Hemorrhoidectomy: Procedure, Benefits, Risks, Recovery and Alternatives

Hemorrhoids are a common and often distressing condition affecting millions of people worldwide. When conservative measures such as dietary changes, topical treatments, and office-based procedures fail, surgical intervention—most notably hemorrhoidectomy—is considered the gold standard for advanced cases. But what does a hemorrhoidectomy involve, what are its benefits and risks, and what does the recovery entail? Just as importantly, are there less invasive alternatives? This detailed guide synthesizes the latest research to give you a comprehensive, patient-centered understanding of hemorrhoidectomy and your options.

Hemorrhoidectomy: The Procedure

When conservative and minimally invasive treatments aren't enough, a hemorrhoidectomy may be recommended, especially for severe (grade III–IV) hemorrhoids. This surgical solution involves removing swollen and inflamed hemorrhoidal tissue. There are several different techniques, each with their own nuances and considerations.

Methods	Description	Indications	Sources
Open (Milligan-Morgan)	Tissue excised, wound left open	Severe, prolapsed hemorrhoids	1, 3, 11
Closed (Ferguson)	Tissue excised, wound sutured closed	Severe, prolapsed hemorrhoids	2, 10, 11
Stapled (PPH)	Circular stapler removes tissue, lifts mucosa	Prolapsed internal hemorrhoids	4, 6, 7, 9
Energy-based (LigaSure, Harmonic)	Uses energy device to seal vessels, excise tissue	All grades, often for less pain	1, 8, 12, 18

Table 1: Main Hemorrhoidectomy Techniques

Surgical Techniques Explained

Open Hemorrhoidectomy (Milligan-Morgan):

• The most time-tested approach.
• Involves excising the hemorrhoidal tissue and leaving the wound open to heal naturally.
• Associated with significant post-operative pain but low long-term recurrence 3, 11.

Closed Hemorrhoidectomy (Ferguson):

• After excision, the wound is sutured closed.
• Aims to reduce healing time and pain compared to the open technique.
• Slightly increased risk of infection but a popular choice among surgeons 2, 10.

Stapled Hemorrhoidectomy (Procedure for Prolapse and Hemorrhoids, PPH):

• Uses a circular stapling device to remove a ring of tissue above the hemorrhoids, repositioning the remaining tissue.
• Less post-operative pain and quicker recovery, but higher long-term recurrence rates 4, 6, 7, 9.

Energy-based Devices (LigaSure, Harmonic Scalpel):

• Use advanced devices to seal blood vessels while excising tissue.
• Offers less bleeding and pain, faster procedure and recovery 1, 8, 12, 18.
• LigaSure and harmonic scalpel procedures are becoming more common due to these benefits.

Indications for Hemorrhoidectomy

• Primarily for internal hemorrhoids grade III or IV (prolapsed, non-reducible, or with significant symptoms) 11.
• Also for cases of failed conservative or less invasive treatments, or for complicated hemorrhoids (thrombosed, strangulated) 11.

What to Expect During the Procedure

• Performed under general, spinal, or local anesthesia.
• Outpatient (“day surgery”) is increasingly common with modern techniques 3, 12.
• Operative time can range from under 15 minutes (energy-based) to over 45 minutes (traditional open) 1, 7, 12.

Benefits and Effectiveness of Hemorrhoidectomy

Hemorrhoidectomy is often considered the most definitive solution for advanced hemorrhoids. But what are the true benefits, and how does it compare to other treatments?

Benefit	Description	Comparative Efficacy	Sources
Definitive relief	Lowest recurrence rates, especially with excisional techniques	Superior to ligation, stapling for long-term	6, 16
Symptom control	Resolves bleeding, prolapse, and pain	Most effective in severe cases	3, 6, 11
Quick return to normal	Especially with stapled or energy-based methods	Faster recovery than open technique	1, 7, 8, 12, 18
Outpatient feasibility	Many procedures can now be done same-day	Shorter hospital stays	3, 12

Table 2: Benefits and Efficacy Highlights

Superior Symptom Relief

Hemorrhoidectomy remains the gold standard for:

• Eliminating prolapse and bleeding in advanced hemorrhoids 3, 6.
• Providing long-term remission, especially compared to non-excisional techniques like stapling or banding 6, 16.

Recurrence Rates

• Conventional excisional hemorrhoidectomy (open or closed) yields the lowest recurrence rates for grade III–IV hemorrhoids 6.
• Stapled hemorrhoidopexy and less invasive techniques offer quicker recovery, but higher rates of recurrence and prolapse over time 4, 6, 7.

Recovery and Patient Satisfaction

• Stapled and energy-based surgeries lead to faster recovery, less post-op pain, and higher early patient satisfaction 1, 7, 8, 12, 18.
• Many patients are able to return to work sooner compared to traditional open surgery 1, 7, 12.

Tailoring to Patient Needs

• There is no universal “best” procedure—choice must be tailored to hemorrhoid grade, size, and patient symptoms 5.

Risks and Side Effects of Hemorrhoidectomy

While effective, hemorrhoidectomy is not without risks. Understanding the potential complications and side effects can help patients make informed decisions.

Risk/Complication	Frequency/Severity	Modifying Factors	Sources
Post-op pain	Most common, varies by technique	Higher in open, less in stapled/energy-based	2, 3, 7, 12, 13, 14, 18
Bleeding	Early or delayed; rare but serious	LigaSure, constipation raise risk; less with Ferguson	10, 12
Urinary retention	Occurs in 1–5%	More common after open techniques	2, 4, 9, 12
Anal stenosis	Scar tissue narrows anal canal	Rare, more with open technique	4, 12
Recurrence	Higher with stapled, lower with excisional	Technique-dependent	4, 6, 7, 8
Incontinence	Very rare, associated with complex cases	Higher risk with pre-existing issues	4, 11

Table 3: Main Risks and Side Effects

Pain Management

• Postoperative pain is the main limitation to widespread use in day-surgery settings 3.
• Pain is highest with open techniques, less with closed, stapled, or energy-based methods 2, 3, 7, 12, 18.
• Strategies to reduce pain include pudendal nerve block, multimodal analgesia (acetaminophen, NSAIDs, opioids), topical agents, and even intraoperative Botox injection 2, 13, 14.

Bleeding

• Both early and delayed bleeding can occur, though serious bleeding is rare (<1%) 10, 12.
• Constipation and use of certain energy devices (e.g., LigaSure) increase the risk 10.
• Timely intervention usually resolves the issue.

Urinary Retention

• Occurs in a minority of patients (1–5%), often related to pain or anesthesia 2, 4, 9, 12.
• Usually managed conservatively.

Anal Stenosis and Incontinence

• Anal stenosis (narrowing) is rare (<5%) but more likely with extensive excision 4, 12.
• Incontinence is even less common, typically in those with prior injury or complex disease 4, 11.

Recurrence

• Stapled and other non-excisional methods are associated with higher recurrence compared to traditional excisional hemorrhoidectomy 4, 6, 8.

Recovery and Aftercare of Hemorrhoidectomy

The journey doesn’t end in the operating room. Recovery and aftercare are essential to ensure the best outcome and minimize discomfort.

Aspect	Key Points	Recovery Time	Sources
Pain Control	Multimodal: oral meds, topical, nerve block, Botox	1–2 weeks (majority)	2, 13, 14
Return to work	Faster with stapled/energy-based	1–2 weeks (stapled), 2–3 weeks (open)	1, 7, 12, 18
Complication monitoring	Watch for bleeding, infection, urinary issues	First 2 weeks	9, 10, 12
Wound care	Sitz baths, hygiene, stool softeners	Daily, 2–4 weeks	2, 12, 13

Table 4: Recovery and Aftercare Essentials

Managing Pain and Discomfort

• Most patients will experience some pain, especially during the first week 2, 3, 12, 13, 14.
• Pain can be minimized with:
  • Combination of acetaminophen, NSAIDs, and occasional opioids 2.
  • Topical lidocaine or glyceryl trinitrate 2.
  • Pudendal nerve blocks during surgery 2, 14.
  • Botox injections to relax the sphincter and accelerate wound healing 13.

Returning to Normal Activities

• Patients undergoing stapled or energy-based hemorrhoidectomy often return to routine activities within 1–2 weeks 1, 7, 12, 18.
• Open and closed techniques may require 2–3 weeks before full return to work 1, 7.

Wound Care and Hygiene

• Sitz baths, gentle cleansing, and stool softeners are important to promote healing and reduce risk of infection or straining 2, 12, 13.
• High-fiber diet and adequate hydration support smooth healing 2.

Monitoring for Complications

• Early complications (bleeding, urinary retention) typically occur in the first few days 9, 10, 12.
• Late complications (anal stenosis, recurrence) may appear weeks to months later—regular follow-up is advised 4, 12.

Alternatives of Hemorrhoidectomy

Not every patient with hemorrhoids needs surgery, and for many, less invasive options can be effective and less painful.

Alternative	Description	Best for Grades	Sources
Rubber-band ligation	Bands cut off blood flow	I–III	16
Sclerotherapy	Injection to shrink tissue	I–II	16
Infrared coagulation	Destroys tissue with heat	I–II	16
Doppler-guided ligation	Suture arteries with Doppler	II–III	15, 17
Transanal dearterialization	Ligation under Doppler	II–III	15, 17
Conservative management	Fiber, fluids, topical meds	I–II	11, 16

Table 5: Non-Surgical Alternatives

Office-Based Procedures

• Rubber-band ligation: Most effective non-surgical treatment for grades I–III; lower recurrence than sclerotherapy or coagulation but more painful 16.
• Sclerotherapy and infrared coagulation: Suitable for early-stage disease; less effective for large or prolapsed hemorrhoids 16.

Doppler-Guided Techniques

• Doppler-guided hemorrhoidal artery ligation (DGHAL) and transanal hemorrhoidal dearterialization (THD):
  • Use Doppler ultrasound to locate and tie off hemorrhoidal arteries 15, 17.
  • Far less postoperative pain than excisional surgery.
  • Effective for controlling symptoms in grades II–III; may not be as durable in advanced disease 15, 17.

When to Choose Alternatives

• Early-stage hemorrhoids or patients who wish to avoid surgery.
• Patients with increased surgical risk or those for whom incontinence is a concern 15.
• Those who have failed conservative therapy but don't have advanced prolapse.

Conclusion

Hemorrhoidectomy remains the most effective option for severe or complicated hemorrhoids, but it comes with trade-offs in terms of pain and risk of complications. Understanding the range of surgical techniques, the expected benefits, and the possible side effects is crucial in making an informed decision. For many, less invasive alternatives may be appropriate, especially for early-stage disease.

Key Takeaways:

• Hemorrhoidectomy is reserved for advanced or unresponsive hemorrhoids and is highly effective at resolving symptoms 3, 6, 11.
• There are multiple surgical approaches (open, closed, stapled, energy-based), each with unique profiles regarding pain, recovery, and recurrence 1, 2, 3, 4, 6, 7, 8, 12, 18.
• Pain and bleeding are the most common complications; modern techniques and pain management strategies can minimize discomfort 2, 3, 10, 12, 13, 14.
• Recovery can be swift, especially with stapled or energy-based methods, but attention to wound care and monitoring for complications is essential 1, 7, 12.
• Alternatives such as rubber-band ligation, Doppler-guided ligation, and conservative measures are effective for many and may be preferred in suitable cases 15, 16, 17.
• Personalized care is key—treatment should be selected based on hemorrhoid grade, patient preferences, and risk profile 5.

With these insights, patients and clinicians can collaborate to choose the most appropriate, effective, and safe treatment for hemorrhoidal disease.