Comparison of Doppler Guided Hemorrhoid Artery Ligation and Milligan Morgan Hemorrhoidectomy in Management of Hemorrhoidal Disease


Hossein Shabahang 1 , Ghodratolah Maddah 1 , * , Asieh Sadat Fattahi 1 , Leila Bahadorzadeh 1 , Sadjad Noorshafiee 2

1 Endoscopic Minimally Invasive Surgery Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran

2 Imam Ali Hospital, Faculty of Medicine, North Khorasan University of Medical Sciences, Bojnurd, IR Iran

How to Cite: Shabahang H, Maddah G, Fattahi A S, Bahadorzadeh L, Noorshafiee S. Comparison of Doppler Guided Hemorrhoid Artery Ligation and Milligan Morgan Hemorrhoidectomy in Management of Hemorrhoidal Disease, Iran Red Crescent Med J. 2013 ; 15(5):-. doi: 10.5812/ircmj.5140.


Iranian Red Crescent Medical Journal: 15 (5)
Published Online: May 5, 2013
Article Type: Research Article
Received: April 15, 2012
Revised: July 22, 2012
Accepted: December 26, 2012




Background: Hemorrhoidal disease is the most common rectal disorder, and many modalities have been suggested for its treatment.

Objectives: In this study, we compared Doppler-guided Hemorrhoid Artery Ligation, one of the newest techniques in the treatment of this disease, to the Milligan-Morgan Hemorrhoidectomy (open Hemorrhoidectomy).

Patients and Methods: One hundred patients were enrolled in this study and divided randomly into two groups of fifty patients. Each group either underwent the Milligan-Morgan procedure or the Doppler-guided Hemorrhoid Artery Ligation method. The outcomes were compared using statistical methods.

Results: Patient demographic results and symptomatology and the type of anesthesia used had no influence on the study results. The mean duration of the operation had no statistical difference. The major impact of this new method had less postoperative pain and more patient satisfaction. After a mean follow up of eighteen months, we had two cases of recurrence in the Doppler-guided Hemorrhoid Artery Ligation group with grade IV hemorrhoidal disease.

Conclusions: Doppler-guided Hemorrhoid Artery Ligation is a safe and easy method for treating hemorrhoidal disease, but its results should be interpreted carefully, especially in grade IV of the disease.


Hemorrhoids Hemorrhoidectomy

Copyright © 2013, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Hemorrhoids are normal structures in the anal canal that mainly help in continence, and hemorrhoid disease is the most common disorder of this canal. This condition occurs as a result of abnormal blood flow that leads to tissue protrusion from the anal canal (1, 2). Patients mostly complain of pain, discomfort, bleeding and itching. Different types of modalities have been introduced such as conservative management, non-excisional to excisional treatment including: Milligan-Morgan hemorrhoidectomy (MMH), fergosen, sclerotherapy, lasertherapy, stapled hemorrhoidopexy, and the innovative technique: Doppler-Guided Hemorrhoidal Artery Ligation (DGHAL). (1, 3, 4). This technique has been introduced by Morinaga in 1995, 23 or Jespersen in 1992, 24 who used a Doppler proctoscope with injected sclerosing agent instead of ligation in the classic Morinaga procedure.

2. Objectives

The aim of this study was to evaluate the results of the DGHAL technique and compare it with Milligan-Morgan Hemorrhoidectomy (Open Hemorrhoidectomy).

3. Patients and Methods

In this prospective study, we compared the results of the MMH and DGHAL techniques by means of postoperative pain, first painless defecation, complications, patient satisfaction, and return to normal daily activity. One hundred patients enrolled in this study and were subsequently divided into two groups of fifty. Patients who had a previous anal operation were excluded from the study. Group A patients received an MMH and Group B received a DGHAL. Randomization was performed by a sealed envelope, and then the patients were informed about their course of treatment and their possible complications. Afterwards, the patients signed an informed contest form. On the night of surgery, patients received two suppositories of bisacodyl and a normal saline enema. They were placed on a liquid diet and became non per os 8 hours before the operation. Patients underwent general or spinal anesthesia regardless of their predetermined operation type. Also, all patients were placed in the lithotomy position for the surgical procedure.

3.1. Techniques and Instruments

A specifically designed proctoscope with a side viewing Doppler probe (AMI, Austria) was inserted into the anal canal distal to the dentate line (Doppler wave frequency 8.2 MHz). Then the proctoscope was turned around slowly and the hemorrhoid arteries were found with a Doppler pulse sound. Next, the arteries were ligated with a 2/0 polyglactin braided suture attached to a 5/8 curved needle (ETHICON, U.S.A), using a knot pusher. The figure-of-eight suture was made into a side hole using another type of probe. The site of ligation was 2-3 cm proximal to the dentate line. Then the site of ligations was checked by a Doppler probe and if there were no pulses distal to the ligation, the ligation was considered successful. Typical vessels were in the right posterolateral, middle right and left posterolateral at 1, 3, 5, 7, 9, and 11 o’clock. After termination of the operation, patients were moved to the general ward and discharged the following day. A general practitioner, blinded to the type of operation, collected data, including the pain scores; another surgeon did the early and late follow ups. The results were statistically analyzed by SPSS version 11.5 and with a 95% confidence interval, a p-value of .05 was considered significant.

4. Results

One hundred patients were enrolled in this study. They were admitted to Ghaem and Sina Hospitals of Mashhad University of Medical Sciences, Iran, at some time during April 2008 to June 2010. The average age in group A (MMH) was 39.8 ± 14.1 and in group B (DGHAL) was 44.9 ± 13.5 (P = 0.07). In group A, we had twenty eight males and twenty two females and in group B we had seven females and forty three males (P < 0.001). The most common symptom in both groups was bleeding with prolapsed hemorrhoids, followed by bleeding alone (Table 1).

Table 1. Patients’ Signs and Symptoms
Clinical Signs And SymptomsMiligan – Morgan, No. (%)DGHAL, No. (%)P value
Bleeding22 (44)22 (44)0.5
Bleeding with Prolapse28 (56)28 (56)
Total50 (100)50 (100)

In group A, twenty eight patients had grade III and IV hemorrhoid disease (56%), and in group B, twenty nine patients had grade III and IV of the disease (58%), so there was no significant difference between the two groups (P = 0.5) (Table 2).

Table 2. Patient Hemohrroid Grading
Grade HemohrroidMiligan –Morgan, No. (%)DGHAL, No. (%)P value
I, II22 (44)22 (44)0.5
III, IV28 (56)28 (56)
Total50 (100)50 (100)

There were five cases of external hemorrhoids in group A, and 4 cases in group B; both without any significant difference. Patient classification according to anesthesia type was performed and results did not show any significant difference (Table 3; P = 0.07). The duration of the operation after anesthesia was 27 ± 5.8 minutes in group A, and 24.1 ± 5.8 min in group B, which was statistically significant (P = 0.004). The mean ligatures in the DGHAL group was 7.42 ± 1.16 (range: 5 to 10) without any difference regarding the type of hemorrhoids (P = 0.4). We used the visual analogue scale (VAS) postoperative pain assessment (0 to 10).

Table 3. Type of Anesthesia Used in Our Patients
Type of AnesthesiaMiligan – Morgan, No. (%)DGHAL, No. (%)P Value
General Anesthesia (GA)35 (44)27 (54)0.07
Spinal Anesthesia (SA)28 (56)23 (46)
Total50 (100)50 (100)

The mean score in group A was 4.6 ± 1.2 and group B was 1 ± 0.6 (P < 0.001). According to the VAS, we divided patients into four groups: no pain, mild pain, moderate pain and severe pain; then patients were compared in groups A and B. The results are shown in Table 4 and Image 1 (P < 0.001). We also evaluated the relationship between the need for analgesics and type of operations. Trained nurses in pain management, who were blinded to the operation types, recorded the results (Table 5).

Table 4. Pain Scores According to Visual Analogue Scale
Score PainMiligan – Morgan, No. (%)DGHAL, No. (%)P value
No Pain-32 (64)< 0.001
Mild Pain9 (18)16 (32)
Moderate Pain41 (82)2 (4)
Severe Pain--
Total50 (100)50 (100)
Table 5. Patients’ Need for Pain Killer
ProcedureMiligan – Morgan, No. (%)DGHAL, No. (%)P value
Need for Pain Killer46 (92)16 (32)< 0.001
No Need Pain Killer4 (8)34 (68)
Total 50 (100)50 (100)

There was a significant difference between the two groups (P < 0.001). In the early postoperative period we recorded complications for both groups: there was only one patient with rebleeding in the DGHAL group, who was returned to the operation room, but no specific site was found and bleeding was ceased conservatively. In the MMH group, we also had a case of rebleeding that was controlled with simple ligature in the operating room. The result of early complications and outcome are shown in Table 6. There were no major complications reported. The mean hospital stay was one day for both groups. We also evaluated the outcome and its relationship with preoperative symptoms and no difference was found in our statistical analysis (Table 7; P = 0.2). After a mean follow up of 18 months, we had two recurrences in the grade IV DGHAL group; however, no complications were detected in either of the groups.

Table 6. Complication
ComplicationMiligan – Morgan, No. (%)DGHAL, No. (%)P value
No Complication21 (67)46 (92)<0.001
Bleeding2 (4)2 (4)
Urinary Retention3 (6)-
Painfull Defecation10 (20)2 (4)
Table 7. Alleviation of Preoperative Symptoms
RecoveryMiligan – Morgan, No. (%)DGHAL, No. (%)P value
Bleeding21 (42)26 (52)0.2
Prolapse29 (58)24 (48)
Total50 (100)50 (100)

5. Discussion

Nowadays, surgical treatments of diseases have become minimally invasive and cause less physiologic stress on patients; (5) so new modalities such as the Stapled Hemorrhoidopexy and DGHAL are gaining much more acceptance globally (1-10). We performed this study to compare the new technique (DGHAL) with the Milligan-Morgan Hemorrhoidectomy excisional hemorrhoidectomy. Patient selection, demographic characteristics, symptomatology, and type of anesthesia had no effect on our results because correct randomization was performed, which was confirmed by our statistical analysis. Regarding the type of operation, we compared the duration of the operation, postoperative pain, need for analgesics, symptom improvement and early or late complications. According to our research, there was only one study by Attila Bursics et al., which was structurally similar to our study (1). In our study, when comparing DGHAL and MMH groups, we observed less postoperative pain, less operative time, similar hospital stay, less need for analgesics and equal complication rates. After 18 month follow up we did not find any complications such as anal stenosis, incontinence or evacuation problems. Our results are supported by Attila Bursics et al.’s study, except their patients’ hospital stay was lower in their DGHAL group (1). In a systemic review by Giordano et al., they evaluated all studies on the DGHAL technique, but they did not find a leading study, and all studies were limited to case series by pioneer surgeons. Finally, after reviewing all of those series, they concluded that this new modality seemed to be beneficial in hemorrhoids grade II and III; (5) two other studies have also confirmed these results (11, 12). In another study, the results of DGHAL alone proved to be satisfactory (13). Regarding items in our study, their results supported our results in group B. (2, 13-15). In a study by Ramirez et al., they also evaluated symptom improvements in patients with grade IV hemorrhoids, who underwent the DGHAL technique and they concluded that most failures occurred in this group (up to 70%). This finding is inconsistent with our study, (8, 16) because we observed much better outcomes (no failure), but other elements of Ramirez’s study and other studies confirmed our results (4, 8, 10, 17, 18). Some studies added some modalities such as recto anal repair adjunct to DGHAL with similar results to DGHAL alone (6, 16, 19). In Khafagy et al. research, they compared Milligan-Morgan Hemorrhoidectomy Hemorrhoidopexy, Stapled Hemorrhoidectomy, and DGHAL and they concluded that the two last techniques have the same outcome as Milligan-Morgan Hemorrhoidectomy, with more patient satisfaction (20). In addition, one study used the DGHAL technique in patients with Crohn’s disease and reported that it was safe and effective in this group of patients provided that they had no active rectal disease. (21). The DGHAL technique is equally safe and effective in patients with grade II and III hemorrhoidal disease, with less postoperative pain and need for analgesics. It has no early or late complications, but recurrence may occur. Using this modality in patients with grade IV of the disease requires careful evaluation because of the varied results.




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