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Surgical Treatment of Hemorrhoidal Disease
Surgical Treatment of Hemorrhoidal Disease
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2023. | This topic last updated: Sep 15, 2021.
INTRODUCTION
Hemorrhoids are normal vascular structures in the anal canal. Approximately 5 percent of the
general population is affected by symptoms related to hemorrhoidal disease [1]. The cardinal
features of hemorrhoidal disease include bleeding, anal pruritus, prolapse, extra tissue causing
difficulty with hygiene, and pain due to thrombosis. Although these symptoms may strongly
suggest the diagnosis, confirmation by flexible sigmoidoscopy, anoscopy, or colonoscopy
should be performed in most patients who present with bleeding, especially those deemed at
higher risk for malignancy or additional symptoms (ie, weight loss, changes in bowel habits)
and those who are not up to date on screening recommendations [2].
This topic will review common surgical techniques used to treat hemorrhoids. The anatomy and
clinical features of hemorrhoids, and nonsurgical treatment options, are discussed separately.
(See "Hemorrhoids: Clinical manifestations and diagnosis" and "Home and office treatment of
symptomatic hemorrhoids".)
INDICATIONS
The initial approach to treating most patients with hemorrhoids is conservative. Patients who
fail medical management may be candidates for a nonsurgical office-based procedure prior to
requiring surgical treatment. Ongoing symptoms in spite of conservative or office-based
treatment usually require surgical intervention. (See "Home and office treatment of
symptomatic hemorrhoids", section on 'Conservative treatment for all patients'.)
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A surgical procedure is generally limited to those with the following clinical conditions [4]:
*It is important to note that for some indications, failed prior treatment is not required prior to
proceeding with surgical treatment.
● Prolapsed internal hemorrhoids that can be manually reduced (Grade III), particularly if
more than one column is involved*
● Prolapsed and incarcerated internal hemorrhoids (Grade IV)* ( picture 1)
● Symptomatic internal hemorrhoids (eg, pain, thrombosis) refractory to conservative
measures
● Symptomatic internal hemorrhoids (eg, pain, thrombosis) refractory to office-based
procedures, or unable to tolerate office-based procedures because of pain*
● Combined internal and external hemorrhoids
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*It is important to note that for some indications, failed prior treatment is not required prior to
proceeding with surgical treatment.
The preoperative assessment includes a detailed history; physical examination, which includes
external inspection of the anus and a digital rectal examination; and anoscopy. Medications,
particularly those that increase the risk of bleeding (eg, warfarin, aspirin, clopidogrel,
nonsteroidal anti-inflammatory drugs [NSAIDs]), should be reviewed and are preferably held in
the perioperative period depending on the indications for treatment and risk of cessation.
Consultation with the patient's primary care provider or cardiologist may be warranted.
Perioperative management of anticoagulation is discussed separately. (See "Perioperative
medication management", section on 'Medications affecting hemostasis' and "Perioperative
management of patients receiving anticoagulants".)
In most cases, the patient is instructed to undergo a cleansing enema before the procedure. A
full mechanical bowel preparation is not indicated and may be counterproductive.
There is a paucity of data regarding the need for antibiotic prophylaxis. One retrospective study
reported that there was no benefit to preoperative use of metronidazole compared with no
antibiotics [5]. The authors agree that antibiotics are not necessary in most clinical settings, as
the risk of infection is low. Patients with underlying immunosuppression or extensive cellulitis
may benefit from perioperative antibiotics, such as metronidazole or a second-generation
cephalosporin.
Immediately prior to performing the procedure, anoscopy should be repeated in the semi-
inverted jackknife or left lateral position. The assessment includes an evaluation for the
presence of external hemorrhoids, location, volume, redundancy, and grade of internal
hemorrhoids. (See "Hemorrhoids: Clinical manifestations and diagnosis".)
ANESTHESIA
Hemorrhoid surgery can be performed using general anesthesia, conscious sedation, regional
anesthesia (spinal, epidural), perianal block, or straight local anesthesia [6-13]. The choice is
often one of surgeon preference, but patient-related factors also play a role. One of the authors
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uses intravenous sedation and a perianal block for nearly all hemorrhoid surgeries.
Occasionally, a regional (spinal) anesthetic or general anesthetic may be needed for selected
patients, such as those with respiratory conditions (ie, cannot lay supine or prone, require
airway protection).
The patient is first anesthetized (general, regional, intravenous) and positioned (see
'Positioning' below) for the procedure. An anal block is performed (see 'Perianal
anesthesia/block' below), and a Hill-Ferguson retractor is placed into the anal canal and rectum
to facilitate adequate inspection of the individual internal hemorrhoid columns.
In all cases, care should be taken to avoid unnecessary pressure on the male genitalia and to
pad all bony prominences, particularly the legs when lithotomy position is used. (See "Nerve
injury associated with pelvic surgery", section on 'Avoid prolonged lithotomy position'.)
If spinal anesthesia is used, perianal anesthesia is not necessary. A formal pudendal nerve block
has also been shown to reduce hemorrhoidectomy pain in a systematic review including 17
studies [17].
An anal block is performed by injecting local anesthetic (eg, lidocaine, bupivacaine), typically
with epinephrine ( table 1), into the ischiorectal fat immediately peripheral to the external
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sphincter [18]. Sodium bicarbonate (1 cc per 30 cc lidocaine) can be added per provider
discretion to help minimize local irritation with injection if the patient remains awake.
EXTERNAL HEMORRHOIDECTOMY
External hemorrhoids generally do not require surgical management. Exceptions may include
thrombosed external hemorrhoids or large external hemorrhoids that cause symptoms that
cannot be controlled or interfere with hygiene. (See "Home and office treatment of
symptomatic hemorrhoids", section on 'Conservative treatment for all patients' and
'Indications' above.)
Techniques — When indicated, external thrombosed hemorrhoids are best treated with
hemorrhoid excision, rather than incision and simple evacuation of the clot, an approach that
should generally be avoided [21,22]. However, if timely evaluation by a surgeon is not available
and the provider is not comfortable with excision of the thrombosed hemorrhoid, incision of
the hemorrhoid can be performed to remove the clot, which should lessen symptoms. (See
'Excision' below and 'Incision' below.)
The recurrence rate for a completely excised thrombosed hemorrhoid is 5 to 19 percent [21,22].
By comparison, simple incision and evacuation of the clot is associated with a 30 percent risk of
reaccumulation and thrombosis, which may disseminate to adjacent hemorrhoidal columns
[20].
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The skin overlying the hemorrhoid is prepped with povidone iodine solution, and local
anesthesia is infiltrated into the skin at the base and overlying the area of excision around the
hemorrhoid. A supplemental anal block, in addition to this infiltration, can also be performed
and is preferred by the authors. (See 'Perianal anesthesia/block' above.)
Following excision of an external hemorrhoid, the anal area is covered by a dressing to protect
the clothing from soilage. (See 'Postoperative care and follow-up' below.)
Incision — For nonsurgeons who do not feel comfortable excising the overlying skin of a
thrombosed external hemorrhoid, an alternative is to simply incise the overlying skin.
Evacuation of thrombus from the hemorrhoid can produce immediate relief of pain. However,
clot evacuation is less likely to be beneficial if the patient is seen after 48 hours following the
onset of pain. In general, the authors do not recommend this technique, as when hemorrhoid
incision, rather than excision, is used, there can be residual clot if the incision is too small, and
reaccumulation of blood and thrombosis can occur. Thus, follow-up within the next 24 to 48
hours for surgical evaluation is generally advised. (See 'Techniques' above.)
INTERNAL HEMORRHOIDECTOMY
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Hemorrhoidectomy techniques differ predominantly based upon how the hemorrhoidal tissue
is removed and whether or not the rectal mucosa is closed. Conventional hemorrhoidectomy
excises the hemorrhoidal tissue with a scalpel, monopolar electrocautery, or other advanced
electrosurgical devices (eg, Ligasure, Harmonic scalpel). Alternative methods of
hemorrhoidectomy, such as stapling and hemorrhoidal artery ligation, have also been
performed. (See 'Techniques' below.)
● Hemorrhoidal artery ligation (HAL) has the lowest rate of postoperative complications but
the highest rate of recurrence.
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Both conventional hemorrhoidectomy and stapled hemorrhoidopexy are most commonly used
to treat symptomatic prolapsing (grade II, III, and IV) internal hemorrhoids. A large randomized
trial (eTHoS) permitted direct comparison of the two techniques [30]. Stapled hemorrhoidopexy
resulted in less pain than conventional hemorrhoidectomy in the initial six weeks postsurgery.
At 12 and 24 months, however, patients treated with stapled hemorrhoidopexy reported worse
incontinence, tenesmus, and hemorrhoid symptoms; more hemorrhoid recurrences; and worse
quality of life compared with those treated with conventional hemorrhoidectomy.
Earlier trials and systematic reviews agreed that stapled hemorrhoidopexy was less painful but
that conventional surgery resulted in better symptom relief and fewer recurrences [31-34].
Additionally, postprocedural tenesmus and reoperations were more prevalent among patients
who underwent stapled hemorrhoidopexy [33]. A 2019 meta-analysis also associated stapled
hemorrhoidopexy with higher rates of complications and recurrences compared with open
procedures [35].
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minimize pain and "downtime" after surgery, however, stapled hemorrhoidopexy remains a
viable option.
Techniques
The goals of hemorrhoid resection are to remove the redundant tissue, avoid damage to the
sphincter, and avoid taking too much anoderm, which might lead to anal stenosis. For
conventional hemorrhoidectomy, the junction of the internal and external component of the
hemorrhoid is grasped with a small clamp (eg, Allis, Babcock) to retract the hemorrhoid away
from the sphincter muscles. Using a scalpel or electrocautery pen, the rectal mucosa is scored
in an elliptical or diamond shape around the hemorrhoidal bundle to delineate the plane for
excision of the hemorrhoid. The incision is carried deeper starting distally on the external
hemorrhoidal tissue and extending proximally across the dentate line to the superiormost
extent of the hemorrhoidal column. The hemorrhoid tissue is carefully dissected from the
superficial internal and external sphincter muscles toward the main vascular pedicle in the anal
canal. Care must be taken not to narrow the anal canal when multiple hemorrhoidal excisions
are performed. Only the redundant anoderm associated with the hemorrhoidal tissue should
be removed, preserving a minimum of 1 cm of anoderm between columns.
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The base of the pedicle is suture ligated, and the hemorrhoidal tissue is removed. The mucosal
defect is then left open to heal by secondary intention or closed with a continuous 2-0 or 3-0
absorbable suture (eg, Vicryl). To minimize the chance of narrowing the anal canal, a Hill-
Ferguson retractor should be left in place until all suturing is complete. (See 'Open versus
closed hemorrhoidectomy' above.)
An anal dilator or obturator is provided with the surgical stapler and provides gentle dilatation
of the anal canal ( figure 2). The circular stapling device is introduced into the anus, and the
mucosa/submucosa contents are brought into the stapler. Before the stapler is engaged or
fired, the posterior wall of the vagina should be assessed to ensure the stapler has not
inadvertently engaged it. This can be noted by moving the stapler and seeing that the posterior
vaginal wall does not tent or move with it. When the stapler is fired, it creates a circular fixation
of all tissues within the nonabsorbable circumferential purse string suture to the rectal wall. In
effect, it will draw up and suspend the prolapsed internal hemorrhoid tissue. The staple line
should be fully evaluated as this is a potential source for early bleeding and may require a
suture ligation. The most critical component of the procedure is the placement of the
pursestring suture in the mucosa/submucosa approximately 4 cm from the dentate line. It is
important that the pursestring suture be placed far enough proximal to avoid involving the
sphincter muscles within the stapling device, and to minimize other complications (eg, changes
in continence, stricture, fistula).
One role for stapled hemorrhoidopexy devices is to treat patients with bleeding and/or
prolapsing grade II to IV internal hemorrhoids who have failed rubber band ligation. Another
role may be for patients seeking a potentially less painful alternative to conventional surgery,
but the patient must be willing to accept a higher risk of recurrence [48]. (See 'Conventional
versus stapled' above.)
above, will not address the external hemorrhoid component if present. Thus, in patients with
combined internal and external hemorrhoids, the external hemorrhoids are surgically excised,
obviating the benefit of using the stapling device.
In a randomized trial of 337 patients with symptomatic grade II or III internal hemorrhoids, HAL
resulted in fewer recurrences than rubber band ligation at 12 months (30 versus 49 percent)
[57]. However, this difference was almost entirely accounted for by the need for repeat banding,
which is a common practice but which was counted as recurrences in this study. Compared with
rubber band ligation, HAL was associated with more pain at one and seven days after the
procedure, more serious adverse events requiring hospitalization (7 versus 1 percent), and
higher cost (£1750 versus £723).
Thus, HAL is more effective but more painful and costly compared with a single rubber band
ligation. For patients with symptomatic grade II or III internal hemorrhoids, a course of rubber
band ligation remains the first-line procedure of choice due to its low morbidity and cost.
Patients who fail, refuse, or cannot tolerate rubber band ligation should be referred for one of
the surgical hemorrhoidectomy procedures. (See 'Choosing a hemorrhoidectomy technique'
above.)
Rubber band ligation of internal hemorrhoids is discussed in detail in another topic. (See
"Home and office treatment of symptomatic hemorrhoids", section on 'Rubber band ligation'.)
OTHER PROCEDURES
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Supplemental sphincterotomy — Patients who have internal hemorrhoids that are associated
with a high resting internal anal sphincter pressure may benefit from supplemental
sphincterotomy. Sphincterotomy should generally be reserved for patients with concomitant
fissure disease, and it should be avoided in those who have normal resting sphincter pressure
[58]. (See "Anal fissure: Surgical management".)
It is fairly common for patients to experience a fair amount of pain over the first few days, along
with significant swelling. Postoperative instructions include warm sitz baths, stool softeners,
and pain medication including oral narcotics and anti-inflammatory medications. Often, the
wounds will open after three to five days, and patients may note mucus drainage from the area.
High fevers (>101° F), significant expanding erythema or necrosis, or unremitting pain are all
concerning and warrant further evaluation.
Pain management — Pain following hemorrhoidectomy is nearly universal and may in part be
due to spasm of the internal sphincter. Perianal anesthetic infiltration at the time of
hemorrhoidectomy is important for reducing postoperative pain. (See 'Perianal
anesthesia/block' above.)
Initial pharmacologic treatment to control postoperative pain consists of oral analgesics, such
as nonsteroidal anti-inflammatory drugs and/or acetaminophen [14]. Opioids may be given if
pain is not well controlled but carry the potential adverse effects of inducing constipation and
possibly worsening the pain.
Other options to manage pain have been evaluated in small randomized trials:
● A trial of 18 patients found that topical diltiazem ointment (2 percent) applied to the
perianal region three times daily for seven days postoperatively was significantly more
effective than placebo in reducing pain and the need for prescription narcotics [59]. The
mechanism of benefit is presumably related to relaxation of the internal anal sphincter.
● Botulinum toxin injection compared with placebo has been associated with significant
reductions in postoperative pain and the time of healing [60].
● Topical metronidazole (10%) has also been shown to decrease postoperative pain
following hemorrhoidectomy as well as decrease postdefecation discomfort [61]. Oral
metronidazole has also been shown to be beneficial for pain control [62], although the
data are still mixed [63].
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Local care — A sensation of "tightness" after the procedure can usually be alleviated with a
warm sitz bath that can be performed as often as needed by the patient. Of note, simple warm
water is all that is required, and the addition of other bath or Epsom salts is not necessary.
Avoiding constipation — A bulk fiber supplement and/or increased dietary fiber and fluid
intake will help reduce postoperative constipation and pain upon defecation. Fecal impaction
after a hemorrhoidectomy is associated with postoperative pain and opiate use. Most surgeons
recommend stimulant laxatives, stool softeners, and bulk fiber to prevent this problem. Should
impaction develop, manual disimpaction with anesthesia may be required.
COMPLICATIONS
The nature of complications depends upon the type and extent of procedure.
● Following excision of a thrombosed external hemorrhoid, minor bleeding (<1 percent) and
local swelling are common, and perianal abscess/fistula can also occur (approximately 2
percent). The most common complication is recurrent hemorrhoids that require another
procedure (approximately 6 percent). Internal sphincter injury occurs infrequently (<1
percent) but has undesirable consequences [22]. (See 'Thrombosed external hemorrhoids'
above.)
● Following excision of internal hemorrhoids, the most common complications are bleeding
and urinary retention [44]. Rare complications are rectal perforation and sepsis,
rectovaginal fistula, minor changes in continence, and retroperitoneal and pelvic abscess
[64]. (See 'Internal hemorrhoidectomy' above.)
require urinary catheterization, although some remain relatively asymptomatic. (See "Acute
urinary retention", section on 'Acute management'.)
Bleeding — Delayed hemorrhage, probably due to sloughing of the primary clot, develops in 1
to 2 percent of patients; it usually occurs 7 to 16 days postoperatively [65]. No specific
treatment is effective for preventing this complication, which usually requires a return to the
operating room for suture ligation.
Other complications include sphincter damage (which is rare) and wound dehiscence (which is
common but usually of no clinical consequence). In most cases, minor alterations in continence
may be noted in the first few weeks following hemorrhoidectomy due to pain, anal spasm, and
changes in sensation (ie, discriminating between liquid, solid stool, and gas). These patients
typically get better with time, though bulking agents may help.
Anal stricture — Anal stricture formation occurs in approximately 1 percent of patients and for
internal hemorrhoidectomy is related to multiple column hemorrhoidectomies where too much
anoderm has been resected.
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Hemorrhoids".)
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
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sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: Hemorrhoids (Beyond the Basics)")
● Hemorrhoids are normal vascular structures in the anal canal. The initial approach to
treating most patients with hemorrhoids is conservative. For patients who fail medical
management or cannot tolerate an office-based procedure, surgical excision remains a
very effective approach for treatment of symptomatic hemorrhoids. For some indications,
failed prior treatment is not required prior to proceeding with surgical treatment. (See
'Introduction' above and 'Indications' above.)
● Routine perioperative antibiotics are not necessary. A full mechanical bowel preparation is
also not necessary, but patients are usually given an enema just prior to the procedure.
Medications that increase the risk of perioperative bleeding (eg, warfarin, aspirin,
clopidogrel, nonsteroidal anti-inflammatory drugs [NSAIDs]) should be reviewed and are
preferably held in the perioperative period depending on the indications for treatment
and risk of cessation. Consultation with the patient's primary care provider or cardiologist
may be warranted. (See "Perioperative medication management", section on 'Medications
affecting hemostasis'.)
● Patient positioning is primarily determined by the surgeon. The authors prefer prone-
jackknife positioning for most cases. For patients unable to tolerate the prone position
because of concerns with airway control, the lithotomy or left-lateral positions are
acceptable alternatives. However, visualization and access to the base of the hemorrhoid
may be more difficult. Care should be taken to avoid pressure points. (See 'Positioning'
above.)
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related factors also play a role. For all hemorrhoid surgeries (external or internal
hemorrhoidectomy, internal hemorrhoidopexy), we infiltrate local anesthetic in the
perianal region at the time of hemorrhoidectomy, except in patients undergoing spinal
anesthesia. Perianal infiltration of local anesthetic provides significant pain relief, whether
given alone or as a supplement to other forms of anesthesia. (See 'Perianal
anesthesia/block' above.)
• The two main types of conventional hemorrhoidectomy are the closed (Ferguson)
hemorrhoidectomy and open (Milligan-Morgan) hemorrhoidectomy (excision and
ligation without mucosal closure). In general, there appears to be no definitive
advantage between open or closed hemorrhoidectomy, but closed hemorrhoidectomy
(or a modification of the technique) is more commonly performed to treat internal
hemorrhoids. All three internal hemorrhoidal columns are usually treated
simultaneously. (See 'Internal hemorrhoidectomy' above.)
● Following hemorrhoid surgery, the anal area is covered by a dressing to protect the
clothing. Pain can be controlled primarily using nonsteroidal anti-inflammatory agents
and warm Sitz baths. Narcotic medications can be used, if needed, but these may cause
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constipation. Patients are instructed to avoid constipation. The wounds will generally heal
within a couple of weeks. (See 'Postoperative care and follow-up' above.)
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Topic 14997 Version 22.0
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GRAPHICS
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Maxim
Physiochemical properties allowa
dose
Infiltration Concentration
anesthetic (percent)
Onset of
Lipid:water Relative Duration
action mg/kg
solubility potency (minutes)
(minutes)
Lidocaine 1%
Mepivacaine 1%
Bupivacaine 0.25%
Procaine 1% Δ
Without 1 0.6 1 5 to 10 60 to 90 7 to 10
epinephrine
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* Maximum total dose for intradermal-subcutaneous infiltration anesthesia may vary according to
site of administration and concomitant use of vasoconstrictors. The maximum dosing values in this
table are at the lower end of what many experts regard as safe. Lower doses and concentrations
than what are listed are generally used for children, debilitated patients, or those with cardiac
disease. Note that preparations of infiltrated local anesthetics are available in concentrations other
than those shown in table. Maximum allowable and maximum total volumes shown apply only to
the specific concentration of the preparation in table. Toxicity may occur with doses within the
suggested range, especially with inadvertent vascular injection.
Data from:
1. McCreight A, Stephan M. Local and regional anesthesia. In: Textbook of Pediatric Emergency Procedures, 2nd edition,
King C, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2008.
2. McGee DL. Anesthetic and analgesic technique. In: Roberts and Hedges Clinical Procedures in Emergency Medicine,
5th edition, Roberts JR, Hedges JR (Eds), Saunders Elsevier, Philadelphia 2010.
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Reproduced with permission of the American Society of Colon and Rectal Surgeons.
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Figure B: Excision of an ellipse of skin with iris scissors. Do not excise deep into
the anal sphincter.
Figure D: Hemorrhoid excised, clot evacuated, wound left open to heal. Note
underlying anal sphincter.
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Postoperative
Recurrence rate
pain/complication rate
Postoperative pain/complication and recurrence rates are ranked from * (lowest) to ***** (highest).
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Stapled hemorrhoidectomy
Stapled hemorrhoidopexy.
(B) Placement of the pursestring suture at least 4 cm above the dentate line.
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Contributor Disclosures
David E Rivadeneira, MD, MBA, FACS, FASCRS No relevant financial relationship(s) with ineligible
companies to disclose. Scott R Steele, MD, MBA, FACS, FASCRS No relevant financial relationship(s) with
ineligible companies to disclose. Martin Weiser, MD Consultant/Advisory Boards: PrecisCa
[Gastrointestinal surgical oncology]. All of the relevant financial relationships listed have been
mitigated. Wenliang Chen, MD, PhD No relevant financial relationship(s) with ineligible companies to
disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
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