 DOI: 10.18311/mvpjms/2016/v3i1/732

A Comparative Study of Open (Milligan-Morgan)

Versus Closed (Ferguson) Hemorrhoidectomy
Hemant Borse1* and Swapnil Dhake2
1
Professor, Department of Surgery, Dr. Vasantrao Pawar Medical College, Hospital and
Research Centre, Nashik - 422203, Maharashtra, India; [email protected]
2
Resident, Department of Plastic and Reconstructive Surgery,
Amrita Institute of Medical Sciences, Kochi - 682041, Kerala, India

Abstract
Introduction: Hemorrhoidectomy is an operation for third and fourth degree haemorrhoids. There are two methods by
which hemorrhoidectomy can be done -open (Milligan-Morgan) in which the wound is left open and allowed to heal by
secondary intension and closed (Ferguson) methods in which the wound is closed with absorbale sutures. Aim: To compare
post operative pain and recovery in open (Milligan-Morgan) and closed (Ferguson) methods and evaluate optimum
choice of the procedure for third or fourth degree hemorrhoids. Study Design: Prospective randomized study. Settings:
Department of Surgery, Dr. Vasantrao Pawar Medical College, Hospital and Research Center. Duration: Two year (August
2010 to August 2012). Sample Size: 70 cases (35 cases in each group). Inclusion Criteria: Patients with third/four degree
hemorrhoids. Exclusion Criteria: Patients with associated anal and perianal conditions like fissure in ano, inflammatory
bowel diseases and rectal malignancy, portal hypertension were excluded from the study. Results: Mean hospital stay for
open group was 5 days and closed group was 3 days. Post operative pain was seen in 77% in open group and 48 % in closed
group. Pain was relieved earlier in closed group. 71% patients had completely healed wounds at 3 weeks in closed group
in comparision to only 42% in open group. Anal stenosis was seen in 2 patients of open hemorrhoidectomy. Conclusion:
Closed hemorrhoidectomy is the procedure of choice for three/four degree hemorrhoids.

Keywords: Ferguson, Hemorrhoidectomy, Milligan-Morgan

1. Introduction of bleeding per rectum2 the disease is called as haemor-

rhoids.
Hemorrhoids is common disease. But there are many Some degree of hemorrhoid formation is seen after
misconceptions regarding this disesae1. Hemorrhoids are 50 yr of age. Many patients never have symptoms of
defined differently over the period of years from simple hemorrhoids, some patients are shy to see Doctor for
varicosities of hemorrhoidal plexus to specialized highly haemorrhoids, so finding out the prevalence of this dis-
vascular “cushions” of discrete masses of thick submu- ease is difficult2.
cosa, containing blood vessels, smooth muscles, elastic There are various methods of treating hemorhoids
and connective tissue1. haemorrhoids. Therapies for the topical treatment of
The term “Hemorrhoid” is derived from Greek adjec- hemorrhoids date back to Egyptian papyri of 1700 BC.
tive meaning bleeding (Haema-Blood, Rhoos-Flowing). Hippocratis in 460 BC described the first surgical treat-
The term “Pile” is derived from the Latin word “Pi la”, a ment for haemorrhoids, and suggested ‘transfixing them
pill or ball3. When the patient complains of a swelling the with a needle and tying them with a very thick and large
disease is called as piles and when the patient complaints woollen thread’4.

*Author for correspondence

 A Comparative Study of Open (Milligan-Morgan) Versus Closed (Ferguson) Hemorrhoidectomy

There are many aetiological factors for haemorrhoids orally the same day. Patients observed for pain. Pain
like erect posture, constipation, straining during defeca- was evaluated by visual analoge scale. Patients were also
tion, sedentary work, low fibre diet, heredity, high resting observed for bleeding, discharge, urinary retention post-
anal pressures. operatively. Patients were discharged depending upon
As per clinical classification for internal hemorrhoids their comfortness and wound condition. The average hos-
they can be classified into four degrees5. First and second pital stay in each technique was recorded. Patients were
degree hemorrhoids can be treated conservatively with reviewed after three weeks, one month, and subsequently
dietary modifications, injection sclerotherapy, rubber band reviewed after two months to six months. They were
ligation etc. For third and fourth degree hemorrhoidal disease asked about their complaints and examined. Digital rec-
surgery is the treatment of choice is surgery6. Hemorrhoids tal examination and proctoscopy was done on each visit.
can be treated by two types of Surgery-open (Milligan-
Morgan) and closed (Ferguson) hemorrhoidectomy. 3. Results
In this study we are comparing open (Milligan-
Morgan) and closed (Ferguson) hemorrhoidectomy for Seventy patients were selected and randomly allocated to
the post operative pain, post operative recovery, wound the procedure, 35 in each group. The age ranged from 17
healing, hospital stay and evaluate procedure of choice for years to 80 years.
third/four degree hemorrhoids. Age distribution is given in Table 1.
The most common presentation of hemorrhoids in
this study was bleeding per rectum seen in 90% of cases,
2.  Materials and Methods mass per rectum 63%and painful defecation 34%.
This is a prospective randomized clinical study of man- In open group 27 (77%) patients experienced pain
agement of third and fourth degree hemorrhoids by open postoperatively which was more as compared to closed
(Milligan-Morgan)/closed (Ferguson) hemorrhoidec- group seen in 18 (51%) patients.
tomy. The aim is evaluation of the post-operative pain, Discharge was also less in closed group (p<0.05).
wound healing, post operative recovery, complications On follow up pain was less in patients who underwent
and follow up. This study has been done from August closed hemorrhoidectomy. Wound healing was complete
2010 to August 2012. Seventy (70) patients with symp- in 25 (71%) patients in closed group at 3 weeks, in com-
tomatic and confirmed third/fourth degree hemorrhoids parison to 15 (42%) patients in open group. On follow up
admitted in the surgical units at Tertiary care centre with at 3 months wound healing was comparable in both the
medical college were included in this study. They were groups. The mean duration of hospital stay for patients
allocated randomly to open or closed hemorrhoidectomy. with closed hemorrhoidectomy was less, 3.8 days com-
pared to 5.2 days in patients with open group.
2.1  Inclusion Criteria
All patients with symptomatic and confirmed third/ 4. Discussion
fourth degree hemorrhoids.
Hemorrhoids is a common disease in our society.
Third and fourth degree haemorrhoids require surgery.
2.2  Exclusion Criteria
Table 1.  Age & Gender distribution of open
Patients with associated anal and perianal conditions like & Closed group
fissure in ano, inflammatory bowel diseases and rectal Open group Closed group
malignancy, portal hypertension.
No. of patients 35 35
In this study 35 patients underwent open technique
Age Range 20 – 60 years 17– 80 years
of hemorrhoidectomy and 35 patients underwent closed
Mean age 37 39
technique of hemorrhoidectomy
Sex
2.3  Post-Operative Course Male 27 29
Female 8 6
All the patients were treated post operatively with anal-
gesics, antibiotics and laxatives. All patients were allowed Male:female ratio 3.8:1 4.8:1

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 Hemant Borse and Swapnil Dhake

Hemorrhodectomy can be done by two methods open wounds are contaminated during defecation causing
(Milligan- Morgan) and closed (Ferguson) hemor- the delay in healing. Furthermore some patients may
rhoidectomy. Most of the patients want less stay in the develop fistulas, abscess and later anal canal stenosis.
hospital and early return to work. Keeping this in mind, A higher rate of wound healing was noted following
this study was conducted to compare two procedures closed hemorrhoidectomy as compared to open in all the
– open (Milligan-Morgan) and closed (Ferguson) hem- studies.
orrhoidectomy and evaluate the optimum procedure for Healing at 3 months in our study was comparable in
third and fourth degree hemorrhoids with regards to post both open and closed groups. The result of our study is
operative pain, discharge, wound healing and hospital also comparable with the study conducted by9. The aver-
stay. In our study, we found that more number of patients age hospital stay for patients in open group was 5.2 days
presented with hemorrhoids in the age group of 31 to 40 and closed group was 3.8 days in our present study. The
years. Early presentation can be attributed to the chang- shorter duration of stay in hospital, cost effectiveness and
ing dietary habits and lifestyle modifications leading to reliable outcome improves the patient compliance. The
chronic constipation and straining for defecation and results of hospital stay in our study were comparable with
micturition. In our study male predominance was seen study conducted by10 which also suggested 5 days for open
over females. Hemorrhoids are common in female, but group and 4 days for closed group. The data was analyzed
due to their reluctant shy nature and fear for surgery most using unpaired ‘t’ test with significant p value (P<0.001).
of the female population do not approach for any treat-
ment and remain undiagnosed. The results of our study
are compared to study conducted by7. The male:female 5. Conclusion
ratio in our study was found to be higher than in study
Closed hemorrhoidectomy leads to faster wound healing.
by7.
It is a safe and effective procedure. The complications
The most common symptom was bleeding per rec-
like pain, discomfort and discharge were less. The
tum, which was present in 90 % patients. Mass per rectum
hospital stay were less in closed technique as compared
was present 61%. Constipation was found to be associated
to open technique. Complications like anal stenosis were
with 24% patients.
not seen in the follow-up. Closed hemorrhoidectomy
Most of the patients experienced pain following hem-
is the procedure of choice for third and fourth degree
orrhoidectomy but it was more (77%) in open group than
hemorrhoids.
those who underwent closed hemorrhoidectomy (51%).
This occurs due to low ligation incorporating the sensi-
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 A Comparative Study of Open (Milligan-Morgan) Versus Closed (Ferguson) Hemorrhoidectomy

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