Hemorrhoids surgery

Hemorrhoids Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Hemorrhoids from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
X Ray
CT
MRI
Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Hemorrhoids surgery On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Hemorrhoids surgery All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Hemorrhoids surgery
CDC on Hemorrhoids surgery
Hemorrhoids surgery in the news
Blogs on Hemorrhoids surgery
Directions to Hospitals Treating Hemorrhoids
Risk calculators and risk factors for Hemorrhoids surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Ahmed Younes M.B.B.CH [3]

Overview

Procedural treatment of hemorrhoidal disease is reserved for symptomatic internal hemorrhoids that fail conservative therapy and for selected external or mixed disease. Conservative therapy includes dietary fiber 20–30 g/day, adequate fluid intake, avoiding straining and prolonged toilet sitting, and optional phlebotonics. Treatment escalates by grade, starting with the least invasive option. Office-based procedures are used for grade I–III internal hemorrhoids. Surgery is used for refractory grade III, grade IV, mixed internal–external disease, and acutely thrombosed external hemorrhoids. About 10% of patients with hemorrhoidal disease eventually undergo surgery. Rubber band ligation is the first-line office procedure. Excisional hemorrhoidectomy is the most durable operation but causes the most postoperative pain. Non-excisional techniques, such as Doppler-guided hemorrhoidal artery ligation, laser hemorrhoidoplasty, and radiofrequency ablation, cause less pain but have higher recurrence rates. Stapled hemorrhoidopexy is not recommended as routine first-line surgery.

Surgery

Indications and Patient Selection

• Before any procedure, confirm the diagnosis and grade. Before attributing rectal bleeding to hemorrhoids, perform a complete colonic evaluation (colonoscopy) in patients who meet screening indications or have alarm features.
• Complete an adequate trial of conservative therapy first (see medical therapy).
• Choose a procedure by weighing pain, recovery time, recurrence, cost, and patient priorities. No single operative "gold standard" exists for every patient.

Grade-based selection of procedural therapy

Grade / presentation	First-line procedural option	Surgical option
Grade I–II internal, refractory to conservative therapy	Rubber band ligation (RBL); alternatives: sclerotherapy, infrared coagulation	Rarely needed
Grade III internal	RBL in selected patients; Doppler-guided hemorrhoidal artery ligation (HAL) ± mucopexy	Excisional hemorrhoidectomy if refractory
Grade IV internal or mixed internal–external	—	Excisional hemorrhoidectomy (first-line surgery)
Thrombosed external hemorrhoid, <72 h from onset, severe pain	—	Excision of clot with overlying skin
Thrombosed external hemorrhoid, >72 h from onset	Medical management (stool softeners, analgesics, topical 5% lidocaine)	—

Office-Based Procedures (Grades I–III)

Rubber Band Ligation

• RBL is the most effective office-based procedure. It is first-line for grade I–II and selected refractory grade III internal hemorrhoids (ASCRS: strong recommendation, moderate-quality evidence; ACG: strong recommendation).
• Technique: During anoscopy, a band is placed at the base of the internal hemorrhoid above the dentate line. A rigid anoscope or a retroflexed flexible endoscope can be used. The band causes ischemic necrosis, and the tissue sloughs over several days.
• Efficacy: Symptoms resolve in about 89% of patients, and up to about 20% need repeat banding.
  • In a meta-analysis of 18 RCTs (n=1,617), RBL improved bleeding and pain more often than sclerotherapy (83% vs 70%).
  • RBL required fewer reinterventions than infrared coagulation (11.4% vs 30.8%).
• Complications (1%–3%): anorectal pain, bleeding (typically when the band sloughs at days 7–10), external thrombosis, vasovagal symptoms, and urinary retention.
• Pelvic sepsis is rare but can be fatal. Fever, perineal pain, and urinary retention after banding require urgent evaluation, antibiotics, and drainage or debridement.
• Cautions:
  • Use caution in patients taking anticoagulants or antiplatelet agents. ASCRS advises considering holding these agents when thrombotic risk permits.
  • RBL is relatively contraindicated in immunocompromised patients (e.g., during chemotherapy, or HIV/AIDS with detectable viral load) because of sepsis risk.

Sclerotherapy

• A sclerosant is injected into the submucosa, where it induces fibrosis. Options include polidocanol foam and phenol in oil. Phenol in oil is contraindicated in patients with tree-nut allergy.
• It is useful for grade I–II bleeding hemorrhoids that are too small to band.
• Comparison with RBL:
  • Less effective for bleeding (66% vs 93%) and prolapse (79% vs 89%).
  • Less postprocedural pain (14% vs 24%).
  • Short-term success is 70%–85%, but durable remission occurs in only about one-third of patients.
• It is a preferred alternative in anticoagulated or immunocompromised patients, in whom banding carries more risk.
• In the United States, sclerosants are used off-label, so RBL is generally preferred.

Infrared Coagulation

• Infrared energy is applied above the dentate line in 1–1.5-second pulses, causing necrosis and scarring. It is best suited to grade I–II disease.
• Comparison with RBL:
  • Efficacy is similar; a 9-trial meta-analysis found no significant difference.
  • RBL requires fewer sessions.
  • In some comparisons, infrared coagulation caused less bleeding but more pain.
• Other energy-based office options include bipolar or heater-probe coagulation and hemorrhoid energy therapy. These are less well supported than RBL.

Operative Procedures

Excisional Hemorrhoidectomy

• Role: First-line surgical treatment and the standard for grade IV disease, mixed internal–external disease, and grade III disease refractory to office procedures (ASCRS: strong recommendation, high-quality evidence; also endorsed by ACG).
• Technique: Performed under anesthesia, either open (Milligan-Morgan; wound left open) or closed (Ferguson; wound sutured).
• Outcomes:
  • Most durable results, with recurrence of 2%–10%.
  • In a meta-analysis of 11 RCTs (n=1,326), open and closed techniques were equivalent: recurrence 5.8%–6.5%, complications 16.4%–19.5%. No energy device was clearly superior.
  • More effective than RBL for grade III disease (RR 1.23), but with more pain and a longer recovery (9–14 days off work).
• Postoperative pain is the main drawback.
  • Use a multimodal regimen that includes topical anesthetics and topical diltiazem (ASCRS grade 1B).
  • Oral metronidazole is no better than placebo for post-hemorrhoidectomy pain.
• Other complications: urinary retention, bleeding, and, less commonly, anal stenosis or fecal incontinence.

Excision of Thrombosed External Hemorrhoids

• Excise the clot together with the overlying skin within about 72 hours of onset; ACG uses a window of 4 days. Early excision reduces pain and recurrent thrombosis (ASCRS: conditional, low-quality evidence; ACG: strong, low-quality evidence).
• After this window, pain is usually resolving and medical management is preferred.
• Simple incision with clot expression risks re-accumulation and is discouraged in favor of excision.

Doppler-Guided Hemorrhoidal Artery Ligation (HAL / Transanal Hemorrhoidal Dearterialization)

• Technique: A Doppler-equipped anoscope locates the terminal branches of the superior rectal artery, which are then suture-ligated. It is often combined with mucopexy for prolapse. No tissue is excised, and the anoderm below the dentate line is spared, which reduces pain (ASCRS: conditional recommendation, moderate-quality evidence).
• Outcomes: Across 28 studies (2,904 patients), pooled recurrence was about 17.5%, ranging from 3% to 60% and highest in grade IV. Bleeding (about 5%) and reintervention (about 6%) rates were low.
• HAL vs RBL (grade II–III):
  • Lower 1-year recurrence (30% vs 49%) and fewer repeat procedures.
  • More early postoperative pain, higher cost, and lower cost-effectiveness.
• HAL vs excisional hemorrhoidectomy:
  • Less early pain, but more recurrent prolapse (59% vs 31% at 1 year in one RCT).
  • Longer operative time and higher cost, which favor excision.
• Patient selection: Best suited to grade II–III disease. Recurrence in grade IV is unacceptably high, so select those patients carefully.

Stapled Hemorrhoidopexy (Procedure for Prolapse and Hemorrhoids)

• Technique: A circular stapler excises a ring of submucosa above the dentate line. This interrupts the feeding vessels and lifts the anal cushions. It does not treat external hemorrhoids.
• Recommendation: Not routinely recommended as first-line surgery, because efficacy is marginal and the risk profile is significant (ASCRS: conditional recommendation against, moderate-quality evidence).
• eTHoS RCT (n=777):
  • Stapling caused less early pain and gave better quality of life in the first 6 weeks.
  • At 24 months, excisional surgery gave better quality of life, fewer symptoms, less recurrence, and less tenesmus and incontinence, and was more cost-effective.
• Cochrane data: After stapling, recurrence is higher (OR 3.22) and additional interventions are more frequent (OR 2.75).
• Serious complications specific to stapling: rectovaginal fistula, rectal perforation, staple-line bleeding, rectal stenosis, chronic proctalgia or urgency (when the staple line encroaches on the dentate line), sepsis, and death. The median complication rate is about 16%, and deaths have been documented.
• Reserve stapling for selected patients with circumferential prolapse, after an informed discussion.

Laser Hemorrhoidoplasty and Radiofrequency Ablation

• These are emerging non-excisional options for grade II–III disease. They are used increasingly in Europe, but the evidence remains limited, and there are no large multicenter RCTs against excision.
• Laser hemorrhoidoplasty delivers endovascular laser energy that obliterates submucosal vessels while sparing the anal mucosa.
  • Symptom resolution is 70%–100% and recurrence 0%–11%.
  • It causes less pain than hemorrhoidectomy or RBL.
• 5-year double-blind RCT: Excisional hemorrhoidectomy gave the best outcomes. Laser hemorrhoidoplasty was only slightly worse (5-year recurrence 29% vs 24%; sutured mucopexy 44%) and had a shorter, less painful recovery.
• Radiofrequency ablation (FDA-cleared Rafaelo procedure) for grade II–III disease: recurrence about 4.8%; complications about 17.6% (bleeding, thrombosis, pain).

Areas of Uncertainty

• HAL vs stapled hemorrhoidopexy: Meta-analyses show less pain but more recurrence with HAL, and no clear difference in complications. The trials are small and heterogeneous.
• Periprocedural anticoagulation: Optimal timing is not established. ASCRS gives only a conditional statement to consider pausing these agents.
• HAL trials: Including grade II disease inflates the apparent benefit, because grade II rarely requires surgery.

Clinical Pearls and Pitfalls

• Band placement: Place bands above the dentate line. Severe pain right after banding suggests the band was placed too low.
• Delayed bleeding: Warn patients about bleeding 7–10 days after RBL, when the band and eschar separate.
• Pelvic sepsis: Fever, perineal pain, and urinary retention after RBL are pelvic sepsis until proven otherwise and require emergency evaluation.
• Stapling limits: Do not use stapled hemorrhoidopexy for external or mixed disease, which it does not treat.
• Grade IV disease: Do not attempt office procedures or rely on HAL for grade IV disease. Recurrence is high, and excision is usually required.
• Thrombosed external hemorrhoids: Excise rather than incise. Avoid surgery after pain has peaked (>72 hours).
• Recovery speed: HAL and stapled techniques offer the fastest return to work. Excision offers the lowest recurrence.