Hemorrhoid surgery is a procedure to remove or shrink swollen hemorrhoidal tissue when other treatments haven’t worked. It’s typically reserved for advanced cases, specifically grade III or IV hemorrhoids, where the tissue bulges out of the anal canal and either needs to be pushed back in manually or can’t be pushed back at all. Several surgical techniques exist, ranging from full tissue removal to newer approaches that cut off blood supply to the swollen tissue. The right option depends on the severity of your hemorrhoids and whether you have both internal and external disease.
When Surgery Becomes Necessary
Hemorrhoids are graded on a four-point scale based on how much tissue protrudes from the anal canal. Grade I hemorrhoids are swollen but stay inside. Grade II hemorrhoids push out during straining but slide back on their own. These two grades almost always respond to dietary changes, topical treatments, or office procedures like rubber band ligation.
Surgery enters the picture at grade III, where the tissue protrudes and you have to push it back in yourself, and grade IV, where the tissue stays outside permanently and can’t be reduced. At these stages, the disease is unlikely to respond to conservative treatment. Surgery is also recommended when you have a combination of internal and external hemorrhoids with a visible bulging component, when hemorrhoids have become trapped and swollen (incarcerated), or when office procedures like banding or infrared coagulation have already been tried and failed.
Types of Hemorrhoid Surgery
Excisional Hemorrhoidectomy
This is the traditional approach and the most thorough. The surgeon physically cuts out the hemorrhoidal tissue. One widely used version leaves the wound open to heal on its own rather than stitching it closed. The procedure takes roughly 20 to 35 minutes. It has the highest success rate and the lowest recurrence rate of any hemorrhoid surgery, but it also comes with the most postoperative pain. It’s the standard choice for large grade III and IV hemorrhoids, especially when external hemorrhoids or significant skin tags are present.
Stapled Hemorrhoidopexy
Unlike excisional surgery, this technique doesn’t actually remove the hemorrhoid. Instead, a circular stapling device repositions the prolapsed tissue back into its normal position inside the rectum and cuts off part of its blood supply. The staples hold the tissue in place while it heals. This approach generally causes less pain than traditional excisional surgery, but it carries a somewhat higher chance of the hemorrhoids returning over time.
Doppler-Guided Dearterialization
This is the least invasive surgical option. The surgeon uses a specialized ultrasound probe inserted into the anal canal to locate the specific arteries feeding blood to the hemorrhoidal tissue. Once identified, those arteries are stitched closed, starving the hemorrhoid of its blood supply so it gradually shrinks. In cases with significant prolapse, the surgeon also performs a “mucopexy,” stitching the drooping tissue back up into its normal position inside the rectum. As the stitches heal, scar tissue forms that anchors the tissue permanently in place. Because no tissue is cut out, this procedure typically produces less pain than the other options.
What Anesthesia to Expect
Hemorrhoid surgery can be performed under local anesthesia (numbing only the surgical area), spinal anesthesia (numbing the lower half of your body), or general anesthesia (fully asleep). Local anesthesia, sometimes combined with intravenous sedation, is associated with shorter procedure times, fewer complications, and lower costs. Spinal anesthesia is common but carries additional risks including urinary retention, post-procedure headache, and requires a specialized anesthesia provider. Your surgeon will recommend an approach based on the complexity of your case and the technique being used.
How to Prepare
Preparation is straightforward. You’ll typically switch to a clear liquid diet the day before surgery after a light breakfast. A laxative or enema may be prescribed to clean out the lower bowel. You’ll need to stop eating and drinking after midnight the night before your procedure. Most regular medications can be taken as scheduled with a small sip of water, but blood thinners and certain other drugs will need to be paused ahead of time per your surgeon’s instructions.
Recovery Timeline
The average recovery from hemorrhoid surgery is two to four weeks, with the worst of it concentrated in the first few days. The single most painful moment for most people is their first bowel movement after surgery. After that initial hurdle, pain generally improves significantly within three days and continues declining over the next two weeks. Most people report being pain-free by the two-week mark.
Returning to desk work is often possible within one to two weeks, depending on your comfort level. Strenuous exercise and manual labor typically need to wait six to eight weeks. During recovery, keeping your stools soft is one of the most important things you can do. Fiber supplements, osmotic laxatives, and plenty of water help make bowel movements less painful. Avoiding spicy foods can also reduce irritation at the surgical site. Warm sitz baths (sitting in a few inches of warm water) are commonly recommended, though their actual pain-relieving benefit varies from person to person.
Possible Complications
Urinary retention is the most common complication after hemorrhoid surgery, affecting roughly 14% of patients in large studies, though reported rates range widely from 1% to over 30% depending on the surgical technique and type of anesthesia used. Spinal anesthesia and the volume of intravenous fluids given during surgery both increase the risk. Urinary retention is usually temporary and resolves with a catheter if needed.
Post-surgical bleeding can occur, most often between 7 and 14 days after surgery when the scab at the wound site separates. A small amount of bleeding is normal; heavy bleeding that soaks through a pad requires medical attention. Anal narrowing (stenosis) is a rarer long-term complication that can develop if too much tissue is removed, making bowel movements difficult. Infection is uncommon but possible with any surgical procedure.
Long-Term Results
Excisional hemorrhoidectomy has the best long-term track record, with recurrence rates significantly lower than stapled or dearterialization procedures. Most people experience a permanent return to normal bowel habits once fully healed. Temporary changes in bowel control, such as minor leakage or urgency, can occur in the weeks following surgery but typically resolve as the area heals. The risk of lasting continence problems is low when the surgery is performed by an experienced surgeon who preserves the sphincter muscles.