Hemorrhoid Surgery: Indications, Procedure & Recovery

Hemorrhoid surgery may be recommended by a doctor to treat grade 3 and 4 internal hemorrhoids, external or mixed hemorrhoids, or when a fiber-rich diet and medications do not provide enough relief. The most appropriate procedure depends on the hemorrhoid type, the severity of symptoms, and how much the condition affects daily life.

Several techniques can be used for hemorrhoid surgery, including office-based procedures and hospital-based operations. A colorectal surgeon typically chooses the approach based on the hemorrhoid’s location and grade.

Recovery after hemorrhoid surgery typically takes between one week and over a month. Most patients are advised to take prescribed medications, do warm sitz baths, and increase their fluid and fiber intake to make bowel movements easier.

Indications for surgery

Hemorrhoid surgery may be indicated in the case of:

• Grade 3 and 4 internal hemorrhoids;

• External and mixed hemorrhoids;

• Strangulated hemorrhoids;

• Thrombosed external hemorrhoids.

Hemorrhoid surgery may be recommended when conservative or office-based treatments are unsuccessful, and when symptoms continue to significantly affect quality of life despite other interventions.

Surgical preparation

Preparation for hemorrhoid surgery includes avoiding heavy alcohol intake in the days before surgery and stopping smoking if the person smokes.

It is also important to tell the doctor about all medications you are currently taking. The surgeon may recommend temporarily stopping anticoagulants and anti-inflammatory medications a few days before surgery.

If anesthesia or sedation will be used, fasting instructions should be followed exactly as directed by the doctor.

Procedure types

Hemorrhoid surgery is performed based on the grade of the disease, the location of the hemorrhoid, and the severity of the patient's symptoms.

1. Rubber band ligation

According to the American Society of Colon and Rectal Surgeons (ASCRS), rubber band ligation is a commonly used office-based treatment for grade 2 and 3 internal hemorrhoids. This procedure is done by placing a small rubber band at the base of the hemorrhoid.

To do this, the doctor inserts an instrument through an anoscope and places the band around the base of an internal hemorrhoid. The band cuts off blood flow, causing the hemorrhoid tissue to die.

2. Sclerotherapy

In sclerotherapy, the doctor injects a sclerosing agent (such as polidocanol) into the hemorrhoid vessels, which leads to tissue destruction.

This procedure can be performed in an office setting and is typically indicated for grade 1 and 2 internal hemorrhoids.

3. Infrared coagulation

Infrared coagulation is an office-based technique that can be used to treat grade 1 and 2 internal hemorrhoids.

It may be performed using infrared light, laser, or electrical current, in which the doctor uses a probe to deliver energy and create intense heat in the hemorrhoid tissue.

The heat leads to necrosis and scarring, which reduces blood flow and shrinks the hemorrhoid.

4. Hemorrhoidectomy

Conventional hemorrhoidectomy is the most effective surgery for severe hemorrhoids, such as external hemorrhoids or grade 3 and 4 internal hemorrhoids, and it can help prevent recurrence. However, it is typically associated with more postoperative pain.

This surgery is performed in a hospital with general or local anesthesia. The doctor may use an open technique, removing hemorrhoidal tissue through an incision in the skin and mucosa, and leaving the wound open to heal naturally.

A closed technique may also be used and is similar to the open method, but the doctor stitches the wound after removing the hemorrhoid to support faster healing.

5. PPH technique

The PPH technique, also known as stapled hemorrhoidopexy, repositions hemorrhoids back to their original location using a special circular stapling device inserted into the anus.

In this procedure, the device removes a ring of rectal mucosa above the hemorrhoids and staples the remaining tissue. This “lifts” prolapsed hemorrhoids back into the anal canal and interrupts their blood supply.

This surgery is indicated for grade 3 internal hemorrhoids and some cases of grade 2 internal hemorrhoids.

This technique usually causes less pain than conventional hemorrhoidectomy and can allow a faster return to activities, but it has higher recurrence rates.

6. Transanal hemorrhoidal dearterialization (THD or HAL)

This surgery is done without skin incisions, using a Doppler ultrasound device to locate the arteries that supply blood to the hemorrhoids.

The doctor then ties off these vessels to stop blood flow, which causes the hemorrhoid to shrink and dry out over time, with the sutures being absorbed.

This surgery can be used for symptomatic internal hemorrhoids and grade 2 and 3 hemorrhoids.

7. Thrombectomy

Thrombectomy is an urgent procedure used for thrombosed hemorrhoids.

The procedure uses local anesthesia. The doctor makes an incision in the hemorrhoid to remove the clot, or removes the entire hemorrhoid if needed.

This procedure can provide immediate pain relief and is most effective when done within 72 hours of symptom onset.

Care instructions

During recovery, the person may feel pain in the perineal area, especially when sitting and during the first bowel movement after surgery.

In general, the doctor may recommend:

• Taking oral pain relievers to control pain and discomfort, such as acetaminophen every 8 hours;

• Using laxatives to soften stool and make bowel movements easier;

• Taking warm sitz baths for 10 to 15 minutes, several times a day, to help ease pain, swelling, and inflammation;

• Avoiding toilet paper and washing the anal area after bowel movements with warm water and mild soap;

• Applying an ointment to the area twice a day to help the region heal;

• Using a donut-shaped cushion when sitting to reduce bleeding risk and relieve pain;

• Increasing fiber intake and drinking plenty of water.

It is also important to avoid straining during bowel movements and not to sit on the toilet for long periods, to help reduce pain and bleeding risk.

Meal plan

A meal plan after hemorrhoid surgery should include fiber-rich foods such as fruits, legumes, vegetables, and whole grains.

The fiber in these foods helps soften the stool and add bulk, making bowel movements easier and less likely to cause strain or discomfort. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), eating high-fiber foods can make stools easier to pass and help both prevent and treat hemorrhoids.

It is also essential to drink at least 6 to 8 glasses of water per day, or about 2 liters.

Hemorrhoid surgery recovery

Recovery time after hemorrhoid surgery depends on the hemorrhoid type and grade, as well as the technique used. It may range from one week to more than one month before a person can fully return to normal daily activities.

During the first week after surgery, small amounts of bleeding from the anal area may occur. If bleeding is heavy, it is recommended to go to the hospital to confirm that recovery is progressing appropriately.