Hemorrhoid Treatment Level Four: Surgery

February 12th, 2013 by Eduardo Krajewski, MD, FACS, FASCRS

A relatively small percentage of persons that suffer from hemorrhoids will find it impossible to get rid of their symptoms with conservative measures or with in-office procedures. These persons will require surgery to resolve the issue. Surgery is indicated for the treatment of hemorrhoids in the following circumstances:

  • Failure to control symptoms with in-office procedures
  • Person cannot tolerate in-office procedures
  • Large external hemorrhoids
  • Combination of internal and external hemorrhoids with significant prolapse
  • Co-existing problems such as anal fissure or fistula

These are serious cases where the only option left is to perform an operation, under anesthesia in a hospital setting.

Excisional Hemorrhoidectomy

In this operation, the surgeon cuts out the problematic hemorrhoid in an operating room. This surgery is also indicated when the hemorrhoids are strangulated or gangrenous. Strangulated hemorrhoids are hemorrhoids that hang out of the anus and cannot be pushed back inside. They are so swollen to the point that the anal orifice constricts tightly around them. This condition is usually very painful.

Excisional hemorrhoidectomy must be done under general anesthesia, but the patient can often go home the same day of the procedure. Pain is the most common and bothersome post-operative side effect, and many times narcotics are required to control the pain. It generally takes about 2-4 weeks to recover from an excisional hemorrhoidectomy.

Other important complications of this surgery can be difficulty urinating, bleeding, infection, narrowing of the anal opening, fecal incontinence and fecal impaction.

Stapled Hemorrhoidectomy

This procedure is used for hemorrhoids that have not responded to in-office rubber band ligation. Stapled hemorrhoidectomy is less invasive and less painful than excisional hemorrhoidectomy, but the risk of hemorrhoid symptom recurrence is greater with the stapling surgery. Also stapling cannot be used for the more severe hemorrhoid cases.

In stapled hemorrhoidectomy a special device applies circular staples to the bothersome tissue thus cutting off the blood supply. The dead tissue eventually falls off on its own. The main side effects for stapled hemorrhoidectomy are rectal perforation and infection.

Transanal Hemorrhoidal Dearterialization

In this procedure a special probe locates the blood vessels that supply the symptomatic hemorrhoids. These blood vessels are then tied off thus cutting off the blood supply. The extra hemorrhoid tissue is also sutured up inside the anal canal returning the hemorrhoids back to their normal anatomic position.

External Hemorrhoid Thrombosis

External hemorrhoids differ from internal hemorrhoids in that they are located further outside of the body. They also have a different nerve supply, making external hemorrhoids much more sensitive to pain. Problematic internal hemorrhoids can extend outwards and cause external hemorrhoids to develop, and surgery might be required to treat this.

In some cases a blood clot forms in the external hemorrhoid, and this can be exquisitely painful. This situation is called a thrombosed external hemorrhoid, and it often must be resolved surgically under anesthesia. However, the thrombosed hemorrhoid can sometimes open up on its own bringing immediate relief. The follow up treatment is then sitz baths, laxatives, dietary fiber and pain relievers.


Some cases of hemorrhoids are too severe to be treated with modifications in diet and exercise or by in-office procedures. In these cases, a surgical procedure must be performed in a hospital. The type of surgery depends on how the case presents itself and on the surgeon’s recommendation.

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