Surgical Treatment & Management of Hemorrhoids

Common Surgical Treatments:

Surgical Management of Hemorrhoids

Surgery is reserved for patients that fail medical treatment or less invasive procedures. In general the larger or more severe the hemorrhoids, the more likely surgery is needed. Less traumatic or office procedure have a higher recurrence rate compared to surgical excision or removal of hemorrhoids. However, in office procedures are typically less painful.

The indications for surgery for hemorrhoids are as follows:

  • Refractory 2nd degree hemorrhoids (small, bleeding hemorrhoids that won’t go away)
  • Symptomatic 3rd & 4th degree hemorrhoids (hemorrhoids that drop out of the anus, bleed and hurt)
  • Rectal mucosal (anal lining) protrusion out of the anus
  • Low grade hemorrhoids w/ other associated disease(s) like a fissure or tear of the anal canal lining
  • Failure of conservative or medical treatment
  • Patient request

Regardless of how hemorrhoids are managed by surgery, there are certain criteria that must be satisfied. Essential elements of surgical treatment of hemorrhoids include:

  • Ligation or interruption of blood flow to the hemorrhoids
  • Excision of extra tissue & dilated hemorrhoidal blood vessels
  • Remodeling of remaining anal tissue (excision of skin tags)
  • Induction of inflammation & fibrosis or scar to hold any remaining hemorrhoid tissue in place

Surgical Options for Management of Hemorrhoids

Surgical Excision:

  • Can be done by a variety of techniques
  • Usually done with a scalpel, scissors or cautery device
  • Performed in outpatient operating room or the office (rarely)
  • Local, regional or general anesthesia is used
  • Moderate to severe discomfort especially in the first several days after surgery
  • Best for high-grade or large internal hemorrhoids or external hemorrhoids
  • Has a lower recurrence rate than in office procedures

Ligasure Excision:

  • A new way to excise or resect large hemorrhoids
  • Another version of surgical excision
  • Safe and effective alternative to traditional techniques
  • May cause less pain after the operation
  • Rapid and nearly bloodless
  • No differences compared with standard surgery in post-op based on multiple studies

THD – Doppler-guided hemorrhoid de-arterialization

  • New technique
  • Done in the operating room
  • Requires anesthesia
  • Minimal pain compared to excising (or removing) the hemorrhoid in recent studies
  • Quick recovery compared to excising the hemorrhoid
  • Useful for large, internal hemorrhoids that protrude
  • Indicated for severe 2nd degree hemorrhoids and 3rd and 4th degree hemorrhoids
  • YouTube animated video

Procedure for Prolapse and Hemorrhoids (PPH):

  • Also called stapled hemorrhoidectomy
  • Requires special training and experience
  • Offers less pain & a quicker recovery in comparison to conventional hemorrhoid techniques.
  • PPH has similar safety parameters. PPHTM has similar morbidities
  • PPH is quicker to perform

Laser treatment:

  • Considered for low grade internal hemorrhoids
  • Can be an office procedure. No anesthesia is needed in most cases
  • A large medical study showed no difference compared with other procedures
  • Another large, randomized study showed higher cost & prolonged healing
  • American Society of Colon and Rectal Surgeons task force doesn’t support its use.
  • Not commonly used and abandoned by most experts