What are the indications for surgery in hemorrhoids (haemorrhoids)?

Indications for Surgery in Hemorrhoids

Surgery is indicated for grade III-IV hemorrhoids, recurrent or persistent hemorrhoids that fail conservative and office-based treatments, complicated hemorrhoids (thrombosed, strangulated), and cases with significant symptoms affecting quality of life. 1

Classification of Hemorrhoids

Understanding the classification is essential for determining appropriate treatment:

• Grade I: Bleed but do not protrude
• Grade II: Protrude with defecation but reduce spontaneously
• Grade III: Protrude and require manual reduction
• Grade IV: Permanently prolapsed and cannot be reduced 1

Treatment Algorithm

First-Line Treatment (Non-Surgical)

For all grades of hemorrhoids, initial management includes:

1. Conservative measures:

   • Increased fiber intake (25-30g daily)
   • Adequate hydration
   • Sitz baths 2-3 times daily
   • Topical treatments (limit corticosteroids to 7 days)
   • Avoiding straining and prolonged sitting 1

2. Pharmacological management:

   • Flavonoids to improve venous tone and reduce symptoms 2, 1
   • Topical muscle relaxants for thrombosed/strangulated hemorrhoids 2

Office-Based Procedures (for Grade I-III)

When conservative management fails:

• Rubber band ligation: First-line procedural treatment with 89% success rate (though 20% may need repeated procedures) 1, 3
• Sclerotherapy: Alternative for grades I-II with 70-85% short-term efficacy 1
• Infrared coagulation: Alternative for grades I-II with 70-80% efficacy 1

Specific Indications for Surgery

1. Grade of Hemorrhoids:

   • Grade III-IV hemorrhoids that fail conservative and office-based treatments 1, 3
   • Gold standard for grade IV hemorrhoids is excisional hemorrhoidectomy 1, 4

2. Failed Non-Surgical Treatment:

   • Persistent symptoms despite conservative management and office-based procedures 5, 3
   • Recurrent hemorrhoids after previous treatments 6

3. Complicated Hemorrhoids:

   • Thrombosed hemorrhoids: Decision between non-operative management and surgical excision should be based on local expertise and patient preference 2
   • Strangulated hemorrhoids requiring urgent intervention 2, 7
   • Mixed hemorrhoidal disease (concurrent internal and external hemorrhoids) 3

4. Specific Clinical Scenarios:

   • Severe bleeding not controlled by conservative measures 3
   • Significant pain and discomfort affecting quality of life 5
   • Irreducible prolapse 3

Surgical Options

Based on the specific indication, surgical options include:

1. Excisional Hemorrhoidectomy (Open or Closed):

   • Gold standard for grade IV hemorrhoids
   • Low recurrence rates (2-10%)
   • Longer recovery period (9-14 days) 1, 3

2. Stapled Hemorrhoidopexy:

   • Alternative for grade III-IV hemorrhoids
   • Less postoperative pain but higher recurrence rates 1

3. Hemorrhoidal Artery Ligation:

   • Useful for grade II-III hemorrhoids
   • Less pain and quicker recovery 1, 7

Special Considerations

• Thrombosed External Hemorrhoids: Surgical excision is most effective if performed within 72 hours of symptom onset 3

• High-Risk Patients:

  • Immunocompromised patients: Higher infection risk with any procedure 1
  • Cirrhosis/Portal Hypertension: Careful evaluation to distinguish from rectal varices 1, 7
  • Inflammatory Bowel Disease: Extreme caution due to high rate of postoperative complications 1
  • Pregnancy: Conservative management preferred; surgery only if absolutely necessary 1

Important Caveats

• Incision and drainage alone is not recommended for thrombosed hemorrhoids 2
• For external hemorrhoid thrombosis, surgical intervention is most beneficial within the first 72 hours 3
• Always rule out other causes of rectal bleeding before proceeding with hemorrhoid treatment 1
• Proper diagnosis through physical examination and appropriate visualization techniques is essential before initiating any treatment 1