Milligan-Morgan vs. Ferguson Technique

Milligan-Morgan (open) and Ferguson (closed) hemorrhoidectomy are the two most widely used excisional techniques, differing mainly in whether the surgical wound is left open to heal by itself or stitched closed at the end of the procedure.

Key takeaways

Milligan-Morgan leaves the wound open; Ferguson closes it with sutures.
Direct comparative studies have found mixed results, with some showing similar outcomes and others showing modest advantages for one or the other depending on the specific measure.
Milligan-Morgan is more standard in Europe; the Ferguson (closed) approach is more commonly preferred in North America.

Milligan-Morgan (open) hemorrhoidectomy

First described in 1937, this remains one of the most widely practiced techniques worldwide, particularly in Europe, where it’s often considered a standard reference approach. The surgical wound is left open, allowed to heal by secondary intention (gradually closing on its own from the inside out) rather than being stitched shut.

Ferguson (closed) hemorrhoidectomy

The Ferguson technique follows similar excision principles but closes the wound with sutures at the end of the procedure. This approach is more commonly preferred in North America, with some studies suggesting a more comfortable postoperative course compared to the open technique, though findings across studies have not been entirely consistent.

What the comparative evidence shows

Direct comparisons between the two techniques have produced somewhat mixed results across different studies:

Some retrospective comparisons found no significant difference in complication rates (surgical site infection, excessive bleeding) between the two approaches
Pain outcomes have varied by study, with some suggesting a modestly more comfortable course with the closed (Ferguson) technique, though this isn’t a universal or dramatic finding across all research
Both are considered effective, well-established options for grade III–IV hemorrhoids

Why the choice often comes down to surgeon training and region

Given the relatively modest and inconsistent differences found between these two approaches in direct comparisons, the choice often reflects a surgeon’s training, regional convention, and personal experience and preference more than a clear, universal evidence-based advantage of one technique over the other.

What to ask your surgeon

Which technique they typically use and why
Their personal experience and outcomes with their preferred approach
Whether your specific presentation (extent of disease, any particular anatomical considerations) makes one approach more suitable for you specifically

The bigger picture

Both techniques share the same fundamental trade-off relative to less invasive options: greater effectiveness and lower long-term recurrence, at the cost of a more significant recovery than office procedures — see How painful is hemorrhoidectomy, honestly, which applies broadly to both techniques rather than being specific to one.

Curious about a less invasive surgical alternative to both of these? See Stapled hemorrhoidopexy (PPH).

This page is for general education. Your surgeon’s specific training and experience, alongside your individual presentation, should guide which technique is used.