Hemorrhoids are removed through several different methods, ranging from a quick office procedure with rubber bands to full surgical excision under anesthesia. The approach depends mainly on the size and severity of the hemorrhoid. Most people start with the least invasive option, and surgery is reserved for larger or more persistent cases.
Rubber Band Ligation
The most common removal method for internal hemorrhoids is rubber band ligation, performed right in a doctor’s office without general anesthesia. Your doctor inserts a thin, lighted tube called an anoscope into the anal canal, then feeds a small instrument called a ligator through it. The ligator uses suction to pull the hemorrhoid into a cylinder, and then slides tiny rubber bands off the cylinder onto the base of the hemorrhoid. These bands choke off the blood supply completely. Over the next several days, the hemorrhoid shrinks, dies, and falls off on its own, typically passing unnoticed during a bowel movement.
The procedure takes only a few minutes. You may feel pressure or a dull ache for a day or two afterward, but most people return to normal activities quickly. Rubber band ligation is 70% to 80% effective, making it the go-to first step for internal hemorrhoids that bleed or prolapse.
Surgical Hemorrhoidectomy
When hemorrhoids are large, involve both internal and external tissue, or haven’t responded to banding, surgical removal becomes the next step. This is the most thorough option and has the lowest recurrence rate, but it also involves the most significant recovery. Current guidelines recommend excisional hemorrhoidectomy for grade III and IV internal hemorrhoids (those that prolapse and either need to be pushed back in or can’t be pushed back at all) and for symptomatic external hemorrhoids.
There are two main surgical techniques. In the open approach, the surgeon cuts away the hemorrhoid tissue and leaves the wound open to heal on its own over time. In the closed approach, the surgeon removes the same tissue but stitches the wound shut before finishing. The closed technique tends to cause less postoperative discomfort, shorter hospital stays, and faster healing. Operating times for both are similar, averaging around 20 to 25 minutes.
Recovery from a hemorrhoidectomy takes two to four weeks on average. Most people report that pain resolves around the two-week mark, though it can be six to eight weeks before you’re ready for strenuous exercise or heavy physical labor. The first week is typically the hardest, with significant soreness during bowel movements.
Stapled Hemorrhoidopexy
A stapled procedure works differently from a traditional hemorrhoidectomy. Rather than cutting the hemorrhoid out, the surgeon uses a circular stapling device to pull prolapsed hemorrhoid tissue back up into the rectum and staple it in place. The stapler also cuts off the blood supply, causing the hemorrhoid to shrink over time. Think of it less as removal and more as repositioning.
This technique is only used for internal hemorrhoids, not external ones. It generally causes less pain and allows a quicker return to light activities compared to traditional surgery. The tradeoff is a higher chance of the hemorrhoid coming back. For people whose main issue is prolapsing internal hemorrhoids, it can be a good middle ground between banding and full excision.
Doppler-Guided Artery Ligation
This minimally invasive surgical option uses a small ultrasound probe to locate the specific arteries feeding blood to the hemorrhoid. Once the surgeon identifies each artery, they stitch it shut with absorbable sutures, starving the hemorrhoid of its blood supply. If the hemorrhoid has prolapsed, the surgeon can also perform a repair that lifts the tissue back into place during the same procedure.
The number of arteries tied off varies from patient to patient based on what the ultrasound mapping reveals. Symptomatic recurrence rates sit around 18%, and people with the most advanced hemorrhoids (grade IV) are roughly 3.5 times more likely to have symptoms return. This procedure appeals to patients and surgeons looking for a less painful alternative to excision, though it’s not as widely available.
What Happens Before Surgery
Preparation for hemorrhoid surgery is relatively simple compared to other abdominal or colorectal procedures. You won’t need to follow a special diet the day before. Instead, you’ll use two fleet enemas to clear the lower bowel. If your surgery is scheduled for the morning, you’ll do one enema a couple of hours after dinner the night before and a second one the morning of the procedure. For afternoon cases, both enemas happen the morning of surgery, spaced about an hour apart.
You’ll need to stop eating and drinking after midnight. Any prescribed medications you normally take can be taken the morning of surgery with a very small sip of water. Your surgeon may ask you to stop blood thinners in the days leading up to the procedure, but those specifics vary by patient.
Managing Pain After Removal
Post-hemorrhoidectomy pain is the main reason people dread the surgery, and it’s a legitimate concern. The surgical wound sits in one of the most sensitive and frequently used areas of the body. Pain management typically involves a combination of approaches rather than relying on a single medication.
Topical ointments applied directly to the surgical site can make a meaningful difference. Certain prescription creams that relax the anal sphincter muscle have been shown to significantly reduce pain in the first four days. Antibiotic ointments applied to the wound can reduce pain throughout the first two weeks while also promoting healing. Numbing creams applied right after surgery help blunt the initial intensity in the first 24 hours.
Oral medications also play a role. Laxatives, both bulk-forming and osmotic types, are important not just for comfort but for protecting the surgical site during bowel movements. Stool softeners make that first postoperative bowel movement (which most people are anxious about) considerably more manageable. Anti-inflammatory medications help with both pain and swelling.
Warm sitz baths are routinely recommended after hemorrhoid surgery, though the evidence for their pain-relieving effect is actually mixed. They may still help with hygiene and general comfort, but they shouldn’t be your only strategy for pain relief. Applying gentle warmth to the area four times a day has shown some benefit in the first few days after surgery.
How the Grade of Your Hemorrhoid Determines the Approach
Internal hemorrhoids are classified on a four-point scale that directly guides which removal method your doctor recommends. Grade I hemorrhoids bulge slightly into the anal canal but don’t prolapse. Grade II prolapse during a bowel movement but slide back in on their own. Grade III prolapse and need to be manually pushed back in. Grade IV stay prolapsed and can’t be reduced at all.
Grade I and II hemorrhoids are typically handled with rubber band ligation or other office-based treatments. Grade III and IV hemorrhoids, especially when combined with external hemorrhoids, are the cases where excisional surgery becomes the recommended path. Stapled procedures and artery ligation fall somewhere in between, suited for grade II and III hemorrhoids where the main problem is prolapse rather than large external tissue.
External hemorrhoids that cause symptoms are handled differently. They can’t be banded because the tissue below the dentate line (the boundary between the sensitive outer anal skin and the less sensitive inner lining) has too many pain receptors. When an external hemorrhoid forms a painful blood clot, a doctor can make a small incision to remove the clot in the office. For chronic or recurring external hemorrhoids, surgical excision is the standard approach.