What surgical procedures can be used to treat hemorrhoids?

Photo of a patient and visitors at the hospital
PantherMedia / Robert Kneschke

Sometimes the symptoms of enlarged are so bad that treating the symptoms alone is no longer enough. There are then various surgical treatment options.

Hemorrhoids are “cushions” of blood vessels and supporting tissue, found at the end of the rectum, just inside the anus. If they become enlarged, they can cause unpleasant symptoms. The decision of whether surgery is needed and, if so, which kind, will mainly depend on the size of the and the severity of symptoms.

For grade 1 and grade 2 , and rubber band ligation ("banding") are considered first. These two treatments can also be combined.

If these procedures don't help enough, then the need to be removed surgically. Doctors also often recommend surgery if someone has very enlarged grade 3 or grade 4 that are sticking out. As well as conventional surgery to remove (known as hemorrhoidectomy), there's a special surgical technique known as stapled hemorrhoidopexy or "stapling."

All of the approaches have their pros and cons. These are summarized in the following tables:

Table: Non-surgical procedures
Approach Sclerotherapy (injections) Rubber band ligation (banding)
Who is the treatment suitable for? For people with grade 1 and 2 . For people with grade 1, 2 or 3 .
What does the treatment involve? A drug is injected into the area under the . They shrink and stabilize. This procedure is usually repeated after a few weeks. A small rubber band is tied around the base of the . The tissue dies and falls off. The procedure is often repeated after a few weeks.
Is anesthesia or a hospital stay needed? No, you can go home after the procedure and anesthesia is not used.
What complications commonly occur? Mild pain,
A feeling of pressure or like there's something there
Occasional pain,
Light bleeding
How likely are the to grow again? This happens in a lot of people. Then they need treatment or surgery again. This happens in some people. Then they need treatment or surgery again.
Table: Surgical procedures
Approach Surgical removal (hemorrhoidectomy) Stapling
Who is the treatment suitable for? For people
  • with grade 3 or grade 4
  • if their symptoms don't improve after non-surgical treatment.
For people with grade 3 .
What does the treatment involve? The are removed using scissors, a scalpel or a laser. The surgical wound is fully or partially closed with stitches, or left open. The are removed using an instrument, and the rest of the tissue is attached to the lining of the anus.
Is anesthesia or a hospital stay needed? Yes, the procedure is done in a hospital under regional or general anesthesia. You may have to stay in the hospital and take sick leave from work.
What complications commonly occur? Pain,
Bleeding,
Problems urinating (peeing)
Pain, but probably less likely than after hemorrhoidectomy,
Bleeding,
Problems urinating (peeing)
How likely are the to grow again? The will probably grow again within one year in about 3 out of 100 people. The will probably grow again within one year in about 9 out of 100 people.

Sclerotherapy (injections)

Sclerotherapy is a treatment option for grade 1 or grade 2 . In this procedure, a proctoscope is gently inserted into the anus. A proctoscope is a short tube with a light on it which the doctor can use to look at the membranes lining the anus. A drug (usually polidocanol) is then injected into the mucous membrane tissue under the enlarged . The aim of this procedure is to shrink the . It typically needs to be carried out several times in order to treat all of the enlarged . The injections are typically given a few weeks apart. You can return to your normal daily activities after each procedure.

After , some patients experience bleeding, mild pain, pressure, or the feeling that there is something in their anus. In rare cases, swelling or infections occur. Sometimes a painful blood clot (thrombus) forms in or near the anus. In many people, the grow again after two to three years and further treatment is then needed.

Rubber band ligation (banding)

This approach is mainly used in the treatment of grade 2 . It is also used for grade 1 and grade 3 , though. In rubber band ligation (also simply known as “banding”), the doctor first gently inserts a proctoscope into the anus. With the help of an instrument (a ligator), he or she then places a small rubber band – only a few millimeters wide – around the base of the enlarged hemorrhoid. The band cuts off the blood supply to the hemorrhoid, causing the tissue to die and fall off after a few days. The dead tissue and rubber band then leave the body when you go to the toilet, without you noticing it. This procedure generally has to be repeated after a few weeks in order to treat all of the enlarged .

Studies suggest that rubber band ligation has some advantages over the surgical removal (hemorrhoidectomy) of grade 2 . The patients have less pain after the procedure and can return to work sooner. Possible complications following the procedure include pain, bleeding, thrombosis or abscesses. Here, too, the may grow bigger again after the procedure.

Hemorrhoidectomy (hemorrhoid removal)

If someone has grade 3 or grade 4 , doctors often recommend surgery. In this kind of operation, the enlarged are removed (“ectomy” means “removal”) using instruments like scissors, a scalpel or a laser. In some approaches the wound is left open afterwards, in others it is partially or completely closed with stitches. These types of surgical techniques are referred to as "open," "partially open," or "closed." Different techniques can also be combined. The doctor will talk to you about the most suitable approach before you have the operation. Leaving the wound partially or completely open has the advantages of fewer stitch-related complications and fewer hematoma (bruising) problems. One disadvantage is that it takes longer for open wounds to heal.

Regardless of which operation they have, most patients experience pain in their anus for a few days afterwards. Bowel movements ("pooping") and sitting may hurt as a result. This can usually be treated with painkillers. Other problems that may arise include bleeding after the operation, wound infections, problems urinating ("peeing") and – rarely – abscesses, narrowing of the anus (anal stenosis) or fecal . Fecal is the inability to control bowel movements properly, causing stool ("poo") to accidentally leak.

Stapling

Stapling is a more recently developed technique, typically used in the treatment of grade 3 . This procedure involves first removing some of the enlarged hemorrhoid tissue, and then “stapling” the remaining tissue to the lining of the anus again.

Current research suggests that people who have this procedure experience less pain afterwards compared to people who have a hemorrhoidectomy. They were also able to return to everyday activities sooner. But stapling was found to have a disadvantage compared to conventional surgery too: The were more likely to come back after stapling. They grew bigger again in

  • 3 out of 100 people who had conventional surgery, and in
  • 9 out of 100 people who had the stapling procedure.

So, compared to hemorrhoidectomy, the stapling procedure may need to be repeated more often. Side effects like itching or bleeding were just as common after stapling as they were after other kinds of surgery.

Deutsche Gesellschaft für Koloproktologie (DGK). Hämorrhoidalleiden (S3-Leitlinie). AWMF-Registernr.: 081-007. 2019.

Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev 2006; (4): CD005393.

Joos AK, Herold A. Hämorrhoidalleiden. Neue konservative und operative Therapien für ein weit verbreitetes Leiden. Der Gastroenterologe 2010; 5: 326-335.

Lan P, Wu X, Zhou X et al. The safety and efficacy of stapled hemorrhoidectomy in the treatment of hemorrhoids: a systematic review and meta-analysis of ten randomized control trials. Int J Colorectal Dis 2006; 21(2): 172-178.

Shanmugam V, Thaha MA, Rabindranath KS et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev 2005; (3): CD005034.

Simillis C, Thoukididou SN, Slesser AA et al. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg 2015; 102(13): 1603-1618.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Updated on December 9, 2021
Next planned update: 2024

Authors/Publishers:

Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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