Hemorrhoid surgery removes or shrinks swollen hemorrhoidal tissue, and the specific method depends on how far the hemorrhoids have progressed. Most procedures take under an hour, are performed as outpatient surgery, and involve a recovery period of two to four weeks. But not all hemorrhoid surgeries work the same way. Some cut the tissue out entirely, some reposition it, and newer techniques shrink it from the inside without any external wounds.
When Surgery Becomes Necessary
Internal hemorrhoids are graded on a four-point scale based on how much they prolapse, or slip outside the anal canal. Grade I hemorrhoids don’t prolapse at all. Grade II prolapse during a bowel movement but slide back on their own. Grade III prolapse and need to be pushed back in manually. Grade IV are permanently prolapsed and can’t be pushed back in.
Non-surgical treatments like rubber band ligation work well for grade II hemorrhoids. Grade IV hemorrhoids generally require surgery. Grade III falls in a gray zone where either approach may be appropriate, and the decision often comes down to symptom severity and how much the hemorrhoids affect daily life. External hemorrhoids that develop painful blood clots may also need surgical removal if the clot doesn’t resolve on its own.
Excisional Hemorrhoidectomy
This is the oldest and most definitive approach. The surgeon physically cuts out the swollen hemorrhoidal tissue, then ties off the blood vessels feeding it. There are two main versions. In the open technique (Milligan-Morgan), the wound is left open to heal on its own from the inside out. In the closed technique (Ferguson), the wound is stitched shut after excision. Both accomplish the same thing: complete removal of the problem tissue.
The closed technique was developed to address the main drawbacks of the open approach, which are significant postoperative pain and slower healing. In practice, excisional hemorrhoidectomy of either type is considered the gold standard for advanced hemorrhoids because recurrence rates are low, around 3.6% for grade IV disease. The tradeoff is that recovery involves more discomfort than newer techniques, often lasting one to three weeks of notable pain.
Stapled Hemorrhoidopexy
Rather than cutting hemorrhoids out, stapled hemorrhoidopexy works by repositioning them. A circular stapling device removes a ring of tissue from above the hemorrhoids, inside the rectum. This pulls the prolapsed hemorrhoidal cushions back up into their normal position inside the anal canal, like tacking a sagging curtain back onto its rod.
The repositioning does two things. First, it restores proper blood drainage from the hemorrhoidal tissue, which allows the swollen cushions to shrink back to normal size. Second, the staple line cuts across the small arteries feeding the hemorrhoids, reducing blood inflow. Over time, the body replaces the staple line with scar tissue that acts as a permanent internal support structure, holding everything in place.
Because the stapler works above the sensitive skin of the anal canal, patients report significantly less pain and higher satisfaction than with traditional excision. The downside is a higher recurrence rate. A meta-analysis found recurrence after stapled hemorrhoidopexy reached 22% compared to 3.6% after conventional excision for grade IV hemorrhoids. Bleeding after the stapled procedure is also somewhat more common, occurring in up to 9.6% of cases versus about 2% with conventional excision.
Doppler-Guided Artery Ligation
This technique uses ultrasound to locate the specific arteries supplying blood to the hemorrhoids, then ties them off with stitches. A specialized probe with a built-in Doppler sensor is inserted into the anal canal. As the surgeon rotates it, an audible signal identifies exactly where each feeding artery runs. The surgeon then places a stitch through each artery to cut off blood flow, which causes the hemorrhoids to gradually shrink over the following weeks.
For patients who also have prolapsing tissue, a second step called mucopexy is added. The surgeon uses a running stitch to gather up the loose, redundant tissue and lift it back into position, similar in concept to the stapled approach but done with sutures instead of a stapling device. Bleeding rates after this procedure are around 4.3%.
Laser Hemorrhoidoplasty
Laser hemorrhoidoplasty is a newer, non-excisional approach. A thin laser fiber is inserted directly into the hemorrhoidal tissue through a small puncture. The laser delivers controlled pulses of energy that coagulate the tissue from the inside, causing it to shrink over time. The key advantage is that it preserves the outer skin and mucosa entirely, leaving no external wound.
Studies and meta-analyses show that laser hemorrhoidoplasty achieves symptom resolution and recurrence rates comparable to conventional excision. Pain scores on the first day after surgery are roughly 2 points lower on a 10-point scale compared to excisional surgery, and that benefit continues through the first week. Recovery time is also notably shorter. Where traditional hemorrhoidectomy may require one to three weeks of convalescence, patients after laser treatment typically resume daily activities sooner.
What to Expect Before Surgery
Preparation is straightforward. You’ll eat a light meal, like soup or salad, the night before. After midnight, nothing by mouth, including water, coffee, or tea. Your surgeon may provide additional instructions specific to your procedure, such as adjusting blood-thinning medications. Most hemorrhoid surgeries are performed under general or regional anesthesia, and you’ll go home the same day. You will need someone to drive you.
Recovery and Pain Management
The average recovery from hemorrhoidectomy is two to four weeks, with six to eight weeks before you can return to heavy lifting or strenuous exercise. Minimally invasive techniques like laser or Doppler-guided procedures tend to fall on the shorter end of that range, while open excision tends toward the longer end.
Pain management typically involves a combination of approaches rather than relying on a single medication. Before and after surgery, you may receive a mix of standard pain relievers alongside medications that target inflammation and swelling. A long-acting local anesthetic injected into the surgical area can provide extended relief in the hours immediately following the procedure. Topical creams applied to the perianal skin help relax the internal sphincter muscle, which reduces the spasm-related pain that many patients find most bothersome. Flavonoid supplements, taken at high doses during the recovery period, can reduce wound swelling and pain.
Stool softeners and a high-fiber diet are standard recommendations during healing. The first few bowel movements after surgery are often the most uncomfortable, and keeping stools soft makes a meaningful difference. Sitz baths, where you soak the area in warm water for 10 to 15 minutes several times a day, also help with both pain and hygiene.
Possible Complications
Urinary retention is the most common complication after any anorectal surgery, affecting roughly 15% of patients, though rates in individual studies range from 3% to 50% depending on the type of anesthesia and procedure. This is usually temporary and resolves within a day or two, sometimes requiring a catheter in the short term.
Significant bleeding after surgery occurs in about 2% of conventional hemorrhoidectomies, up to 9.6% of stapled procedures, and around 4.3% of Doppler-guided procedures. Most bleeding episodes happen within the first two weeks and can often be managed without returning to the operating room.
Anal stenosis, a narrowing of the anal canal from scar tissue, occurs in 1% to 7.5% of cases after excisional or stapled procedures. This is more likely when large amounts of tissue are removed. Mild stenosis may respond to gradual dilation, while severe cases occasionally need a corrective procedure.