Factors affecting the postoperative healing in ferguson technique for hemorrhoidectomy

Journal of military pharmaco-medicine no2-2018

FACTORS AFFECTING THE POSTOPERATIVE HEALING IN
FERGUSON TECHNIQUE FOR HEMORRHOIDECTOMY
Phan Sy Thanh Ha*; Tran Minh Dao*
Nguyen Xuan Hung*; Nguyen Van Xuyen**
SUMMARY
Objectives: To study several factors affecting the postoperative healing with Ferguson
technique for hemorrhoidectomy. Subjects and methods: 190 patients with third-degree and
fourth-degree hemorrhoids underwent the Ferguson procedures at Vietnam-Germany Hospital
from 01 Sep 2012 to 31 Dec 2013. Results: 82.1% had the incision wound healed in phase 1 and
17.9% in phase 2. There was a correlation between the duration of healing and the form of
feces at the first postoperative bowel movement (p < 0.05). There was no correlation between
the duration of healing and the degree of hemorrhoids and numbers of cut hemorrhoids (p > 0.05).
Conclusion: Ferguson technique for hemorrhoidectomy is safe with good treatment outcome,
rapid healing, simple postoperative care and patients soon return to normal life and work.
* Keywords: Hemorrhoids; Ferguson technique; Postoperative healing.

INTRODUCTION
There are many methods of treatment
for hemorrhoids, including adjustment of
diets and sanitary care, procedure, surgery,
oriental medicine, occidental medicine or
combination of oriental and occidental
medicine. Surgical methods aim to cure
hemorrhoids completely. The Ferguson
procedure was introduced in 1959 as an
improvement of the Milligan-Morgan
procedure and has been widely applied in
the United States [1]. The method is the
most commonly indicated for hemorrhoids

for its ability of good bleeding control,
simple postoperative care, rapid healing,
early return to normal life and work. Some

surgeons are still cautious to choose
this method as the closure of skin and
rectal mucous membranes by suturing
may cause postoperative abscesses
and infections. In 2010, the first report
by Nguyen Xuan Hung showed that
Ferguson procedure was safe and effective
with simple postoperative care so it
should be applied [2]. Some brief reports
on this procedure were also available but
they failed to clarify the postoperative
treatment and care and factors affecting
the healing process [1, 2, 3]. Therefore,
this article aimed: To study several factors
affecting the postoperative healing in
Ferguson technique for hemorrhoidectomy.

* 198 Hospital
** 103 Military Hospital
Corresponding author: Phan Sy Thanh Ha ()
Date received: 14/11/2017
Date accepted: 22/01/2018

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Journal of military pharmaco-medicine no2-2018
- Age, sex.

SUBJECTS AND METHODS

- Healing: healing phase 1: 7 - 10 days,
phase 2: > 10 days.

1. Subjects.
190 patients with third-degree and
fourth-degree hemorrhoids underwent the
Ferguson procedures at Vietnam-Germany
Hospital from 01 September, 2012 to 31
December, 2013.

Study of the correlation between the
duration of healing:
- Degrees of hemorrhoid (third-degree
and fourth-degree hemorrhoids).
- Numbers of hemorrhoidectomy, form
of feces at the first postoperative bowel
movement.

2. Methods.
A prospective descriptive study, clinical
intervention and longitudinal study.

The data were processed using SPSS
22.0.

* Research criteria:

RESULTS
Table 1: Age groups per sex.
Sex

Male

Female

Total

Age group

n

%

n

%

n

%

≤ 20

1

0.5

0

0.0

1

0.5

21 - 40

36

18.9

41

21.6

77

40.5

41 - 60

52

27.4

27

14.2

97

41.6

61 - 80

18

9.5

12

6.3

30

15.8

> 80

2

1.1

1

0.5

3

1.6

109

57.4%

81

42.6%

190

100%

Total

The most common age group was 21 - 60, accounting for 82.1%, the average age
was 46.58 ± 14.72 years old. The oldest patient was 83 years old and the youngest
was 18 years old. Male accounted for 57.4%, female 42.6%.
Table 2: Duration of healing per degree of hemorrhoids.
Degree
Healing

Third-degree

Fourth-degree

Total
p

n

%

n

%

n

%

Healing phase 1

113

81.9

43

82.7

156

82.1

Healing phase 2

25

18.1

9

17.3

34

17.9

138

100

52

100

190

100

Total

0.89

82.1% of the patients had their incisions healed in phase 1 and 17.9% had wound
dehiscence. There was no correlation between the healing ratio and the degree
of hemorrhoids.
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Journal of military pharmaco-medicine no2-2018
Table 3: Duration of healing per numbers of hemorrhoidectomy.
Number of
hemorrhoidectomy

1
2
hemorrhoid hemorrhoids

3
hemorrhoids

4
hemorrhoids

Healing

n

%

n

%

n

%

n

%

Healing phase 1

28

87.5

51

85.0

72

80.9

5

55.6

Healing phase 2

4

12.5

9

15.0

17

19.1

4

44.4

32

100

60

100

89

100

9

100

Total

p

0.15

There was no correlation between the duration of healing and the numbers of
hemorrhoidectomy.
Table 4: Duration of healing per form of feces at the first postoperative bowel movement.
Healing

Phase 1

Phase 2

Total
p

Form of feces

n

%

n

%

n

%

Liquid

0

0.0

13

38.2

13

6.8

Mushy

49

31.4

20

58.8

69

36.3

Normal

99

63.5

1

2.9

100

52.6

Lumpy

8

5.1

0

0.0

8

4.2

156

100

34

100

190

100

Total

0.001

33/34 patients (97.1%) with liquid and mushy feces suffered from wound
dehiscence. The difference in the duration of healing and the form of feces at the first
postoperative bowel movement was statistically significant.
DISCUSSION
Postoperative complications of infections
and abscesses in Ferguson technique for
hemorrhoidectomy are always the special
concern of the surgeons. That is one of
the reasons why so far only some
Vietnamese surgeons have chosen this
method to treat hemorrhoids. 100% of
patients in this article were found not to
have postoperative abscesses and
infections. 156 patients had their incision
healed in phase 1, accounting for 82.1%,

phase 2: 17.9% (34 patients). Table 2 and
144

3 showed that there was no correlation
between the duration of healing and the
degree of hemorrhoids and numbers of
hemorrhoidectomy (p > 0.05). Table 4
showed that 33/34 patients (97.1%) with
liquid and mushy feces at the first
postoperative bowel movement suffered
from wound dehiscence. The difference in
the duration of healing and the form of
feces at the first postoperative bowel
movement was statistically significant
(p < 0.05). This can be explained that
liquid and mushy feces at the postoperative


Journal of military pharmaco-medicine no2-2018
bowel movement moisten the anal area,
cause the incision to have infections and
wound dehiscence. 8 weeks after the
procedure, all patients in the study had
their incision completely healed. Patients
were always advised not to immerse their
anus but always leave the anus dry.
Among 50 patients underwent the
Ferguson procedure by Aziz A, 62% had
their incision healed in the first week and
82% after 4 weeks [4]. In the study by Ho

K.S, 33.3% of the patient suffered from
wound dehiscence within the first 2 weeks
and after 8 weeks this rate was 13.8% [5].
Khubchandani I et al (2009) conducted a
study on 3.247 patients, 6 patients
(0.22%) suffered from abscesses, of
which 4 patients (0.12%) did not require
intervention. 2 patients (0.06%) required
re-operation. 163 patients (4.97%) suffered
from partial wound dehiscence. 2 patients
(0.06%) suffered from complete wound
dehiscence. In the study by Khanna R et
al, 20 patients (14%) undergoing the
Ferguson procedure suffered from wound
dehiscence [7]. In a study on 1,184
patients by Wesarachawit W (2007),
4
patients
suffered from
wound
dehiscence after 2 weeks of procedure.
No new case of wound dehiscence was
found after 4 weeks, most patients had
their incision healed with no stenosis.
According to Pattana-Arun J, 100 patients
with third-degree and fourth-degree
hemorrhoids might have complications,
of which 46 cases were performed
emergency operations and 54 patients
were scheduled operations. The author

compared the outcomes of the two
groups. After 2 weeks of the procedure,

wound dehiscence occurred in 5 patients
(10.8%) from emergency operations
and 7 patients (11.7%) from scheduled
operations; this difference was not significant
(p = 0.12). No new case of wound
dehiscence was found after 4 weeks,
all patients had their incision healed
completely. Pattana-arun J et al delivered
the Ferguson procedure to 1,184 patients
with third-degree and fourth-degree
hemorrhoids. Out of 416 emergency
operations and 786 scheduled operations
for treatment of prolapsing internal
hemorrhoid, bleeding hemorrhoid and
thrombosed external hemorrhoid, after
2 weeks of operation, 24 patients suffered
from wound dehiscence, accounting for
2.03%. After 4 weeks, all patients had
their incision completely healed with no
stenosis. Among 130 patients undergoing
the Ferguson procedure by Khalil-urRehman et al, 100% had their incision
healed after 2 weeks [6]. Malik A.G (2009)
delivered the Ferguson procedure to 30
patients and found that their healing
process only took < 2 weeks. 3.03% of
the patients in the study by Nguyen Sy
Tuan Anh suffered from wound dehiscence

and no case had infections and abscesses
[1]. 27.7% of the patients in the study by
Nguyen Van Lam suffered from wound
dehiscence, no case had infections and
abscesses; according to this author,
hemostasis in Ferguson procedure should
be performed carefully and thoroughly
to avoid hematoma which may cause
infections and over-tight incision. Coagulator
may be used for effective hemostasis.
However, this device causes tissue damage
around the edge of the incision and
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Journal of military pharmaco-medicine no2-2018
impedes the healing process. Do not
remove too much skin and mucous
membranes of the anal canal in the
procedure which may cause the sutures
to over-tight and lead to wound dehiscence.
All of these factors contribute to the
occurrence of wound dehiscence.
Numerous clinical trials comparing the
outcomes of the hemorrhoidectomy using
Milligan-Morgan and Ferguson techniques
of international authors have concluded
that the duration of healing in Ferguson
procedure is significantly shorter than that
in Milligan-Morgan procedure despite the

risk of wound dehiscence. Thus, from
these outcomes, we can completely trust
the Ferguson technique for hemorrhoidectomy
incase the principles of surgery, those of
treatment and patient care must be strictly
followed.
* Postoperative treatment and care:
After transferring the patient from the
operating room to the treatment room.
Inject 1,000 mL solution of 500 mL
ringer’s lactate solution + 500 mL glucose
5%. Pain relief after pain assessment:
Efferalgan 1 g IV x 2 vials/day each
8 hours for the first day. Severe pain may
be treated with opioid. Paracetamol 0.5 g
x 4 tablets/day for the following days.
Antibiotics: flagyl 0.5 g IV x 2 bottles/day
for the first day, flagyl 250 mg x 4
tablets/2 times (morning and afternoon)
/day for the following 5 - 7 days. Laxatives
should be used to avoid fecal stagnation
in the rectum which may cause irritation
and prolong pain. Place proctolog
suppositories into the anus from the 7th
day after surgery when the incision was
physiologically healed and a slight shrink
146

may cause mild stenosis; which is a very
effective treatment for stenosis. Patients

were fed porridge 12 hours after the
surgery and could eat regular diets with
more fiber and water, avoid alcoholic
stimulants, tobaco, spicy and hot food.
* Wound care: Change wound dressing
24 hours after the surgery and using
betadine 10% daily.
* Guide the patient to perform wound
care:
- Keep the incision clean (clean the
anus after bowel movement and dry by
permeable materials).
- Do not perform anal dilation without
medical advice and do not immerse the
anus. Always keep the anus dry.
If the patient has no bowel movement
for 4 days after the surgery, take a bottle
of fleet phospho-soda or a bag of fortran
1 g to avoid fecal stagnation in the rectum
which may cause irritation, prolonged pain
and incision infections.
Monitor the patient’s pulse, temperature,
blood pressure and perception. Urinary
retention, incision status: postoperative
bleeding, infections and abscesses.
Hospital discharge standards: no fever,
minor pain in the incision, no urinary
retention, no bleeding, no infection, no
abscess at the incision. Postoperative
visit: 7 or 14 days afterward.

CONCLUSION
Ferguson technique for hemorrhoidectomy
has the advantages of safety, good outcome,
rapid healing, simple postoperative care.
The incision rate was 82.1%. Do not soak
and squeez the anus everyday. Patients


Journal of military pharmaco-medicine no2-2018
soon return to normal life, average time
2.41 ± 0.76 days and quikly return to
work, average time back to work was
13.63 ± 4.29 days.

4. Aziz A, Ali I, Alam S.N et al.
Open hemorrhoidectomy versus closed
hemorrhoidetomy: The choice should be
clear. Pakistan Journal of Surgery. 2008,
24 (4), pp.254-257.

REFERENCES

5. Ho K.S, Ho Y.H. Prospective randomized
trial comparing stapled hemorrhoidopexy versus
closed Ferguson hemorrhoidectomy. Techniques
in Coloproctology. 2006, 10 (3), pp.193-197.

1. Nguyễn Sỹ Tuấn Anh. Kết quả điều trị
bệnh trĩ bằng phẫu thuật Ferguson tại Bệnh
viện Việt Đức. Luận án Tiến sỹ Y học. Đại học

Y. Hà Nội. 2011.
2. Nguyễn Xuân Hùng, Mark Helbraun,
Phạm Đức Huân và CS. Phẫu thuật Ferguson
điều trị trĩ. Tạp chí Đại tràng. 2010, 5, tr.9-13.

6. Khalil-ur-Rehman, Hasan A, Taimur M
et al. A comparison between open and closed
hemorrhoidectomy. J Ayub Med Coll Abbottabad.
2011, 23 (1), pp.114-116.

3. Nguyễn Văn Lâm, Mai Văn Đợi. Đánh
giá kết quả phẫu thuật Ferguson điều trị bệnh
trĩ tại Bệnh viện Trường Đại học Y Dược Cần
Thơ. Tạp chí Y Dược học. 2014, 421 (1),
tr.12-15.

7. Khanna R, Khanna S, Bhadani S et al.
Comparison of ligasure hemorrhoidectomy
with conventional Ferguson’s hemorrhoidectomy.
Indian Journal of Surgery. 2010, 72 (4),
pp.294-297.

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