*Małgorzata Kołodziejczak1, Przemysław Ciesielski1, 2, Paweł Dutkiewicz2
The place of Milligan-Morgan haemorrhoidectomy in the contemporary algorithm for the treatment of haemorrhoidal disease – a review of current literature
1Warsaw Proctology Centre, Saint Elizabeth’s Hospital, Mokotów Medical Centre, Warsaw
Head of Department: Małgorzata Kołodziejczak, PhD, Associate Professor
2Department of General Surgery, County Hospital in Wołomin
Head of Department: Krzysztof Górnicki, MD, PhD
Among the classic methods of hemorrhoidectomy the two most commonly used methods are open Milligan-Morgan hemorhoidectomy (MMH) and closed Ferguson hemorrhoidectomy (FH). Although the Milligan-Morgan method was described by the authors in 1937 it is still, with some modifications, a commonly used method of surgical treatment of hemorrhoids. The advantages of the method are high efficacy, ease of execution, short learning curve and minimal recurrence rate. Disadvantages are pain after surgery and a long, about six-week, healing period of the anal canal. The authors present indications for the procedure, describe the technique of the operation and the place of the MMH procedure in the algorithm of hemorrhoidal disease treatment. The authors also compare the effectiveness of the MMH and the rate of complications to those of other surgical methods such as FH by reviewing the literature of recent years. Despite the introduction of many new surgical techniques the classic open Milligan-Morgan hemorrhoidectomy stood the test of time and still has its place in the treatment of advanced and complicated hemorrhoidal disease.
Currently the indications for the classic haemorrhoid surgery have been significantly narrowed. It is thought that the majority of patients with haemorrhoidal disease should receive effective conservative treatment and only 10-15% of patients require surgery.
The two most commonly used classic methods of haemorrhoid removal are open Milligan-Morgan haemorrhoidectomy and closed Ferguson haemorrhoidectomy. Interestingly enough, while both methods have been known for several decades, they are still in use with certain modifications. The Milligan-Morgan haemorrhoidectomy procedure was described by its authors in 1937 and has been the most commonly used surgical method in the treatment of haemorrhoids up to this day (1).
Classic haemorrhoidectomy is chosen mainly for patients with grade IV haemorrhoidal disease as well as patients with earlier grades of the disease with profuse bleeding resulting in anaemia, for whom other methods of treatment have proven ineffective (including surgical procedures conducted in outpatient settings) and patients with large marginal folds coexisting with haemorrhoids. In patients with prolapsed haemorrhoids with thrombotic lesions there are indications for urgent surgery due to the risk of necrosis that could lead to sepsis (2).
Relative contraindications include pregnancy, immune system disorders, coagulopathies, cirrhosis, portal hypertension (3).
An absolute contraindication is the lack of patient’s consent to the operation.
Description of the method
An open haemorrhoidectomy may be performed using conventional surgical instruments: scissors, scalpel, as well as laser or LigaSure.
A haemorrhoid should be cut around (using a scalpel, scissors or electrocoagulation) and dissected from the bed (from the external sphincter muscle), cutting through the Parks ligament. If the enlarged node is accompanied with an overgrown marginal fold, it should also be removed. While dissecting the node the mucous membrane should be spared with a view to better subsequent regeneration of the anal canal. Subsequently the vascular pedicle is transfixed with an absorbable suture (fig. 1) and the haemorrhoid is ligated to both sides and cut off. The remaining pedicle should not be too long (this causes discomfort for the patient), but it also should not be too short since during the demarcation of the pedicle bleeding from the haemorrhoidal artery may occur. The present author applies an additional suture at the top of the wound in order to approximate the margins of the wound, which also prevents the ligature from sliding off. After the excision of all three nodes and control of haemostasis the cosmetic effect is also evaluated. Excessively overgrown marginal folds may be cut off using radial incisions in relation to the anal canal. If the distances between the different wounds (bridges) are too small and an additional wound would create the risk of stenosis of the anal canal or compromised healing, an overgrown fold may be sutured into the anal canal, thus achieving a good cosmetic effect without widening the surface of the wound.
Fig. 1. Milligan-Morgan surgery: transfixing of a vascular pedicle
Advantages of the method
A major advantage of the method described is its efficacy measured by a low rate of relapse, which has been confirmed in numerous multicentre studies. Other advantages include simplicity of the procedure and a short learning curve (4).
Disadvantages of the method
The main disadvantage of this method is post-operative pain and a long healing period (up to 6 weeks), which, however, is also true for other surgical methods used for this indication.
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