What are the indications for surgery in patients with hemorrhoids?

Indications for Surgery in Hemorrhoids

Surgical hemorrhoidectomy is indicated for symptomatic grade III-IV hemorrhoids that have failed conservative and office-based treatments, mixed internal and external hemorrhoids, hemorrhoids with concomitant anorectal pathology (fissure, fistula), and hemorrhoids causing anemia from chronic bleeding. 1

Primary Surgical Indications

Grade-Based Indications

• Grade IV hemorrhoids require excisional hemorrhoidectomy or stapled hemorrhoidopexy as first-line surgical treatment, with conventional hemorrhoidectomy achieving recurrence rates of only 2-10% 1, 2
• Grade III hemorrhoids may be treated surgically when rubber band ligation fails or when there is a significant external component that cannot be addressed with office procedures 1, 2
• Grade I-II hemorrhoids are not surgical candidates and should be managed with rubber band ligation or conservative measures 1, 2

Failure of Conservative Management

• Persistent symptoms despite adequate trial of dietary modifications (increased fiber 25-30g daily, adequate hydration) and lifestyle changes warrant surgical consideration 3, 1
• Failure of office-based procedures (rubber band ligation, sclerotherapy, infrared coagulation) in appropriate-grade hemorrhoids indicates need for surgical evaluation 1

Hemorrhoids with Complications

• Anemia from hemorrhoidal bleeding represents a critical threshold demanding definitive surgical intervention, as this indicates substantial chronic blood loss requiring definitive control 1
• Mixed internal and external hemorrhoids with symptomatic external component that fails conservative therapy require surgical hemorrhoidectomy 1
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids should undergo either complete hemorrhoidectomy or excision of external component with rubber band ligation of internal hemorrhoids 1

Concomitant Anorectal Pathology

• Hemorrhoids requiring treatment in patients with coexisting anal fissure, fistula, or skin tags that also require surgical correction should undergo combined surgical management 1, 4

Special Considerations for Thrombosed External Hemorrhoids

Timing-Dependent Surgical Indications

• Within 72 hours of symptom onset: Complete surgical excision under local anesthesia is recommended, providing faster pain relief and lower recurrence rates compared to conservative management 3, 1
• Beyond 72 hours: Conservative management is preferred as natural resolution has typically begun; surgical excision is generally not necessary 3, 1, 5

Critical Pitfall

• Never perform simple incision and drainage of thrombosed hemorrhoids—this leads to persistent bleeding and significantly higher recurrence rates; complete excision is required if surgical intervention is chosen 3, 1, 5

Relative Contraindications to Surgery

When Surgery Should Be Avoided

• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic infection and require careful risk-benefit assessment 1
• Patients with portal hypertension or cirrhosis may have anorectal varices rather than true hemorrhoids; standard hemorrhoidectomy can cause life-threatening bleeding in this population 3, 1
• Pregnancy-related hemorrhoids should be managed conservatively during pregnancy, with definitive treatment delayed until after delivery 6

Surgical Options and Selection

Conventional Excisional Hemorrhoidectomy

• Gold standard for grade IV hemorrhoids with lowest recurrence rate (2-10%) but highest postoperative pain 1, 2, 7
• Both open (Milligan-Morgan) and closed (Ferguson) techniques show no significant differences in pain scores or outcomes 1, 4
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Stapled Hemorrhoidopexy

• Produces less postoperative pain, shorter operation time, and faster recovery compared to conventional hemorrhoidectomy 8, 2
• Higher recurrence rate compared to conventional hemorrhoidectomy—this is the price for reduced pain 8, 2, 7
• Rare but serious complications include rectal perforation, retroperitoneal sepsis, and pelvic sepsis 1, 8
• Lacks long-term follow-up data to determine true efficacy 1

Procedures to Avoid

• Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Essential Pre-Surgical Evaluation

Mandatory Workup

• Colonoscopy is required before attributing bleeding or anemia to hemorrhoids, particularly in patients ≥50 years or with risk factors for colorectal neoplasia 1
• Hemorrhoids alone do not cause positive fecal occult blood tests; colon must be adequately evaluated before surgery 1
• Anemia from hemorrhoids is rare (0.5 patients/100,000 population); its presence demands thorough colonic evaluation 1

Clinical Assessment

• Anoscopy when feasible to visualize hemorrhoids and rule out other anorectal pathology 3, 5
• Digital rectal examination to assess for masses, fissures, or other pathology 3, 5
• Vital signs, complete blood count, and coagulation studies if significant bleeding or anemia present 3, 5

Patient Preference and Shared Decision-Making

• For thrombosed hemorrhoids, the decision between non-operative management and early surgical excision should be based on local expertise and patient preference after thorough discussion of treatment options 3, 1
• Patients must understand that surgical hemorrhoidectomy offers lowest recurrence but highest pain, while stapled procedures offer less pain but higher recurrence 1, 2