REVIEW ARTICLE
Ligasure Versus Ferguson Hemorrhoidectomy in the
Treatment of Hemorrhoids: A Meta-Analysis of
Randomized Control Trials
Li Xu, MD,* Honglei Chen, MD,w Guoqiang Lin, MD,* and Qiongxiang Ge, MD*
Aim: To compare outcomes of Ligasure hemorrhoidectomy (LH)
versus Ferguson hemorrhoidectomy (FH) by a meta-analysis of
available randomized controlled trials.
Methods: Original studies in any language were searched from
MEDLINE database, PubMed, Web of science and the Cochrane
Library database, and Wangfang database. Randomizes control
trials that compared LH with FH were identied. Data were
extracted independently for each study and a meta-analysis was
performed using xed-eects and random-eects models.
Results: Five trials including 318 patients met the inclusion criteria.
The urinary retention rate and early postoperative pain scores were
higher in patients undergoing FH. Patients treated with Ligasure
had a signicantly shorter operative time and hospital stay than the
patients submitted to Ferguson techniques. The blood loss during
operation was less in Ligasure group than Ferguson group. No
statistically signicant dierences were noted in postoperative
bleeding, dicult defacating, anal ssure, anal stenosis, and
incontinence.
Conclusions: Our meta-analysis shows that LH is superior to FH in
the short-term outcomes. Future studies addressing long-term
outcomes are needed to prove these results.
Key Words: hemorrhoids, Ligasure, Ferguson hemorrhoidectomy,
meta-analysis
(Surg Laparosc Endosc Percutan Tech 2015;25:106110)
H emorrhoidectomy is considered the most eective
treatment for grade 3 and 4 hemorrhoids.1,2 However,
this procedure may be associated with a signicant post-
operative pain and other complications.3 Several surgical
techniques and devices have been developed to overcome
these postoperative problems.46 The Ligasure vessel seal-
ing system (Valleylab, Boulder, CO) is a new hemostatic
device designed to seal blood vessels with minimal sticking,
charring, or thermal injury to adjacent tissue.7 Compared
with conventional hemorrhoidectomy, the Ligasure hem-
orrhoidectomy (LH) is a fast procedure characterized by
limited postoperative pain, short hospital stay, quicker
Received for publication August 10, 2014; accepted January 22, 2015.
From the *Department of Anorectal Surgery, the First Aliated
Hospital, Zhejiang Chinese Medical University, Shangcheng
District, Hangzhou, Zhejiang Province; and wDepartment of
Gastrointestinal Surgery, the Sixth Aliated Hospital, Sun Yat-Sen
University, Tianhe District, Guangzhou, Guangdong Province,
P.R. China.
L.X. and H.C. are the co-rst authors in this study.
The authors declare no conicts of interest.
Reprints: Li Xu, MD, Department of Anorectal Surgery, the First
Aliated Hospital, Zhejiang Chinese Medical University, No. 54
Youdian Rd, Shangcheng District, Hangzhou, Zhejiang Province
310006, P.R. China (e-mail: 1755889877@qq.com).
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106 | www.surgical-laparoscopy.com Surg Laparosc Endosc Percutan Tech
wound healing, and earlier return to work.8 Ferguson
hemorrhoidectomy (FH) is a modication from the con-
ventional hemorrhoidectomy.9 The present meta-analysis
was conducted to evaluate operative and postoperative
outcomes who underwent LH versus FH.
METHODS
Data Sources
Randomized controlled trials (RCTs) that compared
LH with FH were included in this meta-analysis. To iden-
tify studies published from 1996 to June 31, 2014, a
comprehensive search was performed in the MEDLINE
database, PubMed, Web of science and the Cochrane
Library database, and Wangfang database using the
following search terms: ligasure, Ferguson hemor-
rhoidectomy, closed hemorrhoidectomy, and
hemorrhoids combined with randomized trials. To
indentify all RCTs, the reference lists of the included trials
were searched for additional publications. Two observers
independently and blindly identied the study for inclusion
and extracted the date from each study.
Inclusion and Exclusion Criteria
Studies were included if they met the following criteria:
randomized trials; compared LH and FH; published as a
full article or abstract. Studies in any language were
included. Studies without data for retrieval and retro-
spective trials or duplicate publications were excluded.
Unpublished trials were not included.
Statistical Analysis
RevMan5.2 (The Cochrane Collaboration, Oxford,
UK) was used for the data analysis. For all dichotomous
variables, the odds ratio (OR) was calculated with 95%
condence interval (CI) and weighted mean dierence with
95% CI was calculated for continuous variables. Median
values were used for meta-analysis if mean values were not
available for continuous outcomes. SD was calculated
according to the guidelines of the handbook Cochrane
Collaboration. The overall eect of the combined outcomes
was calculated using the xed-eects model and the ran-
dom-eects model. Heterogeneity was explored using the w2
statistic, with signicance set at P < 0.05. In case of het-
erogeneity, only the random-eects model results were
reported. The forest plot was used to show the results of the
meta-analysis.
Assessment of Methodological Quality of the
Included Studies
The quality of all of the included RCTs was assessed
using the modied Jadad scale.10 Graphical exploration
with funnel plots was used to evaluate publication bias.
 Volume 25, Number 2, April 2015
Surg Laparosc Endosc Percutan Tech  Volume 25, Number 2, April 2015 Ligasure Versus Ferguson Hemorrhoidectomy

RESULTS
Five RCTs on 318 patients qualied for the meta-
analysis.1115 Patients characteristics extracted from these
trials and methodological quality scores are presented
in Table 1. The Search strategy is shown in Figure 1. Funnel
plots showed that there was no publication bias in this
study (gure was not showed).
Postoperative Complications
Bleeding
There was no heterogeneity among trials with regard
to major bleeding after operation (w2 = 0.64, df = 3,
P = 0.89; I2 = 0%). In the xed models, there was no sig-
nicant dierence in the bleeding rate between LH and FH
(OR, 0.82; 95% CI, 0.29, 2.33; Z = 0.37; P = 0.71;
Fig. 2A).

Urinary Retention
Five trials provided the information about the urinary
retention. There was no heterogeneity among trials in terms
of urinary retention (w2 = 0.49, df = 4, P = 0.97; I2 = 0%).
In the xed models, there was no signicant dierence in
the urinary retention rate between LH and FH (OR, 0.32;
95% CI, 0.13, 0.79; Z = 2.47; P = 0.01; Fig. 2B).
Dicult Defacating
Only 3 trials presented data on dicult defacating.
There was no signicant heterogeneity among trials con-
cerning dicult defacating (w2 = 0.03, df = 2, P = 0.99;
I2 = 0%). In the xed models, there was no signicant
dierence in the dicult defacating between LH and
FH (OR, 0.52; 95% CI, 0.19, 1.47; Z = 1.23; P = 0.22;
Fig. 2C).
Anal Fissure
Only 2 trials presented data on anal ssure after
operation. There was no signicant heterogeneity among
trials regarding anal ssure (w2 = 0.34, df = 1, P = 0.56;
I2 = 0%). In the xed models, there was no signicant
dierence in the anal ssure between LH and FH (OR,
0.93; 95% CI, 0.32, 2.65; Z = 0.14; P = 0.89; Fig. 2D). The
other 3 trials did not contribute in the nal analysis as there
was no reported anal ssure in either group.
Anal Stenosis
There was no signicant heterogeneity among trials
with regards to anal stenosis (w2 = 0.22, df = 1, P = 0.64;
I2 = 0%). In the xed models, there was no signicant
FIGURE 1. Search strategy. RCT indicates randomized controlled
trials.
dierence in the anal stenosis between LH and FH (OR,
0.32; 95% CI, 0.05, 3.09; Z = 1.19; P = 0.24; Fig. 2E).
Surgical Parameters and Clinical Outcomes
Early Postoperative Pain Scores
Data from 3 trials suggested that there was no sig-
nicant heterogeneity among trials regarding pain 24 hours
after operation (w2 = 1.76, df = 2, P = 0.41; I2 = 0%). In
the xed-eects model, there was a signicant dierence in
the pain between LH and FH (OR, 2.09; 95% CI,
2.18, 2.01; Z = 48.76; P < 0.00001; Fig. 3A).
Gas or Fecal Incontinence
There was no signicant heterogeneity among trials
regarding gas or fecal incontinence (w2 = 0.29, df = 1,
P = 0.59; I2 = 0%). In the xed models, there was no sig-
nicant dierence in the incontinence between LH and FH
(OR, 0.16; 95% CI, 0.02, 1.32; Z = 1.70; P = 0.09; Fig. 3B).
Two trials did not contribute in the nal analysis as there was
no reported gas or fecal incontinence in either group.
Operative Time
There was a signicant heterogeneity among trials re-
garding operative time (w2 = 233.74, df = 4, P < 0.00001;

TABLE 1. Patients Characteristics and Methodological Quality Scores

Patients (M/F) Mean Age Grade of Follow-up Quality
References Country Type (n) (y) Hemorrhoids Time (wk) Scores
Chung and Wu11 China Ligasure 30 (18/12) 44.9 10.4 3 or 4 2 2
Ferguson 31 (12/19) 47.1 16.6 2
Pattana-Arun et al12 Thailand Ligasure 23 (12/11) 45.7 14.6 3 or 4 4 4
Ferguson 22 (12/10) 41.9 12.9 4
Wang et al13 China Ligasure 42 (20/22) 47.1 2.4 3 or 4 6 3
Ferguson 42 (21/21) 47.5 2.3 6
Fareed et al14 Egypt Ligasure 40 (24/16) 35.85 6.627 3 or 4 6 3
Ferguson 40 (28/12) 35.1 5.702 6
Khanna et al15 India Ligasure 28 (17/11) 43 (22-63) 3 or 4 6 3
Ferguson 20 (11/9) 47 (27-64) 6

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Xu et al Surg Laparosc Endosc Percutan Tech  Volume 25, Number 2, April 2015

FIGURE 2. Postoperative complications: (A) bleeding; (B) urinary retention; (C) difficult defacating; (D) anal fissure; (E) anal stenosis. CI
indicates confidence interval.

I2 = 98%). In the randomized models, there was a sig- Hospital Stay

nicant dierence in the operative time between LH Concerning average hospital stay after hemo-
and FH (OR, 15.12; 95% CI, 20.85, 9.40; Z = 5.18; rrhoidectomy, there was signicant heterogeneity among
P < 0.00001; Fig. 3C). trials (w2 = 29.07, df = 3, P < 0.00001; I2 = 90%),

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Surg Laparosc Endosc Percutan Tech  Volume 25, Number 2, April 2015 Ligasure Versus Ferguson Hemorrhoidectomy

FIGURE 3. Clinical outcomes: (A) early postoperative pain scores; (B) gas or fecal incontinence; (C) operation time; (D) hospital stay; (E)
blood loss. CI indicates confidence interval.

therefore the xed-eects model was inappropriate. In the Blood Loss

random-eects model, there was a signicant dierence in Concerning average blood loss after hemor-
the hospital stay between LH and FH (OR, 0.98; 95% rhoidectomy, there was signicant heterogeneity among tri-
CI, 1.46, 0.51; Z = 4.07; P < 0.00001; Fig. 3D). als (w2 = 145.68, df = 2, P < 0.00001, I2 = 99%), therefore

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Xu et al Surg Laparosc Endosc Percutan Tech
the xed-eects model was inappropriate. In the random-
eects model, there was a signicant dierence in the blood
loss between LH and FH (OR, 18.52; 95% CI, 26.13,
10.90; Z = 4.77; P < 0.00001; Fig. 3E).
DISCUSSION
To improve the postoperative outcomes of the hem-
orrhoidectomy, a variety of techniques such as bipolar
electrothermal device, circular stapler, and the ultrasonic
scalpel has been developed.16,17 None have proved to be
clearly superior to the others.
This meta-analysis showed that LH took signicantly
less time to complete and a shorten hospital stay, with a
signicantly less blood loss during operation and lower
urinary retention after operations. Postoperative pain is
well accepted as a serious problem by patients undergoing
hemorrhoidectomy. There was a signicant dierence
between LH and FH in terms of postoperative pain scores
24 hours after operations, whereas the 2 techniques of
hemorrhoidectomy were not signicantly dierent in terms
of postoperative bleeding, dicult defacating, anal ssure,
anal stenosis, and incontinence. Only Wang et al13 reported
that LH have a shorten time for patients return to normal
activities. Fareed et al14 reported that there is no signicant
dierence in terms of recurrence rate between LH and FH.
Some potential advantages of Ligasure should be showed
in this study. First, Ligasure system can seal blood vessels of
up to 7 mm in diameter which may reduce the rate of post-
operative bleeding.18 Second, the reduced operative time
associated with Ligasure is possibly related to better hemo-
static control and not needing to ligate the pedicles.19 Third,
minimal thermal spread can lead to a less tissue necrosis which
may contribute to lower postoperative pain, this assessment
had a signicant dierence between LH and FH in this meta-
analysis.20 Finally, Ligasure system can improve the hemo-
stasis and provided a better visibility, therefore it seems like an
ideal instrument for hemorrhoidectomy.21
There are a number of limitations with the study. First, a
low number of patients were involved in this meta-analysis
which implied that the quantitative analysis was not very
powerful. The meta-analysis for dicult defacating, anal s-
sure, anal stenosis, and incontinence only included 2 or 3 trials,
respectively. Second, the statistical heterogeneity was high in
terms of operative time, hospital stay, and blood loss during
operation because of the dierent outcome measures and
treatment considered. There was great variation in included
studies in surgical protocol, postoperative care regiment, and
the methods of outcome measures.22 Third, these trial only
reported the short-term outcomes of the LH versus FH.
Standardized outcome measures, especially for postoperative
pain and bleeding, and recurrence with a long-term follow-up
are required. Finally, our meta-analysis demonstrated that
there was no signicant dierence between LH and FH in
postoperative pain scores 24 hours after operations. The
quantity of analgesia used by patients varied which may
inuence the results of the pain scores.
In conclusion, Ligasure vessel sealing system is a safe
and eective device for hemorrhoidectomy with regards to
the short-term outcomes. Further large-volume multicenter
trials are required to further elucidate and conrm the
short-term and long-term results and recurrence rates.
110 | www.surgical-laparoscopy.com Copyright
 Volume 25, Number 2, April 2015
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