What is the role of surgery in the treatment of hemorrhoids?

Updated: Sep 24, 2019
  • Author: Kyle R Perry, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Answer

Many patients have been referred for surgery because they have severely swollen prolapsed hemorrhoids or very large external skin tags. When questioned, the patients are asymptomatic. Treat hemorrhoids only if they cause problems for the patient. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome.

Patients with ulcerative colitis can tolerate aggressive surgery if it is needed. Treat underlying acute disease before any elective anorectal surgery. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. If necessary, operative hemorrhoidectomy is safe in pregnant women. [35]

Hemorrhoid surgery can usually be performed using local anesthesia with intravenous (IV) sedation. Regional or general anesthetic techniques also are used. Routine preoperative workup for these techniques is required. Simple distal rectal evacuation is required for a clean operative field. Distal rectal evacuation is best achieved by small-volume saline enemas.

A systematic review and meta-analysis of 98 trials comprising 7827 patients and 11 surgical treatments for grades III and IV hemorrhoids found that open and closed hemorrhoidectomies resulted in more postoperative complications and slower recovery, but fewer hemorrhoid recurrences, whereas transanal hemorrhoidal dearterialization and stapled hemorrhoidectomies were associated with decreased postoperative pain and faster recovery, but higher recurrence rates. [43]  The investigators did not find any significant differences between treatments for anal stenosis, incontinence, and perianal skin tags.


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