Hemorrhoid removal surgery to remove hemorrhoids is commonly known as hemorrhoidectomy. The most commonly used techniques are Milligan Morgan and Ferguson but there are many others. Recently, stapling has been developed by Longo as a less invasive form of surgery. It is also known as mucopexy, circumferential mucosectomy, anopexy or procedure for prolapsed hemorrhoids (PPH).

This is the most common technique in Europe and was first described in 1937. Studies in Nigeria have shown it to be effective and safe with low recurrence and complication rates. It is particularly useful for grade 3 and 4 hemorrhoids. The technique involves excision of the hemorrhoids with a cold scalpel, followed by stitching of the wound with absorbable stitches.

One study from Israel described the Milligan Morgan technique in 2200 patients, comparing it with the HALO procedure (see below) and stapling from other studies. They found it to be superior to HALO in its effectiveness and better than stapling with regard to the rate of complications. However, it is unclear whether a representative sample of clinical trials was used for the comparison.

Another trial compared Milligan Morgan to stapling. This found a higher recurrence rate with stapling and recommended it only for patients who were happy with the risks and wanted to take advantage of the short-term benefits such as quicker hemorrhoid operation recovery.

Ferguson (closed)
This is the most frequent surgery type in North America. It has similar success rates to the Milligan Morgan technique, with higher rates of wound breakage afterwards. One study has compared it with stapling and LigaSure vessel sealing. They found low pain scores at one day (2.47), seven days (1.34) and two weeks (0.1) and high patient satisfaction rates.

Parks procedure
Parks hemorrhoidectomy was developed in the 1950s to reduce pain after surgery and avoid narrowing of the anal and rectal canal. The procedure requires scissors, a Parks retractor, adrenaline to narrow the arteries and reduce blood loss, and usually a general anaesthetic. The main difference is that the stitches are tied further up. It is a more difficult technique to learn but is a safe procedure and recurrence is uncommon. Its main use is in grade 4 external hemorrhoids.

One study looked at 327 patients treated with the Parks procedure. They found no serious complications during the operation and average pain scores of less than three the day after. The average number of days in hospital was 2.2 and patients had 11 days off work. Anal incontinence worsened in 9.6% and improved in 90.6%.

Another clinical trial of 640 patients also received Parks hemorrhoidectomy. One third received anal sphincterotomy in addition to the Parks procedure as a treatment for increased muscle tone. The main complications were urinary retention requiring a catheter (11.6%), bleeding(external hemorrhoids bleeding) (2.9%), severe pain (1.4%), lodging of faeces/impaction (0.5%) and disruption of stitches (0.3%). After three years, 2.9% had pain on moving their bowels, 1.6% had skin tags or recurrence of hemorrhoids and 0.8% had gas incontinence.

Stapled hemorroidopexy
This involves lifting the hemorrhoids higher into the canal and stapling them to cut off the blood supply in the hope they will eventually be absorbed into the surrounding tissue. Sometimes the excess tissue will be removed before stapling. It is best done with an anoscope (a type of video telescope) to gain a good view of the area.

Stapling tends to be less painful than conventional surgery, with faster recovery times and lower rates of bleeding and itching. There are also fewer complications following the procedure.

Hemorrhoidal artery ligation (HALO)
This is a new technique that ties off the arteries supplying the hemorrhoids rather than removing them and is now approved in many countries. It has a recurrence rate of 12%, which decreases with the surgeon’s experience of the procedure. A trial comparing its effectiveness with stapling is currently being analysed and is due to be published in the near future.

Suture of Farag/Pile suture method
This uses several stitches to tie up the hemorrhoids and was proposed in 1978. It has a high rate of recurrence but is useful in rural settings where access to surgical theatres is limited, and has a lower cost than conventional surgery.

Complications
General complications of haemorrhoid removal surgery are divided into early and late.

Early
Early complications include severe pain (for more than two weeks after the operation), wound infection, bleeding, skin swelling, difficulty urinating, delayed bleeding (one to two weeks after surgery) and short-term incontinence.

Late
Later complications may include narrowing of the anal canal (also known as stenosis), skin tags and requirement for re-operation due to recurring hemorrhoids.

After removal surgery, it is recommended you eat a well-balanced diet with plenty of fiber and gradually build up the amount you exercise. You may also want to take stool softeners such as Citrucel® or Metamucil® for the first few weeks.