Complications of Hemorrhoidectomy
Hemorrhoidectomy complications are usually minor but occur with significant frequency, including urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%), with postoperative pain being the most common and significant drawback requiring narcotic analgesics and 2-4 weeks off work. 1
Major Complications by Category
Most Common: Pain and Urinary Issues
- Postoperative pain remains the primary drawback of excisional hemorrhoidectomy, requiring narcotic analgesics in most patients 1
- Most patients do not return to work for 2-4 weeks following surgery 1
- Urinary retention occurs in 2-36% of patients, representing the most variable complication rate 1
- Pain affects up to 71% of patients in some series 2
Bleeding Complications
- Hemorrhage occurs in 0.03-6% of patients 1
- Bleeding requiring reoperation occurs in approximately 1% of cases 2
- Early postoperative bleeding (within first week) affects 4.2% of patients 3
- Late bleeding (after 1 week) occurs in 0.5% of patients 3
Structural Complications
- Anal stenosis develops in 0-6% of patients 1
- Stenosis typically requires treatment by dilatation (55%) or anoplasty (45%) 3
- Anal fissure occurs in 0.5-0.9% of patients 3, 4, 2
- Skin tags develop in approximately 0.5% of patients 3
Infectious Complications
- Infection occurs in 0.5-5.5% of patients 1
- Local infection affects approximately 0.6-1.2% of patients 5, 2
- Sepsis is rare but serious, occurring in 0.5% of cases 4
- Abscess formation occurs in 0.6% of patients 2
- Fistula formation occurs in 0.9-1.2% of patients 4, 2
Incontinence and Sphincter Injury
- Fecal incontinence occurs in 2-12% of patients 1
- Sphincter defects have been documented by ultrasonography and anal manometry in up to 12% of patients after hemorrhoidectomy 1
- De-novo anal incontinence (Wexner score >5) affects 8.5% of patients at 1 year 5
- The use of excessive retraction with extensive dilation of the anal canal is probably responsible for sphincter injury and incontinence 1
Critical Pitfalls to Avoid
Technique-Related Complications
- Avoid lateral internal sphincterotomy as an adjunct to hemorrhoid excision—randomized studies have shown an increase in incontinence rather than benefit 1
- Avoid anal dilatation entirely—this technique causes sphincter injuries documented by endosonography, with 52% of patients showing impaired continence at long-term follow-up (median 17 years) 1
- Excessive retraction and extensive dilation of the anal canal should be avoided to prevent sphincter injury 1
Mortality Risk
- Death is rare but documented, occurring in approximately 0.2% of cases (2 deaths in 1,134 patients) 2
Stapled Hemorrhoidectomy-Specific Complications
Advantages
- Stapled hemorrhoidectomy is associated with significantly less pain than conventional hemorrhoidectomy 1, 6
- All 8 randomized controlled trials showed decreased pain in stapled groups 1
- Six trials showed more rapid return to normal activities 1
Unique Complications
- Overall complication rate of 15-19% in large series 3, 4
- Severe persistent pain and fecal urgency lasting up to 15 months occurred in one suspended trial (5 of 22 patients) 1
- Anastomotic dehiscence occurs in 0.5-1.6% of patients 3, 4
- One patient with anastomotic dehiscence required pelvic drainage and colostomy formation 3
- Recurrence of hemorrhoids occurs in 2.3-3.2% of patients 3, 4
- Most recurrences require treatment by ligation (40%) or Milligan-Morgan procedure (32%) 3
Timing of Complications
- Most complications (65%) occurred after the surgeon had more than 25 cases of experience 3
- The most common complication in the first 25 cases was bleeding (48%) 3
Special Population Considerations
- Immunocompromised patients are at increased risk for severe infection, particularly after rubber band ligation 6
- Special situations including inflammatory bowel disease, pregnancy, or immunosuppression can present increased rates or more severe complications 7