Hemorrhoidectomy (Ferguson / Milligan-Morgan)

Procedure Snapshot

• Indication: Symptomatic grade III–IV hemorrhoids or failed office therapy.
• Expected duration: ___
• Special instruments: Hill-Ferguson retractor, LigaSure, bipolar device.

Step Workflow

1. Lithotomy; expose anus.
2. Identify hemorrhoid columns at 3, 7, 11 o’clock.
3. Grasp and incise over hemorrhoid.
4. Dissect to pedicle; ligate and excise.
5. Leave skin bridges between wounds (prevent stenosis).
6. Closed (Ferguson) = primary mucosal closure; open = leave to heal.

Key Pimp Questions

• Q: Pectinate line significance?
  A: Visceral vs somatic pain sensation.
• Q: Complications?
  A: Urinary retention, bleeding, stenosis (PMID 32949111).

Critical Anatomy

• Landmarks: Anal canal, internal/external sphincter, pectinate line.
• Danger zones: Sphincter injury → incontinence.

Informed Consent Highlights

• Risks: Pain, bleeding, retention, recurrence.

Post-op Considerations

• Sitz baths, fiber, stool softeners; analgesia routine.

References

• Chassin’s, Anorectal section.
• Clinical Scenarios, Anorectal.
• Brown 2020 (PMID 32949111).