Hemorrhoidectomy — How It Works, Benefits & Recovery — Procedure Guide, Recovery & Risks | MyMedicPlus

Hemorrhoidectomy is the surgical removal of haemorrhoids (piles) — enlarged, symptomatic vascular cushions in the anal canal that have become pathologically swollen, prolapsed, or thrombosed. Haemorrhoids are classified by the Goligher grading system: Grade I bleed but do not prolapse; Grade II prolapse on defaecation but reduce spontaneously; Grade III require manual reduction; Grade IV are irreducible. Surgery is the definitive treatment for Grade III–IV internal haemorrhoids, large symptomatic external haemorrhoids, and combined haemorrhoidal disease unresponsive to non-operative treatment. The two principal surgical techniques are excisional haemorrhoidectomy — Milligan-Morgan (open wounds), the most widely used technique, and Ferguson (closed technique with absorbable sutures) — and stapled haemorrhoidopexy (procedure for prolapse and haemorrhoids, PPH), which uses a circular stapling device to reposition and devascularise prolapsing haemorrhoids without excising the haemorrhoidal columns themselves. Excisional haemorrhoidectomy achieves superior long-term results with lower recurrence rates; stapled haemorrhoidopexy offers lower post-operative pain and faster recovery but carries higher recurrence rates at 5–10 years.

This treatment represents an important component of modern medical management, supported by clinical evidence from multiple randomised controlled trials and systematic reviews. Treatment protocols are continually refined based on emerging evidence to optimise patient outcomes while minimising treatment burden.

Patient suitability is assessed through a structured multidisciplinary evaluation incorporating clinical history, physical examination findings, and results of relevant investigations. Treatment planning considers the full clinical context including disease characteristics, patient comorbidities, functional status, and individual treatment goals to ensure the most appropriate therapeutic approach is selected for each patient.

Surgical haemorrhoidectomy is indicated for Grade III haemorrhoids (prolapsing, requiring manual reduction) that have not responded to adequate non-operative treatment (dietary modification, rubber band ligation, sclerotherapy), Grade IV haemorrhoids (permanently prolapsed, irreducible), large symptomatic external haemorrhoids causing significant perianal discomfort, skin hygiene difficulties, and bleeding, thrombosed external haemorrhoids presenting acutely within 72 hours of thrombosis with severe pain (incision and excision provides immediate relief), and mixed (internal and external) haemorrhoidal disease requiring circumferential treatment. Non-operative treatments are exhausted sequentially before surgery: dietary fibre supplementation (25–35 g/day) and adequate hydration control symptoms in mild disease; rubber band ligation in the clinic is effective for Grade I–III internal haemorrhoids with a 70% success rate at 5 years requiring no anaesthesia; injection sclerotherapy is used for Grade I–II bleeding haemorrhoids. Haemorrhoidectomy is the gold-standard definitive treatment when these measures fail or when the degree of disease is beyond their scope.

Excisional haemorrhoidectomy is performed under general or spinal anaesthesia in the lithotomy or prone jack-knife position. A Parks anal retractor exposes the anal canal. Each haemorrhoidal column (typically three — at 3, 7, and 11 o'clock positions) is treated sequentially. In the Milligan-Morgan technique, a haemostat is applied to the haemorrhoidal pedicle at the anorectal junction; the haemorrhoid is dissected off the underlying sphincter with diathermy; a suture ligation is placed at the apex of the pedicle and the haemorrhoidal tissue excised distal to the ligature; the wound is left open to granulate. Skin bridges between the excised columns are preserved to prevent anal stenosis. In the Ferguson technique, the wound is closed with a running absorbable suture after excision. Intraoperative mucosal infiltration with bupivacaine and adrenaline reduces intraoperative bleeding and provides post-operative analgesia. Stapled haemorrhoidopexy (PPH) uses a circular stapling device introduced per anum to resect a doughnut of rectal mucosa proximal to the dentate line, lifting the prolapsed haemorrhoids back into the anal canal and interrupting their blood supply. Duration is 30–60 minutes for excisional haemorrhoidectomy; 20–40 minutes for stapled PPH.

The procedure is performed in an appropriately equipped facility by experienced specialist clinicians. Prior to commencement, the patient undergoes pre-procedural assessment including vital signs measurement, review of relevant investigations, and confirmation of informed consent. Intravenous access is established and monitoring equipment including ECG, pulse oximetry, and blood pressure monitoring is applied.

The procedural site is prepared according to aseptic technique standards. Anaesthesia or analgesia is administered as appropriate for the specific procedure and patient needs, ranging from local anaesthesia for minor procedures to regional or general anaesthesia for more complex interventions.

The procedure is performed under direct visualisation or image guidance as appropriate. Key technical steps are executed with attention to anatomical landmarks and patient safety parameters. Haemostasis is achieved and confirmed before completion. Post-procedural assessment includes clinical evaluation of the immediate result, complication surveillance, and documentation of the procedure.

Recovery room monitoring continues until the patient meets defined discharge criteria. Written post-procedural instructions covering activity restrictions, wound care, medication management, and symptoms requiring urgent review are provided before discharge.

Excisional haemorrhoidectomy achieves symptom resolution (bleeding, prolapse, discomfort) in 90–95% of patients at 10-year follow-up — the most durable treatment for haemorrhoidal disease, significantly better than rubber band ligation (approximately 70% success at 5 years) and sclerotherapy. The ASCRS systematic review consistently confirms haemorrhoidectomy as the definitive treatment with the lowest recurrence rate. Immediate resolution of acute symptoms including bleeding (in over 95% of cases), prolapse reduction, and elimination of associated perianal soiling occurs within the surgical field. Compared with rubber band ligation, which often requires multiple sessions and has a meaningful recurrence rate, haemorrhoidectomy achieves one-time definitive treatment in the majority of patients. Stapled haemorrhoidopexy offers 40–50% less post-operative pain and faster return to work (3–5 days vs 7–10 days) compared with excisional haemorrhoidectomy, making it appealing for patients with bilateral disease or those unable to take extended time off work, though its 10–15% higher recurrence rate at 5 years is an important consideration in patient counselling.

Post-operative pain is the most significant and expected complication of excisional haemorrhoidectomy — among the more painful day-case procedures, with significant discomfort for 7–14 days that requires multimodal analgesia (regular paracetamol, NSAIDs, topical local anaesthetic ointment, warm sitz baths, and opioids if needed). Urinary retention occurs in 5–15%, more common in older men and following spinal anaesthesia; a urinary catheter is placed if retention persists beyond 6 hours. Secondary haemorrhage — delayed bleeding at 7–14 days from wound infection or clot separation — occurs in 1–2% and usually settles with bed rest and conservative management but occasionally requires examination under anaesthesia and suturing. Anal stenosis (stricture) is a long-term complication of inadequate skin bridge preservation, occurring in less than 1% with careful technique; it is managed by anal dilation or surgical anoplasty if severe. True faecal incontinence is rare (under 0.5%) with careful sphincter preservation; subtle continence impairment (urgency, soiling) is occasionally reported. Stapled haemorrhoidopexy carries rare but serious complications not seen with excisional surgery: recto-vaginal fistula (under 0.1%), rectal perforation (rare), and pelvic sepsis — the latter potentially life-threatening and reported in registries from multiple countries.

Post-operative pain management is the central focus of recovery from excisional haemorrhoidectomy. A multimodal analgesic regimen is essential: regular paracetamol 1g four times daily, ibuprofen or diclofenac (if not contraindicated by renal function or NSAID hypersensitivity), topical lignocaine gel applied to the wound, and warm sitz baths (sitting in a bowl of warm water for 10–15 minutes, 2–3 times daily) provide significant comfort and promote wound cleansing and healing. Laxatives (lactulose or macrogol) and a high-fibre diet are essential to prevent constipation, which causes severe pain during defaecation on passage of hard stool through the healing wounds. Most patients manage pain adequately with the above regimen; a minority require a short course of oral opioid for the first 3–5 days. Hospital discharge is typically same-day or after one overnight stay. Return to desk work for most patients is possible at 1–2 weeks; more active occupations at 2–3 weeks; heavy manual work at 3–4 weeks. Full wound healing takes 4–6 weeks in the Milligan-Morgan technique. Dietary modifications to prevent recurrence are permanent: a high-fibre diet (25–35 g/day), 2 litres of fluid daily, and avoidance of prolonged straining. Post-operative clinic review at 6 weeks confirms wound healing and discusses prevention of recurrence.