When is surgical operation warranted in hemorrhoids?

Surgical Management of Hemorrhoids: When Operation is Warranted

Surgical hemorrhoidectomy is indicated for: (1) failure of conservative and office-based treatments, (2) symptomatic grade III or IV internal hemorrhoids, (3) mixed internal and external hemorrhoids, (4) hemorrhoids causing anemia from chronic bleeding, and (5) acutely thrombosed external hemorrhoids presenting within 72 hours of symptom onset. 1

Specific Indications for Surgical Intervention

Grade-Based Surgical Indications

Grade III hemorrhoids warrant surgical consideration when:

• Office-based procedures (rubber band ligation) have failed 1
• Patient presents with persistent bleeding despite conservative management 1
• Multiple hemorrhoid columns are present, making office procedures less effective 1

Grade IV hemorrhoids require surgical hemorrhoidectomy as primary treatment:

• These irreducible, permanently prolapsed hemorrhoids are not amenable to rubber band ligation 1, 2
• Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) achieves 90-98% success with only 2-10% recurrence 1, 3

Critical Clinical Scenarios Requiring Surgery

Hemorrhoids causing anemia:

• Active bleeding on anoscopy with documented low hemoglobin represents a critical threshold demanding definitive surgical intervention 1
• Anemia from hemorrhoidal disease is rare (0.5 per 100,000 population), so when present, it indicates substantial chronic blood loss requiring definitive control 1
• Critical pitfall: Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1

Mixed internal and external hemorrhoids:

• Surgical excision is the only effective treatment when both components are symptomatic 1
• Office-based procedures cannot adequately address the external component 1

Concomitant anorectal conditions:

• When hemorrhoids coexist with anal fissures, fistulas, or abscesses requiring surgical repair 1
• Up to 20% of patients with hemorrhoids have concurrent anal fissures 1

Thrombosed External Hemorrhoids: Time-Dependent Surgical Decision

Within 72 hours of symptom onset:

• Surgical excision under local anesthesia provides fastest pain relief and reduces recurrence risk 1, 4, 2
• This is superior to simple incision and drainage, which causes persistent bleeding and higher recurrence 1, 4

After 72 hours:

• Conservative management is preferred (stool softeners, topical 0.3% nifedipine with 1.5% lidocaine every 12 hours for 2 weeks) 1, 4
• Natural resolution process has typically begun by this point 1

Treatment Algorithm Before Considering Surgery

Step 1: Conservative Management (First-Line for All Grades)

• Increase fiber intake (5-6 teaspoons psyllium with 600 mL water daily) and water to soften stool 1, 4
• Avoid straining during defecation 1
• Topical treatments: 0.3% nifedipine with 1.5% lidocaine (92% resolution rate) 1, 4
• Short-term corticosteroids (≤7 days only to avoid mucosal thinning) 1, 4

Step 2: Office-Based Procedures (for Grade I-III)

Rubber band ligation is first-line procedural treatment:

• Success rates 70.5-89% depending on grade 1, 2
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can treat up to 3 hemorrhoids per session, though many limit to 1-2 columns 1

Alternative office procedures:

• Infrared photocoagulation: 67-96% success for grade I-II, but requires more repeat treatments 1
• Sclerotherapy: 70-85% short-term success for grade I-II, but only one-third achieve long-term remission 2

Step 3: Surgery When Non-Operative Approaches Fail

Conventional excisional hemorrhoidectomy remains the gold standard:

• Most effective treatment overall, particularly for grade III-IV hemorrhoids 1, 3
• Recurrence rate only 2-10% 1, 3, 2
• Both open (Milligan-Morgan) and closed (Ferguson) techniques show comparable efficacy 3

Surgical Techniques and Considerations

Conventional excisional hemorrhoidectomy:

• Ferguson (closed) technique: wounds closed primarily, may have reduced postoperative pain 3
• Milligan-Morgan (open) technique: wounds heal secondarily over 4-8 weeks 3
• Narcotic analgesics generally required; most patients off work 2-4 weeks 1, 3

Stapled hemorrhoidopexy:

• Significantly less postoperative pain than conventional hemorrhoidectomy 3
• Faster recovery but higher recurrence rate 5
• Appropriate for circular hemorrhoids 3

Techniques to absolutely avoid:

• Anal dilatation: 52% incontinence rate at 17-year follow-up, causes sphincter injuries 1, 3
• Cryotherapy: prolonged pain, foul-smelling discharge, greater need for additional therapy 1
• Simple incision and drainage of thrombosed hemorrhoids: persistent bleeding and higher recurrence 1, 4

Special Populations and Precautions

Immunocompromised patients:

• Increased risk of necrotizing pelvic sepsis after rubber band ligation 1
• Require closer monitoring if surgical intervention needed 4

Pregnant patients:

• Hemorrhoids occur in 80% during third trimester 1
• Surgery generally deferred; conservative management with fiber, fluids, and safe topical agents 1

Red Flags Requiring Immediate Surgical Evaluation

• Active bleeding with hemodynamic instability 4
• Incarcerated, gangrenous hemorrhoids 3
• Severe pain unresponsive to conservative measures within 1-2 weeks 1, 4
• Signs of infection or abscess formation 4

Common Pitfalls to Avoid

• Never assume all anorectal symptoms are hemorrhoids: up to 20% have concurrent anal fissures 1, 4
• Hemorrhoids alone do not cause positive fecal occult blood tests: evaluate colon adequately before attributing bleeding to hemorrhoids 1, 4
• Anal pain is NOT typical of uncomplicated hemorrhoids: suggests alternative pathology like fissure 1
• Do not delay definitive treatment when active bleeding has caused anemia: natural history will be continued blood loss 1