Milligan Morgan Hemoroidektomi
Özet
Açık hemoroidektomi, 1937 yılında Milligan tarafından tanımlanan ve günümüzde de temel cerrahi yöntemlerden biri olarak kabul edilen efektif bir prosedürdür. Ameliyat genel, rejyonel veya lokal anestezi altında, litotomi veya prone pozisyonlarında gerçekleştirilebilir. Operasyon sırasında anodermden V şeklinde bir insizyon yapılarak hemoroid pakesi eksternal ve internal sfinkterlerden ayrılır, pedikül bağlanarak eksize edilir. Cerrahide anal stenoz oluşumunu engellemek adına mukokutanöz köprü alanlarının korunması kritik bir öneme sahiptir. Gelişen teknolojiyle birlikte monopolar koter, Ligasure ve Harmonic scalpel gibi cihazların kullanımı operasyon sürelerini kısaltmış, hemostazı kolaylaştırmış ve ameliyat sonrası erken dönem ağrıları azaltmıştır. Postoperatif en sık görülen komplikasyon olan ağrıyı azaltmak amacıyla lateral internal sfinkterotomi (LİS) eklenebilse de, özellikle yaşlı ve kadın hastalarda inkontinans riskini artırdığı için dikkatli olunmalıdır. Major iki yöntem olan Milligan Morgan ve Ferguson operasyonları karşılaştırıldığında, hastanede yatış süresi, rekürrens ve komplikasyonlar açısından benzer sonuçlar elde edildiği görülmektedir.
Open hemorrhoidectomy, introduced by Milligan in 1937, remains a fundamental and highly effective surgical procedure for treating hemorrhoidal disease. Conducted under general, regional, or local anesthesia in either lithotomy or prone positions, the technique involves a V-shaped incision made from the anoderm. The hemorrhoid pile is meticulously dissected from the external and internal sphincters, ligated at the pedicle, and excised. Preserving adequate mucocutaneous tissue bridges during excision is highly critical to prevent postoperative anal stenosis. Contemporary advancements incorporating monopolar cautery, Ligasure, and Harmonic scalpel devices have significantly optimized the procedure by shortening operative time, facilitating easier hemostasis, and minimizing early postoperative pain. Although lateral internal sphincterotomy (LIS) can be concurrently performed to reduce internal anal sphincter spasms and associated pain, it significantly elevates incontinence risks, particularly in elderly and female patients. Comparative meta-analyses between Milligan Morgan and Ferguson (closed) techniques reveal comparable outcomes regarding hospital stay, recurrence rates, and overall postoperative complications.
Referanslar
Xu L, Chen H, Lin G, Ge Q. Ligasure versus Ferguson hemorrhoidectomy in the treatment of hemorrhoids: a meta-analysis of randomized control trials. Surgical laparoscopy, endoscopy & percutaneous techniques. 2015;25(2):106-10.
Giannini I, Pecorella G, Pennisi D, Santangelo G, Digennaro R, Latorre F, et al. Control of post-hemorrhoidectomy symptoms and wound healing by Triclosan: a randomized, double-blind, controlled trial. Minerva chirurgica. 2014;69(2):75-82.
Lohsiriwat V. Approach to hemorrhoids. Current gastroenterology reports. 2013;15(7):1-4.
Chung CC, Ha JP, Tai YP, Tsang WW, Li MK. Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: ligation technique. Dis Colon Rectum. 2002;45(6):789-94.
Castellví J, Sueiras A, Espinosa J, Vallet J, Gil V, Pi F. Ligasure™ versus diathermy hemorrhoidectomy under spinal anesthesia or pudendal block with ropivacaine: a randomized prospective clinical study with 1-year follow-up. International journal of colorectal disease. 2009;24(9):1011-8.
Sakr MF, Moussa MM, Elserafy M. LigaSure hemorrhoidectomy vs stapled hemorrhoidopexy: a prospective randomized clinical trial. Dis Colon Rectum. 2010;53(1161):e7.
Ramadan E, Vishne T, Dreznik Z. Harmonic scalpel hemorrhoidectomy: preliminary results of a new alternative method. Tech Coloproctol. 2002;6(2):89-92.
Romaguera VP, Sancho-Muriel J, Alvarez-Sarrdo E, Millan M, Garcia-Granero A, Frasson M. Postoperative complications in hemorrhoidal disease and special conditions. Reviews on Recent Clinical Trials. 2021;16(1):67-74.
Liu J-W, Lin C-C, Kiu K-T, Wang C-Y, Tam K-W. Effect of glyceryl trinitrate ointment on pain control after hemorrhoidectomy: a meta-analysis of randomized controlled trials. World journal of surgery. 2016;40(1):215-24.
Das D, Choudhury U, Lim Z. Effectiveness of internal sphincterotomy in reducing post open hemorrhoidectomy pain: a randomized comparative clinical study. International journal of collaborative research on internal medicine & public health. 2013;5(6):0-.
Wang WG, Lu WZ, Yang CM, Yu KQ, He HB. Effect of lateral internal sphincterotomy in patients undergoing excisional hemorrhoidectomy. Medicine (Baltimore). 2018;97(32):e11820.
Emile SH, Youssef M, Elfeki H, Thabet W, El-Hamed TM, Farid M. Literature review of the role of lateral internal sphincterotomy (LIS) when combined with excisional hemorrhoidectomy. Int J Colorectal Dis. 2016;31(7):1261-72.
Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist’s view. World Journal of Gastroenterology: WJG. 2015;21(31):9245.
Bhatti MI, Sajid MS, Baig MK. Milligan–Morgan (open) versus Ferguson haemorrhoidectomy (closed): a systematic review and meta-analysis of published randomized, controlled trials. World journal of surgery. 2016;40(6):1509-19.
Balciscueta Z, Balciscueta I, Uribe N. Post-hemorrhoidectomy pain: can surgeons reduce it? A systematic review and network meta-analysis of randomized trials. International Journal of Colorectal Disease. 2021;36(12):2553-66.
Ho Y, Buettner P. Open compared with closed haemorrhoidectomy: meta-analysis of randomized controlled trials. Techniques in coloproctology. 2007;11(2):135-43.
