International Journal of Colorectal Disease

https://doi.org/10.1007/s00384-021-03953-3

REVIEW

An update on surgical treatment of hemorrhoidal disease:

a systematic review and meta‑analysis
Bianca Aibuedefe1   · Sarah M. Kling2 · Matthew M. Philp3 · Howard M. Ross3 · Juan Lucas Poggio3

Accepted: 14 May 2021

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2021

Abstract
Background  Pathologic hemorrhoids are common among adults age 45–65. Hemorrhoids are characterized as internal or
external, and grades 1–4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades
3/4. The aim of this study is to compare clinical outcomes of various surgical treatments.
Methods  A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade
3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS.
Results  A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included.
Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01–6.51), infrared photocoagulation (OR 0.38, CI
0.02–5.61), and stapling (OR 0.48, CI 0.19–1.25), compared to open and closed hemorrhoidectomies. There was less recur-
rence with Starion (OR 0.01, CI 0.00–0.46) and harmonic scalpel (OR 0.00, CI 0.00–0.49), compared to infrared photoco-
agulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared
photocoagulation (OR 0.04, CI 0.00–2.54) and LigaSure (OR 0.16, CI 0.03–0.79), compared to suture ligation and open
hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05–1.51) and stapled (OR 0.36, CI 0.15–0.84) techniques, patients
return to work earlier when compared to open hemorrhoidectomy and laser.
Conclusion  There are multiple favorable techniques without a clear “gold standard” based on current literature. Open discus-
sion should be had between patients and physicians to guide individualized care.

Introduction

Hemorrhoids are veins that all people have, located in the

* Bianca Aibuedefe lower part of the rectum and anus that function to assist with
tuh24999@temple.edu continence. When they are pathologic, they become enlarged
Sarah M. Kling and occasionally symptomatic. Pathologic hemorrhoids are
sarah.kling@tuhs.temple.edu common among adults from the age of 45 to 65. It is esti-
Matthew M. Philp mated that 39% of patients who undergo routine colorectal
matthew.philp@tuhs.temple.edu cancer screening have enlarged hemorrhoids, with 55% of
Howard M. Ross them reporting no symptoms [1].
howard.ross@tuhs.temple.edu There are 2 different classifications for hemorrhoids,
Juan Lucas Poggio internal and external, which is based on the location in
Juan.poggio@tuhs.temple.edu regard to the dentate line. Internal hemorrhoids are located
1
Temple University Lewis Katz School of Medicine, 3500 N above the dentate line, while external hemorrhoids are
Broad St, Philadelphia, PA 19140, USA located below the dentate line. Hemorrhoids are further
2
Department of General Surgery, Temple University Lewis categorized into 4 different grades. Grade 1 hemorrhoids
Katz School of Medicine, 3401 N. Broad St., Zone C, 4th prolapse past the dentate line when straining, grade 2 pro-
floor, Philadelphia, PA 19140, USA lapses through the anus when straining and reduces spon-
3
Department of General Surgery, Department of Colon taneously, grade 3 is similar to grade 2 except they need to
and Rectal Surgery, Temple University Lewis Katz School be reduced manually, and lastly, grade 4 prolapses through
of Medicine, 3401 N. Broad St., Zone C, 4th Floor, the anus but cannot be reduced [2]. Based on the type and
Philadelphia, PA 19140, USA

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 International Journal of Colorectal Disease

grade of hemorrhoid, physicians can then choose which
treatment is best for their patients. Grades 1 and 2 hem-
orrhoids respond well to medical therapy and office-based
procedures such as rubber band ligation. Grades 3 and 4
hemorrhoids can be removed via surgery, yet there are differ-
ent surgical techniques that can be used which give different
clinical outcomes. The outcomes vary in terms of recurrence
rate and clinical complications such as bleeding, urinary
incontinence, and recovery time to return to work. There
are numerous clinical trials which compare short-term and
long-term outcomes of different surgical treatments to assess
their outcomes for patients. Surgical options for hemorrhoids
include closed hemorrhoidectomy, open hemorrhoidectomy,
bipolar diathermy, stapling, LigaSure, and more. Thus, it is
challenging to conduct a large enough clinical trial to com-
pare every one of the different options there are [3].
A systematic review and network meta-analysis by Similis
et al. compare 11 different surgical treatments for grades 3 and
4 hemorrhoids in order to analyze their clinical outcomes.
This meta-analysis was conducted 5 years ago and concluded
that each treatment has its pros and cons, without any final
recommendations on which methods to use [4]. The aim of
this study is to do a systematic review of the literature from
2015 to 2020 comparing surgical treatments for grade 3 and 4
hemorrhoids and conducts an updated network meta-analysis
in order to compare short- and long-term clinical outcomes
for the different surgical treatments.
Methods
Study selection
Prior to study selection, a protocol was created to estab-
lish the research question, guide the literature search,
determine criteria for inclusion or exclusions, and limit
selection bias. A literature search was conducted using
a combination of terms including “hemorrhoid disease”
and “comparing surgical treatments” on the following
databases: Cochrane Central Register of controlled tri-
als, MEDLINE, Embase, PubMed, and Science Citation
Index expanded. Fig. 1 provides details of the search strat-
egy. Publications in English from the years 2015–2020
were included in this analysis. Studies that were chosen
for screening were based on the title of the publication
including words such as “compare” or “vs” and a brief

Fig. 1  Inclusion and exclusion

steps of studies used for the meta-
Idenficaon

analysis. From: Moher D, Liberati Records idenfied through Addional records idenfied
A, Tetzlaff J, Altman DG, The database searching through other sources
PRISMA Group (2009). Preferred (n = 427) (n = 0)
reporting items for systematic
reviews and MetaAnalyses: the
PRISMA statement. PLoS Med
6 (7): e1000097. https://​doi.​org/​ Records aer duplicates removed
10.​1371/​journ​al.​pmed1​000097. (n=422)
For more information, visit www.​
prisma-​state​ment.​org
Screening

Records screened Records excluded

(n = 358) (n = 294)

Full-text arcles assessed Full-text arcles excluded,

for eligibility with reasons
Eligibility

(n =64) (n = 38)

Studies included in
qualitave synthesis
(n = 26 )
Included

Studies included in
quantave synthesis
(meta-analysis)
(n = 26 )

13
International Journal of Colorectal Disease
skim through the abstracts looking for the grade of hemor-
rhoids of the study population that was included for that
particular study’s analysis. Once studies were chosen for
screening, each study was further assessed looking at the
full text. Full text of studies had to clearly define the type
of surgical treatments used and had clearly defined results,
and the grade of hemorrhoids was clearly stated, if not
stated in the abstract. There were studies where the full
text could not be accessed and were removed from the
analysis. Randomized control trials (RCT) studying grade
3 and 4 hemorrhoids were included in the network meta-
analysis. Any studies that did not mention which grade the
hemorrhoids, or only looked at grade 2 and 3 hemorrhoids,
were excluded from the network meta-analysis.
Outcomes of interest
All of the studies included for the meta-analysis either
looked at short-term outcomes, long-term outcomes, or
both. Short-term outcomes are defined as occurring from
the day of surgery to 1 month postoperatively. Short-term
outcomes assessed in the meta-analysis include postopera-
tive pain, return to work, and clinical complications (bleed-
ing, urinary/fecal incontinence, wound problems, edema,
itching, and anal fissures). Long-term outcomes are defined
as occurring greater than 6 months from surgery and are lim-
ited to hemorrhoid recurrence. Recurrence is defined in this
study as patients reporting reoccurring symptoms that were
consistent with hemorrhoid symptoms, or it was reported
that they were having surgery due to recurrent hemorrhoids.
Statistical analysis
The meta-analysis was conducted using NetMetaXL and
WinBUGS. All treatments that were identified from the
included studies were inputted into NetMetaXL along with
a unique identifier for each study, first author, and year pub-
lished. Each outcome of interest was analyzed separately,
inputting the quantitative results from each study. Once the
number of patients who experienced the outcome of inter-
est (exact number or mean) and the number of patients in
the study were recorded, the data was converted to Win-
BUGS in order to run the network meta-analysis. A random
effect model was used for postoperative pain, postoperative
clinical complications, and return to work to account for
the heterogeneity of each study. A fixed effect model was
used for recurrence because the variables in the study were
non-random. Once WinBUGS was done with the analysis,
the results were converted back to NetMetaXL in order to
view the ranking of each surgical treatments based on the
WinBUGS analysis.
Results
Eligible studies
A total of 427 studies were identified from electronic
searches. Out of the 427,64 studies were chosen to be
screened further, based on the title and skim of the abstract.
Then, 38 of the 64 were excluded because they had grade 2
hemorrhoids included in the study and were not RCTs, or
it did not specify the grade the hemorrhoids studied. After
application of the inclusion and exclusion criteria, a total
of 26 studies with 3,137 participants were included for the
meta-analysis (Table 1).
Surgical treatments compared
A total of 14 surgical techniques were identified for the treat-
ment of grade 3 and 4 hemorrhoids: open (Milligan-Morgan)
hemorrhoidectomy, closed (Ferguson) hemorrhoidectomy,
transanal hemorrhoidal dearterialization (THD), harmonic
scalpel, LigaSure, Starion, suture ligation, semi-closed,
bipolar diathermy, partial stapled, stapled, Doppler-guided
hemorrhoidal artery ligation, infrared photocoagulation, and
laser.
Postoperative pain
Postoperative pain was discussed in 25 of the 26 studies,
which collectively provided information on all 14 surgical
treatments for the network meta-analysis. A random effect
model shows that, out of the 14 surgical treatments, the
conventional hemorrhoidectomies (closed and open) have
the worst outcomes for postoperative pain. More patients
experienced mild, moderate, and severe pain and for a long
period of time with conventional hemorrhoidectomies when
compared to the top ranked surgical treatments: laser (OR
0.34, CI 0.01–6.51), infrared photocoagulation (OR 0.38, CI
0.02–5.61), and stapling (OR 0.48, CI 0.19–1.25). Patients
who had received laser, infrared photocoagulation, and sta-
pling reported pain scores that were in the mild range of pain
(0–3/10) and pain often subsided by the first postoperative
week (Fig. 2).
Clinical complications
Clinical complications were discussed in 22 of the 26 stud-
ies, which collectively provided information on 13 of the
surgical treatments for the network meta-analysis. A random
effect model shows that open hemorrhoidectomy and suture
ligation have the most clinical complications after surgery.
More patients experienced bleeding for a few days after the
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 International Journal of Colorectal Disease

Table 1  Summary of studies Study ID Treatment Total

included in the analysis number of
patients

Aigner et al. [5] Doppler-guided vs suture mucopexy 40

Genova et al. [6] Open vs TH 89
Mahmood et al. [7] Open vs closed 100
Abid et al. [8] Open vs stapled 50
Zhai et al. [9] Doppler guided vs suture mucopexy 100
Giarratano et al. [10] THD vs stapled 100
Tsunoda et al. [11] THD vs harmonic 44
Bilgin et al. [12] Stapled vs harmonic 99
Mengal et al. [13] Open vs stapled 100
Samee et al. [14] Open vs stapled 258
Bakhtiar et al. [15] Open vs LigaSure 55
Alhomoud et al. [16] Open vs harmonic 50
Megahed et al. [17] Open vs harmonic 40
Lin et al. [18] Stapled vs partial stapled 300
Aljabery et al. [19] Open vs LigaSure 60
Shoukat et al. [20] Harmonic vs bipolar diathermy 130
Nikshoar et al. [21] Closed vs infrared photocoagulation 40
Trenti et al. [22] Doppler guided vs open vs closed 83
Lopez et al. [23] Doppler guided vs open 40
Titov et al. [24] Doppler guided vs harmonic 240
Kendirci et al. [25] Open vs harmonic vs LigaSure 90
Ripetti et al. [26] Open vs stapled vs semiclosed 163
Trenti et al. [27] THD vs vessel sealing device 80
Maloku et al. [28] Open vs laser 200
Haksal et al. [44] Open vs LigaSure 365
Kim et al. [29] Harmonic vs Starion 221

N = 3137

operation as well as a longer number of days with urinary Infrared photocoagulation and LigaSure ranked top two,
incontinence and constipation when compared to the top having fewer patients who experienced clinical complica-
ranked surgical treatments: infrared photocoagulation (OR tions (Fig. 3).
0.04, CI 0.00–2.54) and LigaSure (OR 0.16, CI 0.03–0.79).

Fig. 2  Results for postoperative

pain. 25/26 studies compared
postoperative pain on 14
surgical treatments. This is a
league table that arranges the
treatments in order of most pro-
nounced impact on the outcome
based on surface under the
cumulative ranking (SUCRA).
SUCRA is a simple numerical
summary of the probabilities.
It is 100% when a treatment is
certain to be the best and 0%
when a treatment is certain to
be the worst. The treatments are
ranked best to worst from top to
bottom based on the SUCRA​

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International Journal of Colorectal Disease

Fig. 3  Results for clinical com-

plications. 22/26 studies com-
pared clinical complications on
13 surgical techniques. This is
a league table that arranges the
treatments in order of most pro-
nounced impact on the outcome
based on surface under the
cumulative ranking (SUCRA).
SUCRA is a simple numerical
summary of the probabilities.
It is 100% when a treatment is
certain to be the best and 0%
when a treatment is certain to
be the worst. The treatments are
ranked best to worst from top to
bottom based on the SUCRA​

Return to work treatments for the network meta-analysis. A fixed effect

Patients’ return to work was discussed in 13 of the 26 stud-
ies, which provided information on 9 of the surgical treat-
ments for the network meta-analysis. A random effect model
shows that open hemorrhoidectomy takes longer for patients
to recover from and get back to work when compared to
Doppler-guided hemorrhoidal artery ligation (OR 0.26, CI
0.05–1.51) and stapling (OR 0.36, CI 0.15–0.84). Doppler-
guided hemorrhoidal artery ligation and stapling ranked top
two, having more patients returning to work sooner than the
other treatments analyzed (Fig. 4).
model shows that infrared photocoagulation and THD
have a higher rate of recurrence when compared to Starion
(OR 0.01, CI 0.00–0.46), harmonic scalpel (OR 0.01, CI
0.00–0.49), and suture ligation (OR 0.01, CI 0.00–0.36).
Starian, harmonic scalpel, and suture ligation ranked top
three, having lower recurrence rates, and fewer patients hav-
ing postoperative symptoms consistent with recurrent hem-
orrhoids or who ended up having additional surgery due to
recurrence (Fig. 5).
Discussion

Recurrence There are different surgical treatments that can be consid-

ered for management of grade 3 and 4 hemorrhoids. Open
Hemorrhoid recurrence was discussed in 16 of the 26 hemorrhoidectomy begins with a “V”-shaped incision with
studies, which provided information on 12 of the surgical a scalpel in the skin around the base of the hemorrhoid,

Fig. 4  Results for return to

work. 13/26 studies compared
return to work on 9 surgical
techniques. This is a league
table that arranges the treatment
in order of most pronounced
impact on the outcome based
on surface under the cumulative
ranking (SUCRA). SUCRA is
a simple numerical summary
of the probabilities. It is 100%
when a treatment is certain to
be the best and 0% when a treat-
ment is certain to be the worst.
The treatments are ranked best
to worst from top to bottom
based on the SUCRA​

13

Fig. 5  Results for recurrence.
16/26 studies compared recur-
rence on these 12 surgical
techniques. This is a league
table that arranges the treatment
in order of most pronounced
impact on the outcome based
on surface under the cumulative
ranking (SUCRA). SUCRA is
a simple numerical summary
of the probabilities. It is 100%
when a treatment is certain to
be the best and 0% when a treat-
ment is certain to be the worst.
The treatments are ranked best
to worst from top to bottom
based on the SUCRA​
then scissors are used to dissect the submucosal space
in order to strip the entire hemorrhoid from its bed [5].
Closed hemorrhoidectomy is similar to open hemorrhoid-
ectomy, but the incisions are totally or partially closed
with absorbable running suture, then the hemorrhoid is
surgical ­excised5. Harmonic scalpel uses ultrasonic energy,
to allow for both cutting and coagulation of hemorrhoidal
tissue which results in minimal lateral thermal damage
[5]. LigaSure is an isolated output electrosurgical genera-
tor which provides power for vessel sealing and bipolar
surgery which allows for precise thermal energy delivery
to achieve competitive and permanent fusion of the vessel
lumen [5]. Starion is similar to the LigaSure but uses tissue
welding technology to simultaneously fuse vessels and tis-
sue structures closed [5]. Suture ligation, the pile method,
uses 3 interrupted sutures to secure the hemorrhoids in
place without excision, thus strangulating and preventing
flow into the hemorrhoid [5]. Bipolar diathermy hemor-
rhoidectomy uses the help of a bipolar diathermy set on
cutting and coagulation, where coagulation is only during
dissection and division of pedicle [5]. Dissection is carried
from a “V”-shaped incision in the skin around the base of
the hemorrhoids unto the pedicle, which is dissected and
divided [5]. Stapled hemorrhoidectomy pulls the prolapsed
tissue into a circular stapler which allows the excess tissue
to be removed while the remaining hemorrhoidal tissue is
stapled off [5]. Doppler-guided hemorrhoidal artery liga-
tion uses a Doppler (ultrasound) device to find hemor-
rhoidal arteries which allows for the surgeon to identify
and ligate the hemorrhoidal vessels by placing a suture
around them [5]. THD utilizes an anoscope to reach the
upper portion of the lower rectum; a Doppler device is
used to identify the terminal branches of the hemorrhoi-
dal arteries at the 1, 3, 5, 7, 9, and 11 o’clock positions;
the vessels are then ligated up to the lower limit of the
13
International Journal of Colorectal Disease
Doppler signal above the dentate line; and a mucopexy of
the ligation is performed to reduce prolapse [6]. Infrared
photocoagulation uses an infrared probe which is applied
to the base of the hemorrhoids through a proctoscope [5].
This is most effective for grade 1 and 2 hemorrhoids but
has been tried on grade 3 hemorrhoids [5]. Laser hem-
orrhoidectomy vaporizes or excises the hemorrhoids by
using carbon dioxide or a laser [5].
In the network meta-analysis done by Simillis et  al.
5 years ago, they determined that open and closed hemor-
rhoidectomies resulted in more postoperative pain at post-
operative day 1, day 7, and day 14. In a systematic review by
Cerato et al. [31] comparing postoperative pain in patients who
underwent either open hemorrhoidectomy, closed hemor-
rhoidectomy, Doppler-guided hemorrhoidal artery ligation,
THD, or stapling, they observed that THD and stapling
resulted in less postoperative pain compared to the other
methods. An analysis of main hemorrhoidectomies (open,
closed, stapled, THD, and LigaSure) by De Freitas et al.
observed that THD and LigaSure resulted in less postop-
erative pain. In our meta-analysis, we observed that laser,
infrared photocoagulation, and stapling resulted in less
postoperative pain. In contrast to these studies, we found
THD to be the 3rd worst surgical treatment with respect
to producing more postoperative pain, preceded by closed
then open hemorrhoidectomies. These findings are consist-
ent with Simillis et al.
Recurrence is seen in all surgical treatments for grade 3
and 4 hemorrhoids, although at different rates. In the analy-
sis by Simillis et al. THD and stapling had a higher rate of
recurrence when compared to other hemorrhoidectomies.
In multiple studies, stapling has been observed to have
higher rates of recurrence when compared to open or closed
hemorrhoidectomy [7-40]. In one study, the incidence of
recurrence with stapling was as high as 26% with 16.7%
International Journal of Colorectal Disease
of patients undergoing reoperation, compared to the recur-
rence rate for closed hemorrhoidectomy which was 18.2% with
0.8% of patients undergoing reoperation [41]. Cerato et al.
[31] noted that, although THD and stapling yield less post-
operative pain, both techniques have a greater likelihood of
recurrence when compared to other hemorrhoidectomies.
In our analysis, infrared photocoagulation and THD had
higher recurrence rates, with closed hemorrhoidectomy and
stapling not far behind them. Starion and harmonic scalpel
were ranked 1 and 2, respectively, for having the lowest rates
of recurrent hemorrhoids.
Simillis et  al. reported that harmonic, LigaSure, and
THD have fewer postoperative clinical complications. In
our analysis, we observed that infrared photocoagulation
and LigaSure had fewer postoperative clinical complica-
tions. Many studies that compare LigaSure with conven-
tional hemorrhoidectomy see fewer postoperative clinical
complications [42-45]. It has been proposed that the reason
for fewer patients having postoperative clinical complica-
tions is because of the technique of LigaSure, being closed
and suture-less by using a modified electro-surgical unit and
vessel sealing [6, 42].
In our analysis, we observed that Doppler-guided hemor-
rhoidal artery ligation and stapling had patients returning to
work faster than the other hemorrhoidectomies. The average
time for patients to return to work after getting stapled hem-
orrhoidectomy was 7–12 days [45]. Tolendo et al. did a study
looking at the short-term and medium-term (1 to 6 month-
spostoperative) outcomes of Doppler-guided hemorrhoidal
artery ligation and observed that the average time to return
to work was 11 days. In the network meta-analysis done
by Simillis et al. they observed that patients who under-
went stapling, LigaSure, and harmonic scalpel returned to
work sooner than those who underwent closed and open
hemorrhoidectomy.
This study must be considered within the context of its
limitations. Given the nature of this study as a meta-analysis,
there is the potential for selection bias in the selection of
studies from the literature search as it excluded studies that
were not in English, if the full text was unable to be accessed,
and if the study was not explicitly only involving grade 3 and
4 hemorrhoids. Publication bias also needs to be considered
studies that lack statistical significance may not have been
published and, thus, been unable to be included in this study.
A limitation when looking at the analysis of postoperative
pain is from 2015 to 2020, and there was only one RCT done
by Maloku et al. that included laser and only one RCT done
by Nikshoar et al. that included infrared photocoagulation.
Both were compared against either closed or open hemor-
rhoidectomy only, which we have been shown to produce the
most postoperative pain compared to all other techniques in
this network meta-analysis. There needs to be more RCTs
that compare laser and infrared photocoagulation to more
surgical methods than just closed and open hemorrhoid-
ectomies to determine their relative propensity to result in
postoperative pain. Another limitation in this analysis is that
we could not fully analyze the clinical outcomes of bipolar
diathermy. There was one RCT done by Shoukat et al. which
only looked at postoperative pain and operating time when
comparing to harmonic scalpel. There needs to be more stud-
ies to look at other clinical outcomes to determine its rank
among the other surgical modalities.
Each of these hemorrhoidectomy methods has their pros
and cons. If a patient is looking for a hemorrhoidectomy
where they would have less postoperative pain and return to
work sooner, stapling is a good option; however, it does have
a higher rate of recurrence, and complications can be serious
if present. If a patient is more concerned with not getting
recurrent hemorrhoids after surgery, Starion, LigaSure, and
harmonic scalpel are three options that have lower rates of
recurrence, but patients do experience more postoperative
pain and clinical complications although much less than
open and closed hemorrhoidectomy techniques. There is a
need for more studies on infrared photocoagulation, laser,
and bipolar diathermy for the treatment of grade 3 and 4
hemorrhoids. There are studies comparing them only to
closed or open hemorrhoidectomy in the past 5 years, thus
limiting the utility of the data retrieved from them. Overall,
we conclude that there are multiple favorable methods to
consider for hemorrhoidectomy including stapling, Starion,
and LigaSure techniques and harmonic scalpel; however,
each patient scenario requires open discussion between
patient and physician with a discussion about surgeon’s
experience with each technique along with risk–benefit
analysis to determine what the best option is for that patient.
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