Fewer than 10% of all patients evaluated with symptomatic hemorrhoids will require surgical management. Most patients respond to non-operative treatment and do not require a surgical procedure. Hemorrhoidectomy, or surgical removal of the hemorrhoidal tissue, may be considered if a patient presents with symptomatic large external hemorrhoids, combined internal and external hemorrhoids, and/or grade 3-4 prolapse. Hemorrhoidectomy is highly effective in achieving relief of symptoms and it is uncommon to have any significant recurrence. However, it also causes much more pain and disability than office procedures and has somewhat more complications.

Hemorrhoidectomy may be done using a variety of different techniques and instruments to remove the hemorrhoids and the particular technique is usually chosen based on a particular surgeon’s preference. In basic terms, the excess hemorrhoidal tissue is removed and the resultant wound may be closed or left open. Hemorrhoidectomy is performed in an operating room and may be done while you’re completely asleep (general anesthesia), under a spinal block (analogous to an epidural injection during childbirth), or with a combination of intravenous relaxing medications and local anesthesia injected around your anus after you’re relaxed.

In an attempt to avoid some of the postoperative pain associated with hemorrhoidectomy, a more recently developed option has emerged, called a stapled hemorrhoidopexy (sometimes inaccurately referred to as “stapled hemorrhoidectomy”). The procedure involves a circular stapling device which removes some of the tissue located upstream from the hemorrhoids, thereby pulling the hemorrhoids upward, returning the problematic hemorrhoidal tissue to its normal position, and staples this tissue up into place. Most or all of the staples later fall out over time. Studies comparing stapled hemorrhoidectomy to standard hemorrhoidectomy have found it to be equally safe and associated with a shorter time to full recovery. Long term recurrence rates appear to be higher than with hemorrhoidectomy, and this operation is not effective for treating large external hemorrhoids. All operative procedures for hemorrhoidal disease carry their own set of risks and benefits and the ultimate choice of procedure must be made between you and your surgeon.