Hemorrhoidectomy - Hemorrhoid Removal Surgery

The gentler hemorrhoid operations buy their comfort on credit. Two easier weeks, then three times the odds that it all comes back.

A British trial randomized 777 people between stapled surgery and having the piles cut out. Stapled hurt less in the early weeks, exactly as promised. Over the following twenty four months, quality of life came out better in the group who had the old painful operation, and the trial concluded that excisional surgery should be the treatment of choice.

Comfort bought on credit

Hemorrhoid surgery has spent twenty five years trying to stop hurting. Every few years a new device arrives promising the same thing, which is the result of the old operation without the three weeks of dreading the bathroom, and every few years the long term figures come back and say the same thing in return. The comfort arrives as promised. That comfort also gets borrowed, and the loan is repaid in recurrence, in prolapse coming back, and in a second operation that somebody has to pay for with a worse anal canal than the one they started with. That pattern has now been shown by a Cochrane review, by the largest randomized trial ever run in this field, and by a twelve year follow up survey, which is an unusual degree of agreement for surgery. None of which means the old operation is the right answer for you. It means the opposite of what most clinic websites imply. The right answer for the majority of people arriving with bleeding and a lump is a five minute procedure in an outpatient room with no anesthetic at all, repeated once or twice if needed, and no operation ever. Surgery belongs to a minority. Large hemorrhoids, permanent prolapse, simple treatments already tried and failed, or skin tags and fissures tangled up with the problem. Sorting out which group you fall into is most of the value a consultation can deliver, and it takes an examination that nobody can do over the internet.

This page sets out the evidence for each option in plain figures, says where the evidence is thin, and describes the pain honestly instead of around it.

The grades, and where to go next

Hemorrhoids begin as normal anatomy and turn into a disease later. Three cushions of blood vessels sit inside the anal canal in everybody, helping to seal it, and the problem starts when the tissue holding them in place stretches and they slide down. That explains a field organized around one four point scale, and why the grade decides the treatment far more than the symptoms do.

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Three things sit outside that scale and change the plan completely.

How the figures on this page are described

Every number below names the study it comes from and the kind of study it is, because a pragmatic randomized trial with 777 patients and a retrospective telephone survey answer different questions. Where a treatment has been tested badly, the sentence says so.

One word on language

British and American papers spell this condition differently and both spellings appear in the reference list at the bottom, which is the authors spelling their own titles and not an inconsistency on this page.

What to try before an operation

The unglamorous part of this field does most of the work, and it gets skipped constantly because nobody markets it, and hemorrhoids come from a mechanical problem produced by straining, by sitting on the toilet with a phone, and by stool that is too hard to pass without effort. Fixing those three things fixes a large proportion of grade one and grade two disease outright, and it does something more useful for everybody else, which is to stop the surgical result from unraveling within two years. An operation performed on somebody who will carry on straining is an operation with a countdown attached to it.

The three that actually matter

Fiber intake raised deliberately to around thirty grams a day, which for most diets means a supplement and not just more vegetables, softens stool enough that the cushions stop being dragged down. Time on the toilet cut to under three minutes, which sounds trivial and is the single hardest instruction to follow, since the phone has made ten minute visits normal and ten minutes of sitting with the pelvic floor relaxed is exactly the position that pushes hemorrhoids out. And treating constipation properly with an osmotic laxative where diet alone fails, instead of a stimulant that produces urgency and more straining, and those three together are the reason many people who were referred for surgery never need it, and they take six to eight weeks to show their effect, which is why a surgeon who books an operation at the first appointment has skipped a step.

Rubber band ligation

Banding deserves to be the commonest procedure and gets described properly least of all. A surgeon or a gastroenterologist passes a short scope into the anal canal, sucks the base of an internal hemorrhoid into a small cylinder, and releases a tight rubber ring around it, after which the ring cuts off the blood supply, the tissue dies over the following week, and the whole thing falls off into the toilet without anybody noticing. It takes five minutes. It needs no anesthetic, because the bands go above the line where the anal canal has pain sensation, and it is done in a clinic room with the patient going back to work afterward.

What banding achieves, and what it does not

A meta analysis of eight randomized trials compared banding directly with surgery for grade two and grade three hemorrhoids. Surgery controlled symptoms better. Banding produced less pain and fewer complications, meaning less bleeding, less urinary retention and less trouble with continence, and patient satisfaction came out equal between the two groups, while the reviewers were blunt about the quality of the underlying trials, describing all eight as moderate at best with outcome measures that were poorly defined and inconsistent, and they refused to name a winner. That refusal counts as the finding. Two treatments produce equal satisfaction, one of them takes five minutes with no anesthetic, and the choice between them belongs to the person who has to live through the recovery.

The operations, side by side

Four things get offered under the heading of hemorrhoid surgery and they differ far more than the marketing suggests. One cuts the piles out. One staples a ring of lining above them to pull everything back up, and one ties off the arteries feeding them under ultrasound guidance. And one uses a laser fiber to shrink them from the inside. The first has the best long term evidence and the worst first two weeks. The rest reverse that trade to varying degrees.

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The trial that settled it

Between January 2011 and August 2014 seven hundred and seventy seven adults with grade two to grade four hemorrhoids were randomized across British hospitals to either stapled hemorrhoidopexy or traditional excisional surgery. Pragmatic in design, meaning ordinary surgeons in ordinary hospitals rather than a handful of enthusiasts, it took as its main measurement not recurrence but quality of life tracked over a full twenty four months, and that design choice matters, because a trial measuring pain at two weeks and a trial measuring life at two years answer opposite questions and the marketing has always quoted the first.

1. Stapled hemorrhoidopexy was less painful in the short term, confirming what its advocates had always claimed.
2. Complication rates were similar between the groups, with serious adverse events in 7 percent after stapling and 9 percent after excisional surgery.
3. Quality of life over the first six weeks was better after stapling, as expected.
4. Across the whole twenty four months the excisional group came out ahead, and the difference reached statistical significance.
5. The authors concluded that traditional excisional surgery should be considered over stapled hemorrhoidopexy as the surgical treatment of choice.

Read that sequence carefully, because it is the shape of the entire field. The gentler operation wins the first six weeks and loses the next twenty two months. Anybody selling you a hemorrhoid procedure on the strength of how comfortable the first two weeks will be is quoting the part of the graph that goes their way.

What stapled surgery costs later

A Cochrane review pooled twelve randomized trials covering 955 patients and found recurrence significantly commoner after stapling, with odds of 3.22 against conventional excision. Thirty seven recurrences among 479 stapled patients against nine among 476 who had the piles removed. Prolapse as a reported symptom ran at odds of 2.65. Needing a further operation ran at 2.75. When all symptoms were considered together, patients who had conventional surgery were significantly more likely to be free of them, while pain, itching and urgency all trended in favor of stapling and none of those trends reached significance, which is the whole argument compressed into one sentence.

Those figures come from first generation stapling devices and from a single retrospective survey with all the recall problems that implies, and the authors argue that tighter patient selection and larger devices would improve on them. Both points land. Neither changes the direction of travel across three independent lines of evidence.

Artery ligation, and the cost question

Hemorrhoidal artery ligation sounds like it should be the elegant answer. A probe with a Doppler ultrasound sensor finds the arteries feeding each hemorrhoid, the surgeon stitches them closed, and nothing is cut away, so a British multicenter trial randomized 370 patients with grade two and grade three hemorrhoids between artery ligation and rubber band ligation, then followed them for a year, and the results are worth walking through slowly because they are widely misquoted in both directions.

Which operation suits whom

Pulling four sections of evidence into a decision is the part that a page can genuinely help with, provided it stops short of pretending to examine you, and grade four hemorrhoids, meaning permanently prolapsed tissue that will not go back, get an excisional operation, because nothing else addresses tissue that is already outside. Large external components and skin tags get excision for the same reason, since stapling and artery ligation both work above the pain line and cannot reach anything outside it. Grade two and grade three disease should meet a rubber band before it meets an operating room, and where banding has been tried properly and failed, the evidence supports excision over the gentler alternatives. Circumferential grade three disease, meaning hemorrhoids all the way around rather than in three separate places, is the one setting where stapling has a randomized trial genuinely on its side, with five year recurrence of 18 percent against 23 percent for excision and far less early pain.

The operation itself

An excisional hemorrhoidectomy takes twenty to forty minutes and happens under a general or a spinal anesthetic, with the patient positioned either on the back with the legs raised or face down with the buttocks taped apart, according to which the surgeon prefers. Each hemorrhoid is lifted, its base tied or sealed, and the tissue removed with care taken to leave bridges of normal skin and lining between the wounds, since removing the whole circumference produces a narrowed anal canal that causes far more trouble than the hemorrhoids ever did. The wounds are then either left open to heal from the bottom up over four to six weeks or closed with dissolving stitches, and the argument between those two approaches has run for decades without producing a decisive answer.

What happens before you arrive

• A colonoscopy already done, or scheduled, for anybody over forty five or with a family history, because bleeding attributed to hemorrhoids is the commonest way a rectal cancer gets missed.
• Blood thinners stopped on a written schedule agreed at the consultation, since this is an operation on tissue that bleeds generously.
• An enema or a single sachet of laxative on the morning, without a full bowel preparation, which serves no purpose here.
• Laxatives and painkillers prescribed and collected before the day, rather than sent home with you afterward, because the first bowel movement arrives whether or not somebody has been to a pharmacy.

The order of those last two matters more than it looks. Pain control for this operation begins the day before it happens.

1. Local anesthetic injected around the anus at the end of the operation, which the evidence supports in every technique and which buys the first twelve hours.
2. A stool softener started that evening and continued for a full two weeks, so the first movement is soft.
3. Regular painkillers taken by the clock for the first week instead of waiting for pain to arrive, because pain in this area produces spasm and spasm produces more pain.
4. A warm bath two or three times a day, which relaxes the sphincter and does more for comfort than anything applied to the skin.

Going home

Most leave the same day or the next morning. Urinary retention accounts for most unexpected overnight stays, particularly in men, and it happens to somewhere between one and ten patients in a hundred depending on the series and on how much fluid was given during the anesthetic.

The pain, described honestly

Every other page on this subject either skips this or buries it under the word discomfort, and skipping it is what produces patients who stop their laxatives on day three and end up in an emergency department on day five. So here it is plainly. Nobody enjoys week one. Cutting hemorrhoids out hurts more than most abdominal operations, the pain peaks with the first two or three bowel movements rather than immediately after the anesthetic wears off, and it stays significant for two to three weeks before fading over a fourth. In the German trial that measured it on a ten point scale, patients scored 6.2 at one week after excision against 3.1 after stapling, and were still at 3 out of 10 in week two against 0.5. Those numbers are what the trade looks like from the inside. The pain also runs to a predictable schedule, which makes it manageable in a way that unexpected pain never is, and it comes from the wounds sitting in the part of the anal canal that has ordinary skin sensation, and from the sphincter going into spasm around them. Everything that works, works by attacking one of those two things, and soft stool means the wounds never get stretched. Warm baths and prescribed relaxant ointments stop the spasm. Painkillers taken on a schedule keep the level below the point where spasm starts. Somebody who does all four has a difficult two weeks. Somebody who does none of them has the experience their neighbor warned them about, and the difference between those two people is almost entirely preparation rather than luck or surgical skill.

Recovery week by week

Knowing the shape of the recovery in advance removes most of the fear from it, because almost every alarming thing that happens is on the expected list.

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Work, and what to tell your employer

Two weeks off is the realistic figure for an office job and three to four for anything physical, and the single commonest mistake is booking one week and then negotiating with an employer while sitting on a raw wound. Book the two weeks. Driving returns once an emergency stop would not make you flinch, which lands around the end of the second week. Flying gets its own answer further down.

One instruction sits above all the others and gets ignored constantly. Do not stop the stool softener when you start to feel better. A hard stool passing through healing wounds in week three undoes two weeks of recovery in about four seconds, and it is the single commonest reason somebody rings a surgeon in tears. Six weeks of laxative is the standard, and two weeks is not.

What can go wrong

Serious trouble after this operation is uncommon and worth recognizing early, and the three that matter arrive at recognizable times.

Timing tells you which one it is.

Continence, and why it belongs here

Every hemorrhoid procedure works within a centimeter or two of the muscles that hold the anus closed, and all of them carry some risk to control, while minor and temporary changes are common after excisional surgery and settle within six months in the great majority. The figures that should give anybody pause come from the long term stapling data, where 39.1 percent of patients reported impaired continence at twelve years and 38.2 percent reported tenesmus. Whether those numbers belong to the operation or to the hemorrhoidal disease that preceded it cannot be settled by a retrospective survey, and that uncertainty is itself an argument for treating the question seriously in advance. Ask before you choose.

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Having this done in Istanbul

Hospital pages turn into advertisements at exactly this point, so here are the two things that ought to be said first, of which the more important is that an excisional hemorrhoidectomy and a long haul flight fit together badly, because the worst days fall between the third and the tenth and nobody wants to spend those on an aircraft or in a hotel bathroom. And a substantial number of people who write to us describing hemorrhoids turn out, after an examination, to need a five minute banding or a fissure treated instead, which no clinic can establish from an email.

What to send, and what comes back

Send a description of what the lump does, whether it goes back on its own, whether you push it back, or whether it stays out, and send what has already been tried and for how long, including fiber, laxatives, creams and any previous banding. Send your age, any colonoscopy result, any problem with control of wind or stool, and any obstetric history where relevant, and one of our surgeons reads it and replies in writing, at no charge, naming the grade we suspect and what that grade needs. Where the sensible answer is a banding you could have near home for a fraction of the trouble, the reply says exactly that and offers no date.

Nobody is booked for an operation on the strength of an email. The examination on arrival decides the procedure, and where it shows something different from what the correspondence suggested, the plan changes that morning and the price changes with it. A clinic that confirms both the operation and the price before seeing you is guessing about one of them.

The plan for a planned operation

Six to seven nights is the honest figure for this operation, which is longer than most hospital pages quote and reflects where the pain actually falls, while a banding needs no stay at all beyond the appointment itself. Budget the whole week. Several things that would otherwise need arranging separately come as part of the pathway. We work in seven languages without booking an interpreter, those being English, Arabic, French, Russian, Serbian, Romanian and Spanish, and anything outside that list is arranged in advance. One coordinator takes your first message, stays with you to discharge, and goes on answering on WhatsApp after you return home, where a photograph of the wounds is looked at the same day and a written follow up goes out at six weeks. A companion sleeps in the room on a bed the ward provides. Hotel nights and airport transfers are booked before you land. An invitation letter for a visa application leaves our office around ten days ahead of the flight. Meals come halal, vegetarian or adjusted for diabetes, and a prayer room sits on the ward floor. On cost we publish no figures, because the price turns on the grade, on how many hemorrhoids are removed, on whether an external component and skin tags are dealt with at the same time, and on whether a night on the ward is needed, and a number quoted before anybody has examined you is a number that will change.

Questions we are asked, a hemorrhoid surgery FAQ

References

1. Watson AJM, Hudson J, Wood J, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS), a pragmatic, multicentre, randomised controlled trial. Lancet. 2016;388(10058):2375-2385.
2. Lumb KJ, Colquhoun PHD, Malthaner RA, Jayaraman S. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev. 2006;2006(4):CD005393.
3. Brown S, Tiernan J, Biggs K, et al. The HubBLe Trial, haemorrhoidal artery ligation versus rubber band ligation for symptomatic second and third degree haemorrhoids, a multicentre randomised controlled trial and health economic evaluation. Health Technol Assess. 2016;20(88):1-150.
4. Dekker L, Han-Geurts IJM, Rørvik HD, van Dieren S, Bemelman WA. Rubber band ligation versus haemorrhoidectomy for the treatment of grade II to III haemorrhoids, a systematic review and meta analysis of randomised controlled trials. Tech Coloproctol. 2021;25(6):663-674.
5. Sturiale A, Fabiani B, Menconi C, et al. Long term results after stapled hemorrhoidopexy, a survey study with mean follow up of 12 years. Tech Coloproctol. 2018;22(9):689-696.
6. Kim JS, Vashist YK, Thieltges S, et al. Stapled hemorrhoidopexy versus Milligan Morgan hemorrhoidectomy in circumferential third degree hemorrhoids, long term results of a randomized controlled trial. J Gastrointest Surg. 2013;17(7):1292-1298.
7. Alshreef A, Wailoo AJ, Brown SR, et al. Cost effectiveness of haemorrhoidal artery ligation versus rubber band ligation for the treatment of grade II to III haemorrhoids. Pharmacoecon Open. 2017;1(3):175-184.