Topography of haemorrhoidal arteries 119 Commentary Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications (Br J Surg 2012; 99: 112 – 118) Since the original description of the Milligan – Morgan haemorrhoidectomy in 1937, other surgical approaches have been described. Despite these alternative methods the Milligan – Morgan continues to hold its place as the procedure of choice and is almost certainly, even now, the most commonly performed operation for advanced haemorrhoidal disease. Why have other procedures not come to the fore? The Parks and Whitehead procedures offer a more radical approach. They are easy operations to draw, but technically difﬁcult and often bloody. The Ferguson approach simply closes the wounds of the Milligan – Morgan. Frequently they break down and no advantage is conferred. All of these procedures were aimed at the haemorrhoids themselves. The Longo procedure was different1. It aimed to avoid surgery directly to the anal canal and haemorrhoids, by excising a cuff of lower rectal mucosa including its submucosal vascular supply; with the incorporation of small islands of muscularis propria into the staple line, the reduced mucosa was ﬁxed to the underlying tissue. The resulting effect was haemorrhoidal shrinkage and reduction, with signiﬁcantly less postoperative pain and a shorter recovery. However, there were case reports of serious complications such as retroperitoneal sepsis requiring stoma formation. Such complications are enough to discourage the majority of cautious surgeons. Morinaga’s approach2, transanal haemorrhoidal dearterialization/Doppler-guided haemorrhoidal artery ligation with mucopexy, is incisionless. It is aimed at accurate identiﬁcation and ligation of the haemorrhoidal arteries rather than excision, reducing the cushions to their anatomical location with subsequent scar ﬁxation and shrinkage. The literature attests to its success, with a symptom reduction rate of 85 – 90 per cent or more. Patient satisfaction is high and complications minimal. Still, there is resistance. Conference chatter conﬁrms scepticism toward the published outcomes or even the need for the Doppler. Adoption is slow. This elegant paper conﬁrms the anatomy of the vascular supply to the haemorrhoids, their source, course, depth and consistency. It directs the procedure to the appropriate height from the anorectal junction, further improving the chances of success. It conﬁrms Morinaga’s original hypothesis. 1937 was a long time ago. D. M. Gold St Vincent’s Hospital/UNSW, Sydney, New South Wales, Australia (e-mail: d.gold@unsw.edu.au) DOI: 10.1002/bjs.7722 References 1 Longo A. Treatment of hemorrhoids disease by reduction of mucosa and hemorrhoidal prolapse with a circular suturing device: a new procedure. Proceedings of the 6th World Congress of Endoscopic Surgery, June 3, 1998. Mundozzi Editore: Rome, 1998; 777–784. 2 Morinaga K, Hasuda K, Ikeda T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler ﬂowmeter. Am J Gastroenterol 1995; 90: 610–613. If you wish to comment on this, or any other article published in the BJS, please visit the on-line correspondence section of the website (www.bjs.co.uk). Electronic communications will be reviewed by the Correspondence Editor and a selection will appear in the correspondence section of the Journal. Time taken to produce a thoughtful and well written letter will improve the chances of publication in the Journal.  2011 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd www.bjs.co.uk British Journal of Surgery 2012; 99: 119