Hemorrhoid Surgery: When is it Necessary and What to Expect

Itching, bleeding, swelling, lumps, pain, and overall anal/rectal discomfort…if you’ve ever had hemorrhoids (also known as piles, from Latin pili, which means “ball” or “pile”), you’ve likely experienced some or all of these symptoms. While simple lifestyle changes like increasing fibre and fluid intake can help in some cases, other, more severe cases of hemorrhoids may require hemorrhoid surgery. 

Hemorrhoid surgery (surgical hemorrhoid excision) is usually reserved for severe cases where other treatments, including office-based procedures, have failed or complications have occurred. Read on to learn about what hemorrhoids are, the different types of hemorrhoid surgery, the risks associated with hemorrhoid surgery, and hemorrhoid surgery aftercare tips.

What are Hemorrhoids

Hemorrhoids occur when the veins around your anus or lower rectum become swollen and inflamed. 

There are two types of hemorrhoids – internal and external. Internal hemorrhoids form in the anal and lower rectum lining, while external hemorrhoids form under the anal skin.

Internal hemorrhoids can be classified based on their degree of prolapse (when the hemorrhoidal tissue from the inside can be felt on the outside of the anus).

• Grade One: No prolapse
• Grade Two: Prolapse that goes back into the anal canal on its own
• Grade Three: Prolapse that can be pushed back manually into the anal canal by the patient or someone else
• Grade Four: Prolapse that cannot be pushed back into the anal canal (hemorrhoids of this grade are often very painful)

Sometimes, internal hemorrhoids bleed. The blood from internal hemorrhoids is usually bright red. However, some people with internal hemorrhoids don’t bleed, and their only symptom is prolapse.

On the other hand, external hemorrhoids often look like a bluish-coloured, sore lump outside the anus. They can become quite painful if a blood clot (thrombosis) develops in this tissue.

Hemorrhoids are extremely common, and about half of people over 50 have hemorrhoids. It’s estimated that between 60% and 70% of Canadians will develop hemorroids at some point in their lifetime.

 You’re more likely to develop hemorrhoids if you:

• Strain during bowel movements
• Have chronic constipation or diarrhea
• Don’t eat enough fibre
• Are over 50
• Are pregnant

Types of Hemorrhoid Surgery

Fortunately, most people with hemorrhoids do not require surgery. Around 10% of people with symptomatic hemorrhoids need surgical management.

Hemorrhoidectomy

Hemorrhoidectomy, or the surgical removal of hemorrhoids, is often considered when office-based procedures have failed or if a person has grade three or four hemorrhoids.

When you undergo a hemorrhoidectomy, it can be performed under:

• General anesthesia (a type of anesthesia that makes you completely unconscious and unaware of pain).
• Spinal anesthesia (a regional anesthesia injected into your spinal fluid to numb the lower half of your body).
• Caudal block (a type of regional anesthesia injected near the tailbone to numb the lower body).
• Nerve block (a targeted anesthesia to block pain in a specific nerve or group of nerves for a particular part of the body).
• Local anesthesia (a numbing medication applied to a small, specific area to prevent pain).
• Combined anesthesia (a mix of two or more types of anesthesia for better pain control during surgery).

Some studies have shown that getting a hemorrhoidectomy under local anesthesia results in less pain after surgery and shorter hospital stays than with regional or general anesthesia. However, your surgeon will determine the best type of anesthesia for your specific case. 

There are three  types of hemorrhoidectomy – closed, open, and stapled. Closed hemorrhoidectomy (also known as a Ferguson hemorrhoidectomy) involves surgical removal of the hemorrhoid followed by complete closure of the wound with absorbable stitches. Some studies show that people experience less pain after the surgery with this type of hemorrhoidectomy.

In contrast, open hemorrhoidectomy (also known as a Milligan-Morgan hemorrhoidectomy) still involves surgical removal of the hemorrhoid, but the wound is left open. Surgeons may choose this type of hemorrhoid surgery if the location makes wound closure tricky or if there is a high chance of infection developing after the surgery. 

Hemorrhoid stapling is a more recent technique compared to conventional hemorrhoidectomy  that is used for prolapsing hemorrhoids. It is typically used when a person has grade three or four hemorrhoids or for people whose hemorrhoids have returned after less invasive treatments. Like for a hemorrhoidectomy, you will be given anesthesia for this procedure. This type of surgery lifts the hemorrhoids back to their normal position in the anal canal. 

While some studies suggest that hemorrhoid stapling results in less pain after surgery (and a shorter recovery time), there is a higher rate of hemorrhoid recurrence with this type of surgery. 

There are also two related procedures that are commonly used to treat hemorrhoids. They include rubber band ligation and lateral internal sphincterotomy.

Rubber band ligation is an office-based procedure during which a small rubber band is placed around the base of the hemorrhoid, cutting off its blood supply. This causes the hemorrhoid to eventually shrink and fall off.

Lateral internal sphincterotomy is a surgical procedure where the surgeon makes a small cut in the muscle around the anus (called the internal anal sphincter). This helps relieve tension in the muscle, making it easier for the area to heal. It is frequently done following an excisional hemorrhoidectomy to relieve postoperative pain.

Many different instruments can be used to remove the hemorrhoid. They include:

• Scissors 
• Diathermy (a tool that uses heat produced by radio and sound waves to heat tissue).
• Laser (a tool that emits a focused beam of light for precise cutting or tissue removal with minimal damage).
• Ultrasonic scalpel (a surgical tool that uses high-frequency vibrations to cut and clot tissue at the same time).
• Vascular sealing device (a tool designed to seal blood vessels to prevent bleeding).
• Radiofrequency device (a surgical tool that uses radio waves to cut or clot tissue while minimizing blood loss).

Some studies show that hemorrhoidectomy using a vascular sealing device or ultrasonic scalpel results in less pain after the surgery. However, like the form of anesthesia, your surgeon will choose the most appropriate surgical tools for your specific situation.

Preparing for hemorrhoid surgery

To prepare for hemorrhoid surgery, you may need an enema to clear the anal canal.

If you take medications or herbal supplements, your surgeon may ask you to stop taking them before the surgery. You will also need someone to take you home after the procedure, as it’s unsafe to drive after receiving anesthesia and pain medicine.

Risks Associated with Hemorrhoid Surgery

While the risk of minor complications with hemorrhoidectomy is relatively high, major complications after this kind of surgery are uncommon.

Some of the short-term complications of hemorrhoidectomy include:

• Bleeding
• Infection
• Inability to fully empty the bladder (urinary retention)
• Constipation
• Development of blood clots (thrombosed hemorrhoids)
• Tears in the anal lining (fissures)

Some of the long-term complications of hemorrhoidectomy include:

• Narrowing of the anal canal (anal stenosis)
• Difficulty holding in your bowel movements (fecal incontinence)
• Chronic anal pain

However, while complications can happen, identifying and treating them quickly can reduce their long-term impact.

Hemorrhoid Surgery Aftercare

After hemorrhoid surgery, it’s important to use proper aftercare to prevent complications.

Aftercare for hemorrhoid surgery includes:

• Sitz baths (soaking your bottom in 3 to 4 inches of warm water a few times daily).
• Icing the area for up to 10 minutes a few times daily
• Mild painkillers (oral and topical)
• Rest
• Preventing constipation (this is important for preventing the hemorrhoids from returning) 

Here are some tips for preventing constipation:

• Eat enough fibre (increase your fibre intake gradually to prevent side effects like excess gas and bloating). Women need 25 grams of fibre daily, while men need 38 grams of fibre daily.
• Drink enough fluids to prevent dehydration
• Engage in regular physical activity
• Use laxatives if diet and lifestyle changes are not effective (speak with your doctor about which laxatives are right for you)

Final Thoughts

While hemorrhoids can often be managed with lifestyle changes and non-surgical treatments, severe or recurrent cases may need surgery to relieve symptoms and improve your quality of life. Understanding the types of hemorrhoid surgeries, their risks, and proper aftercare can help ensure a smoother recovery and minimize complications.

If you’re considering hemorrhoid surgery, consult with your healthcare provider to determine the best treatment option for your specific needs.

References

1. National Institutes of Health (2016, October 1). Hemorrhoids. National Insititute of Diabetes and Digestive and Kidney Diseases. Retrieved November 27, 2024, from https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/all-content
2. Davis, B. R., Lee-Kong, S. A., Migaly, J., Feingold, D. L., & Steele, S. R. (2018). The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Diseases of the Colon and Rectum, 61(3), 284–292. https://doi.org/10.1097/DCR.0000000000001030
3. ASCRS (n.d.). Hemorrhoids: Expanded Information. American Society of Colon & Rectal Surgeons. Retrieved November 27, 2024, from https://fascrs.org/patients/diseases-and-conditions/a-z/hemorrhoids-expanded-version
4. Fox, A., Tietze, P. H., & Ramakrishnan, K. (2014). Anorectal conditions: hemorrhoids. FP essentials, 419, 11–19.
5. Cristea C, Lewis CR. Hemorrhoidectomy. [Updated 2024 Feb 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK549864/
6. Lohsiriwat, V., & Jitmungngan, R. (2022). Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review. Medicina, 58(3), 418. https://doi.org/10.3390/medicina58030418
7. National Library of Medicine (n.d.). Anesthesia. MedlinePlus. Retrieved November 27, 2024, from https://medlineplus.gov/anesthesia.html
8. National Library of Medicine (2023, April 1). Spinal and epidural anesthesia. MedlinePlus. Retrieved November 27, 2024, from https://medlineplus.gov/ency/article/007413.htm
9. Kao, S. C., & Lin, C. S. (2017). Caudal Epidural Block: An Updated Review of Anatomy and Techniques. BioMed research international, 2017, 9217145. https://doi.org/10.1155/2017/9217145
10. Johns Hopkins Medicine (2023, April 1). Nerve Blocks. Retrieved November 27, 2024, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/nerve-blocks
11. University of California San Francisco (n.d.). Hemorrhoidectomy. UCSF General Surgery Department of Surgery. Retrieved November 27, 2024, from https://generalsurgery.ucsf.edu/conditions–procedures/hemorrhoidectomy.aspx#:~:text=Closed%20hemorrhoidectomy%20is%20the%20surgical,wound%20closure%20with%20absorbable%20suture
12. Cleveland Clinic (2024, April 24). Diathermy. Retrieved November 27, 2024, from https://my.clevelandclinic.org/health/treatments/24926-diathermy
13. Johns Hopkins Medicine (n.d.). Laser Surgery Overview. Retrieved November 27, 2024, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/laser-surgery-overview
14. Kokudo, N., & Hasegawa, K. (2017). Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas (8th ed.). Elsevier. https://www.sciencedirect.com/topics/nursing-and-health-professions/ultrasonic-scalpel
15. Hon, L., Ganeshan, A., Thomas, S., Warakaulle, D., Jagdish, J., & Uberoi, R. (2010). An overview of vascular closure devices: What every radiologist should know. European Journal of Radiology, 73(1), 181-190. https://doi.org/10.1016/j.ejrad.2008.09.023
16. Filingeri, V., Bellini, M. I., & Gravante, G. (2012). The role of radiofrequency surgery in the treatment of hemorrhoidal disease. European review for medical and pharmacological sciences, 16(4), 548–553.
17. Giordano, P., Gravante, G., Sorge, R., Ovens, L., & Nastro, P. (2009). Long-term outcomes of stapled hemorrhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of randomized controlled trials. Archives of surgery (Chicago, Ill. : 1960), 144(3), 266–272. https://doi.org/10.1001/archsurg.2008.591
18. Cleveland Clinic (2023, October 11). Hemorrhoidectomy. Retrieved November 27, 2024, from https://my.clevelandclinic.org/health/procedures/hemorrhoidectomy
19. Kunitake, H., & Poylin, V. (2016). Complications Following Anorectal Surgery. Clinics in Colon and Rectal Surgery, 29(1), 14. https://doi.org/10.1055/s-0035-1568145
20. Włodarczyk, J., Waśniewska, A., Fichna, J., Dziki, A., Dziki, Ł., & Włodarczyk, M. (2021). Current Overview on Clinical Management of Chronic Constipation. Journal of Clinical Medicine, 10(8), 1738. https://doi.org/10.3390/jcm10081738
21. (n.d.). Hemorrhoidectomy: Before Your Surgery. MyHealth.Alberta.ca. Retrieved November 27, 2024, from https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=ud1114
22. Online Etymology Dictionary (n.d.). Piles (n.). Retrieved December 5, 2024, from https://www.etymonline.com/word/piles
23. Canadian Digestive Health Foundation (n.d.). Hemorrhoids. Retrieved December 5, 2024, from https://cdhf.ca/en/digestive-conditions/hemorroids/
24. Albuquerque A. (2016). Rubber band ligation of hemorrhoids: A guide for complications. World journal of gastrointestinal surgery, 8(9), 614–620. https://doi.org/10.4240/wjgs.v8.i9.614
25. Wang, Wei-Guo PhDa; Lu, Wen-Zhu MDa; Yang, Chun-Mei BSb; Yu, Ke-Qiang MDb; He, Hong-Bo BSa,*. Effect of lateral internal sphincterotomy in patients undergoing excisional hemorrhoidectomy. Medicine 97(32):p e11820, August 2018. | DOI: 10.1097/MD.0000000000011820
26. Cleveland Clinic (2024, January 10). Lateral Internal Sphincterotomy. Retrieved December 5, 2024, from https://my.clevelandclinic.org/health/procedures/lateral-internal-sphincterotomy
27. Canadian Digestive Health Foundation (2022, November 15). Recommended Daily Fibre Intake. Retrieved December 5, 2024, from https://cdhf.ca/en/recommended-daily-fibre-intake/