Hemorrhoidectomy is the surgical removal of hemorrhoidal tissue and remains the most effective treatment for advanced hemorrhoids, particularly when less invasive options have failed or when the disease is severe enough to cause significant prolapse. It is generally reserved for grade III and IV hemorrhoids because, while it produces the best long-term cure rates, it also comes with more postoperative pain and a longer recovery than office-based procedures like rubber band ligation. The procedure has evolved considerably over the past century, with several distinct techniques now available, each carrying its own trade-offs in pain, healing time, and risk of complications.
When Hemorrhoidectomy Becomes Necessary
Hemorrhoids are not simply swollen veins. The underlying problem involves dilated and distorted blood vessels along with breakdown of the connective tissue that normally anchors the anal cushions in place.1PubMed Central. Hemorrhoids: from basic pathophysiology to clinical management Research has shown that patients with hemorrhoidal disease have a significantly altered ratio of collagen types in their anal tissue compared to healthy controls, which helps explain why the cushions slide downward and become symptomatic.2PubMed Central. Abnormalities in collagen composition may contribute to the pathogenesis of hemorrhoids: morphometric analysis
For mild to moderate hemorrhoids (grades I through III), rubber band ligation is generally recommended as first-line therapy. A meta-analysis comparing treatments found that while hemorrhoidectomy produces better overall response rates, it carries more complications and pain, so it should be reserved for cases that do not respond to banding.3PubMed Central. Comparison of hemorrhoidal treatments: a meta-analysis A Cochrane systematic review confirmed this approach: rubber band ligation works well for grade II hemorrhoids, while excisional hemorrhoidectomy is more appropriate for grade III disease or for hemorrhoids that recur after banding.4PubMed Central. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids
In practice, hemorrhoidectomy is most commonly performed for people with large external hemorrhoids, prolapsing internal hemorrhoids that cannot be pushed back in, or hemorrhoids that have not improved after one or more rounds of office-based treatment. Patients with mixed internal and external disease, or those with circumferential hemorrhoids involving multiple columns of tissue, are often directed straight to surgery because rubber band ligation cannot adequately address external components.
Open Versus Closed Hemorrhoidectomy
The two traditional approaches are named after their inventors. The Milligan-Morgan (open) technique, developed in the 1930s, involves excising the hemorrhoidal tissue and leaving the surgical wound open to heal on its own. The Ferguson (closed) technique, introduced later, uses the same excision but stitches the wound closed. Both aim to remove the enlarged tissue and tie off the blood vessels feeding it.5PubMed Central. Milligan–Morgan hemorrhoidectomy combined with rubber band ligation and polidocanol foam sclerotherapy for the management of grade III/IV hemorrhoids: a retrospective study
A systematic review and meta-analysis of randomized trials comparing the two found that the closed (Ferguson) approach comes with less postoperative pain, faster wound healing, and a lower risk of bleeding, though it takes somewhat longer in the operating room.6PubMed. Milligan-Morgan (Open) Versus Ferguson Haemorrhoidectomy (Closed): A Systematic Review and Meta-Analysis of Published Randomized, Controlled Trials A head-to-head study of over 200 patients showed that while the open technique had lower pain scores in the first 24 hours and at the first bowel movement, the closed technique led to quicker wound healing and shorter time away from work. However, the closed method carried a small risk of anal stenosis (about 3% of patients), which was not seen with the open technique.7PubMed Central. An evaluation of Milligan-Morgan and Ferguson procedures for haemorrhoidectomy at Liaquat University Hospital Jamshoro, Hyderabad, Pakistan
A large case series of nearly 700 patients who underwent Ferguson hemorrhoidectomy for grade III and IV disease reported low pain scores and high patient satisfaction, with recurrence rates remaining modest at one and two years. The authors argued that closed hemorrhoidectomy still represents the benchmark against which newer techniques should be measured.8PubMed. Ferguson hemorrhoidectomy: is still the gold standard treatment?
Stapled Hemorrhoidopexy and Its Limits
Stapled hemorrhoidopexy, sometimes called the procedure for prolapse and hemorrhoids (PPH), took a different conceptual approach when it was introduced in the 1990s. Instead of cutting out the hemorrhoidal tissue directly, it uses a circular stapler to remove a ring of rectal mucosa above the hemorrhoids, pulling the prolapsed cushions back up into their normal position and reducing blood flow to them. The appeal is less pain, because the staple line sits above the dentate line in an area with fewer pain-sensing nerves.
The pain advantage is real. In a randomized trial of circumferential grade III hemorrhoids, patients who had stapled hemorrhoidopexy reported substantially lower pain scores at one and two weeks compared to those who had open (Milligan-Morgan) hemorrhoidectomy.9PubMed. Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy in circumferential third-degree hemorrhoids: long-term results of a randomized controlled trial That same trial found similar five-year recurrence rates between the two techniques, at roughly 18% and 23% respectively.
But larger meta-analyses paint a different picture of recurrence. A pooled analysis of 14 studies with over a thousand patients found that prolapse recurrence at one year was about five and a half times more likely after stapled hemorrhoidopexy than after conventional excisional surgery, and patients in the stapled group were nearly twice as likely to need additional treatment.10JAMA Surgery. Long-term Outcomes of Stapled Hemorrhoidopexy vs Conventional Hemorrhoidectomy: A Meta-analysis of Randomized Controlled Trials Another meta-analysis confirmed this, reporting that conventional hemorrhoidectomy was roughly four times more effective at preventing long-term recurrence.11PubMed. Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery
The problem is especially pronounced with the most advanced disease. A study focused on grade IV hemorrhoids found that nearly a quarter of stapled patients developed recurrence, detected at 8 and 12 months after surgery. The researchers concluded that stapled hemorrhoidopexy is not appropriate for grade IV disease and that open surgery remains the better option for these patients.12PubMed Central. Analysis of recurrence after stapled hemorrhoidopexy in grade IV hemorrhoid disease
Energy Devices, Laser, and Dearterialization
Several newer tools and techniques aim to reduce pain while preserving the thoroughness of conventional excision. The LigaSure device uses bipolar electrothermal energy to seal blood vessels and cut tissue simultaneously, which makes the operation faster and can reduce bleeding. A meta-analysis of 11 trials found that conventional hemorrhoidectomy took about 9 extra minutes to complete compared to LigaSure-assisted surgery.13PubMed. Pain after conventional versus Ligasure haemorrhoidectomy. A meta-analysis Another meta-analysis confirmed a shorter operating time with LigaSure compared to stapled hemorrhoidopexy as well.14PubMed Central. LigaSure hemorrhoidectomy versus the procedure for prolapse and hemorrhoids A meta-analysis of randomized controlled trials
Laser hemorrhoidoplasty uses a diode laser fiber inserted directly into the hemorrhoidal tissue to shrink it from the inside. A comparative study of 154 patients found that laser-treated patients had the lowest pain scores across all time points compared to Ferguson hemorrhoidectomy alone, though a combined approach using both laser and Ferguson techniques on different hemorrhoidal columns also performed better on pain than Ferguson alone.15Signa Vitae. Is the combination of laser hemorrhoidoplasty and Ferguson hemorrhoidectomy superior to conventional surgical techniques in terms of postoperative pain in hemorrhoid patients? A retrospective comparative analysis
Doppler-guided hemorrhoidal dearterialization (sometimes called transanal hemorrhoidal dearterialization or THD) takes yet another approach. Using an ultrasound probe inserted into the anal canal, the surgeon locates the arteries feeding each hemorrhoidal cushion and ties them off, often adding a mucopexy stitch to lift prolapsed tissue back into place. A 20-year literature review found the technique to be safe and effective for grades II through IV disease, with satisfactory outcomes even in patients with significant prolapse.16PubMed Central. Doppler-guided hemorrhoidal dearterialization/transanal hemorrhoidal dearterialization: Technical evolution and outcomes after 20 years However, a cost-effectiveness study found that while dearterialization led to less pain and shorter sick leave, it cost more per patient at one year than conventional excision.17Annals of Surgery. Cost-effectiveness of New Surgical Treatments for Hemorrhoidal Disease
Managing Pain After Hemorrhoidectomy
Postoperative pain is the single biggest concern with conventional hemorrhoidectomy and the primary reason less invasive alternatives keep being developed. Much of that pain comes from spasm of the internal anal sphincter muscle, which tightens reflexively after surgery. Several strategies specifically target this spasm, and a systematic review and meta-analysis found that topical medications applied directly to the anal canal can meaningfully reduce pain scores in the first week.
Topical diltiazem, a calcium channel blocker that relaxes smooth muscle, reduced pain on the visual analog scale during the first three days. Glyceryl trinitrate (GTN), which works through nitric oxide-mediated relaxation, reduced pain at seven days. Botulinum toxin injection into the sphincter also lowered pain scores at seven days.18PubMed Central. Can Targeting Sphincter Spasm Reduce Post-Haemorrhoidectomy Pain? A Systematic Review and Meta-Analysis A network meta-analysis that ranked multiple analgesic strategies confirmed that GTN and diltiazem were among the most effective options at 24 hours after open hemorrhoidectomy, with diltiazem maintaining its advantage through the first week.19PubMed. Comparing the efficacy and safety of different analgesic strategies after open hemorrhoidectomy: a systematic review and network meta-analysis
A randomized trial of topical diltiazem after closed hemorrhoidectomy illustrated the magnitude of the benefit. Patients using diltiazem had pain scores roughly a third to a fifth of those in the control group at 24, 48, and 72 hours, and they needed far fewer rescue analgesic doses.20PubMed. Topical diltiazem for pain after closed hemorrhoidectomy
Regional nerve blocks also help during and immediately after surgery. A meta-analysis of double-blind randomized trials found that pudendal nerve blocks significantly lowered pain scores within the first 6, 12, and 24 hours after hemorrhoid surgery, though the effect faded by 48 hours.21PubMed Central. The role of pudendal nerve block in hemorrhoid surgery: a systematic review and meta-analysis of double-blind randomized controlled trials This makes nerve blocks useful as a bridge to get patients through the worst of the immediate postoperative period, after which topical sphincter-relaxing agents can take over.
Complications Worth Knowing About
While hemorrhoidectomy is generally safe, it does carry recognized risks. The most common complication is urinary retention, the temporary inability to urinate after surgery. In a large study of over 2,100 patients, about 14% developed urinary retention after hemorrhoidectomy. Risk factors included being male, older age, higher body mass index, having four or more hemorrhoids removed, and receiving supplementary analgesics.22PubMed Central. Predictors of postoperative urinary retention after semiclosed hemorrhoidectomy Urinary retention is almost always temporary and resolves with catheter drainage, but it can extend your hospital stay.
Delayed postoperative bleeding is another concern. It typically occurs days to weeks after surgery, well after you have gone home, and can sometimes require a trip to the emergency department. In one study of LigaSure hemorrhoidectomy, delayed bleeding occurred in about 5% of patients, with male sex and constipation identified as independent risk factors. Constipation raised the odds of delayed bleeding substantially, which underscores how important stool softeners are during recovery.23PubMed Central. Risk factors of delayed hemorrhage after LigaSure hemorrhoidectomy A separate comparative study found that delayed bleeding was more common after LigaSure-assisted surgery than after conventional Ferguson hemorrhoidectomy, and that constipation was again a major risk factor.24PubMed Central. Risk of delayed bleeding after hemorrhoidectomy
Anal stenosis, a narrowing of the anal canal caused by excessive scar tissue, is the most feared long-term complication. It is almost always preventable and most commonly results from overly aggressive removal of tissue during surgery. A well-performed hemorrhoidectomy that preserves adequate bridges of skin and mucosa between excision sites is the best defense against this outcome.25PubMed. Anal stenosis If stenosis does develop, treatment ranges from gentle self-dilation with progressively larger dilators to surgical correction with advancement flaps in severe cases.
Continence After Surgery
One concern patients rarely bring up but often worry about is whether hemorrhoidectomy will affect their ability to control gas or stool. Reported rates of continence disturbance after hemorrhoidectomy vary widely, ranging from under 1% to as high as 28% across different studies and definitions.26SciELO – Scientific Electronic Library Online (J. Coloproctol. (Rio J.)). Fecal incontinence as consequence of anorectal surgeries and the physiotherapeutic approach That enormous range reflects both the different ways studies define incontinence (from occasional difficulty controlling gas all the way to loss of solid stool) and the different surgical techniques involved. In one Brazilian series of 580 anorectal surgeries, all cases of temporary fecal incontinence occurred in the open (Milligan-Morgan) group and resolved over time.
The risk is higher in people who already have some degree of sphincter weakness before surgery, such as older adults or women who had pelvic floor injuries during childbirth. Surgeons typically assess sphincter function before operating and may modify their approach if there are concerns. For most patients undergoing a standard hemorrhoidectomy by an experienced surgeon, the risk of lasting continence problems is low.
Hemorrhoidectomy in Patients With Crohn’s Disease
Surgeons have traditionally been cautious about performing hemorrhoidectomy in patients with Crohn’s disease, out of concern that the impaired wound healing and perianal inflammation associated with Crohn’s could lead to devastating complications like non-healing wounds or fistulas. This concern has kept many Crohn’s patients from receiving surgical treatment even when their hemorrhoidal symptoms are severe.
A study examining this question directly found that excisional hemorrhoidectomy could be performed safely in Crohn’s patients who had exhausted non-surgical options, without a significant increase in new perianal disease or the need for proctectomy (removal of the rectum).27PubMed. Excisional Hemorrhoidectomy: Safe in Patients With Crohn’s Disease? This does not mean surgery should be the first choice for these patients. It means that when less invasive measures have failed, the historical blanket prohibition against hemorrhoidectomy in Crohn’s disease may not be warranted. Careful patient selection and close follow-up remain essential.
What Anatomy Has to Do With Technique Choice
The anal canal is divided by a visible landmark called the dentate line, a scalloped ring of tissue sitting roughly two centimeters above the anal opening. Above this line, the tissue is lined with mucosa that has relatively few pain fibers. Below it, the tissue transitions to highly sensitive skin supplied by somatic nerves.28Seminars in Colon and Rectal Surgery. Anatomy of the anal canal with attention to the clinical management of symptomatic hemorrhoids
This anatomical divide explains why different procedures produce different pain profiles. Techniques that work above the dentate line, like stapled hemorrhoidopexy and dearterialization, cause less pain because they avoid cutting through the sensitive skin below it. Conventional excisional hemorrhoidectomy, which removes tissue both above and below the dentate line, necessarily involves cutting through nerve-rich skin, which is why pain tends to be more intense. For patients whose primary disease involves external hemorrhoids or combined internal-external disease, there is no way to avoid working below the dentate line, and excisional surgery becomes the logical choice despite the pain trade-off. For predominantly internal hemorrhoids, the newer techniques that stay above the line can offer a meaningful advantage in comfort.
Recovery Timeline and Practical Expectations
Most people underestimate how long recovery from hemorrhoidectomy takes. The procedure is technically outpatient in many centers, meaning you go home the same day, but the healing process extends well beyond that. Pain is typically worst during the first week, particularly during and just after bowel movements. It gradually improves over two to four weeks, though some tenderness at the surgical site can persist for six weeks or longer, especially after open hemorrhoidectomy where the wounds heal by secondary intention.
Time off work varies depending on the technique and the nature of your job. In a cost-effectiveness study comparing dearterialization to conventional excision, the mean sick leave was about 12 days for dearterialization and about 15 days for excision.29Annals of Surgery. Cost-effectiveness of New Surgical Treatments for Hemorrhoidal Disease People with physically demanding jobs often need longer. Sitting can be uncomfortable for the first couple of weeks, and many patients find that a donut-shaped cushion, warm sitz baths, and stool softeners are indispensable during recovery.
Constipation is the enemy during healing. Hard stools passing over fresh surgical wounds are painful and raise the risk of delayed bleeding. Stool softeners are typically started before surgery and continued for several weeks afterward. A high-fiber diet and adequate water intake matter more during this period than at almost any other time. The goal is soft, formed stools that pass easily without straining, since straining was likely part of what contributed to the hemorrhoids in the first place.
Combination Approaches
Surgeons increasingly tailor procedures to the individual patient’s anatomy rather than applying one technique uniformly. A patient with one large prolapsing column of hemorrhoids and two smaller ones might have the large column excised conventionally while the smaller ones are treated with rubber band ligation or sclerotherapy during the same session. This reduces the total amount of tissue removed and the number of surgical wounds, which means less pain and a lower risk of complications like stenosis.30PubMed Central. Milligan–Morgan hemorrhoidectomy combined with rubber band ligation and polidocanol foam sclerotherapy for the management of grade III/IV hemorrhoids: a retrospective study
The same logic applies to laser-assisted approaches, where a laser probe can be used on internal components while conventional excision handles the external disease. The emerging trend is away from one-size-fits-all surgery and toward a personalized approach that matches the tool to each hemorrhoidal column based on its size, position, and whether it is internal, external, or mixed.