Overview
Definition:
The Ferguson hemorrhoidectomy, also known as the open hemorrhoidectomy, is a surgical procedure to remove symptomatic internal hemorrhoids using electrocautery or scissors, leaving the wounds open to granulate
It is a traditional technique that involves excising the hemorrhoidal tissue and coagulating the base
The procedure aims to alleviate symptoms such as bleeding, prolapse, and pain associated with advanced hemorrhoidal disease.
Epidemiology:
Hemorrhoidal disease is highly prevalent, affecting up to 75% of adults at some point in their lives
Surgical intervention, including hemorrhoidectomy, is typically reserved for patients with symptomatic grade III and IV internal hemorrhoids, or those who have failed conservative management
The Ferguson technique, while less common now than closed or semi-closed methods, is still utilized and taught.
Clinical Significance:
Hemorrhoidectomy remains a cornerstone in the surgical management of severe hemorrhoidal disease
Understanding the Ferguson technique is crucial for surgical residents preparing for DNB and NEET SS examinations, as it represents a fundamental surgical approach
Proper technique, patient selection, and postoperative care are vital to minimize complications and ensure successful outcomes, impacting patient quality of life significantly.
Indications
Indications:
Significant prolapse of internal hemorrhoids (Grade III and IV).
Bleeding that is unresponsive to conservative treatment.
Intractable pain or discomfort related to hemorrhoids.
Thrombosed external hemorrhoids that are extremely painful.
Anal canal symptoms not attributable to hemorrhoids but requiring examination and potential intervention.
Contraindications:
Active perianal infection.
Severe immunocompromise.
Uncontrolled bleeding disorders.
Patients with a very narrow anal canal or significant anal stenosis.
Inflammatory bowel disease affecting the anal region without adequate control.
Patient Selection:
Careful patient history to rule out other anorectal pathology.
Assessment of hemorrhoid grade and symptoms.
Patient understanding of the procedure, risks, and recovery.
Suitability for general or regional anesthesia.
Preoperative Preparation
History And Physical:
Detailed history of bowel habits, bleeding, pain, and prolapse.
Digital rectal examination to assess sphincter tone and identify masses.
Anoscopy to visualize internal hemorrhoids.
Exclusion of other anorectal conditions like fissures, fistulas, or malignancy.
Investigations:
Routine pre-operative blood tests (CBC, Coagulation profile, Electrolytes).
ECG and chest X-ray for patients with comorbidities.
Colonoscopy may be indicated in patients with rectal bleeding, especially those over 40 or with risk factors for colorectal cancer.
Bowel Preparation:
Clear liquid diet for 24-48 hours prior to surgery.
Laxatives or enemas on the evening before surgery to ensure an empty bowel.
Antibiotic prophylaxis may be administered to reduce the risk of surgical site infection, often with metronidazole or a cephalosporin.
Anesthesia:
General anesthesia is most common.
Spinal or epidural anesthesia can also be used.
Sedation with local anesthesia may be an option for select patients.
Procedure Steps
Positioning:
Patient is placed in the lithotomy position to provide optimal exposure of the anal canal.
Anoscopy And Marking:
An anoscope is inserted, and the prolapsed hemorrhoidal tissue is identified.
The surgeon may mark the extent of excision with a surgical marker.
Excision:
Using scissors or electrocautery, the surgeon incises the mucocutaneous junction distal to the hemorrhoid.
The hemorrhoidal tissue is then dissected proximally, elevating the hemorrhoid from the underlying internal sphincter.
The base of the hemorrhoidal pedicle is grasped and ligated with absorbable sutures.
The excised hemorrhoidal tissue is removed, leaving the surgical bed open.
Wound Management:
The surgical wounds are left open to granulate.
Hemostasis is achieved by cauterizing bleeding vessels.
A small gauze packing may be inserted into the anal canal temporarily to absorb exudate and prevent early bleeding, but it is usually removed within a few hours post-operatively.
Postoperative Care
Pain Management:
Aggressive pain control is essential.
Opioids (morphine, fentanyl) for severe pain.
Non-steroidal anti-inflammatory drugs (NSAIDs).
Topical anesthetics (lidocaine gel or suppositories).
Sitz baths (warm water soaks) multiple times daily to relieve pain and promote healing.
Bowel Regulation:
Stool softeners (e.g., docusate sodium) are crucial to prevent straining.
High-fiber diet once tolerated.
Adequate hydration to maintain soft stools.
Wound Care:
Gentle cleansing of the perianal area after each bowel movement.
Avoidance of harsh soaps or antiseptics.
Observation for signs of infection or excessive bleeding.
Discharge Instructions:
Instructions on pain management, bowel regimen, wound care, and activity restrictions.
Warning signs of complications (fever, severe bleeding, inability to void).
Follow-up appointment with the surgeon.
Complications
Early Complications:
Postoperative pain (significant and often severe).
Urinary retention.
Bleeding (immediate or delayed).
Infection (abscess formation).
Fecal impaction.
Anal stenosis (early).
Late Complications:
Chronic anal pain.
Anal stenosis (late).
Anal fissure.
Recurrence of hemorrhoids.
Rectovaginal or rectourethral fistula (rare).
Skin tags.
Scarring.
Wound dehiscence.
Prevention Strategies:
Meticulous surgical technique to achieve adequate hemostasis.
Appropriate patient selection and bowel preparation.
Aggressive postoperative pain management to facilitate early mobilization and bowel function.
Proactive use of stool softeners and laxatives.
Patient education on wound care and hygiene.
Key Points
Exam Focus:
Ferguson hemorrhoidectomy is an open technique
It is indicated for grade III-IV internal hemorrhoids
Postoperative pain is a major concern
Aggressive pain control and stool softeners are critical
Complications include pain, bleeding, infection, and stenosis.
Clinical Pearls:
Ensure adequate hemostasis during excision
Leave wounds open to granulate
Counsel patients thoroughly on the expected recovery, especially regarding pain
Utilize a multimodal approach to pain management
Early mobilization and bowel management are key to preventing complications.
Common Mistakes:
Inadequate hemostasis leading to postoperative bleeding.
Over-excision of tissue causing excessive pain or anal stenosis.
Insufficient pain management leading to urinary retention or fear of defecation.
Inadequate bowel preparation or advice on stool softeners leading to constipation and straining.
Failure to identify and manage other anorectal pathology during examination.