Hemorrhoidectomy: Everything You Need to Know

Hemorrhoid surgery (hemorrhoidectomy) involves the surgical removal of one or more hemorrhoids. These are swollen veins in the rectum or anus that can occur either internally or externally.

This surgery may be indicated when a patient's hemorrhoids cannot be treated with medical therapies or office-based procedures, and/or if the hemorrhoid is particularly large or causing symptoms (e.g., causing severe, acute pain, or significant bleeding).

While a highly effective therapeutic option, hemorrhoid surgery carries risks and requires a decent recovery period.

If you are considering surgery for your hemorrhoids, reading about the different surgical techniques available and what you can expect from the preparation and healing processes is a sensible first step. This article is a great place to start.

What Is a Hemorrhoidectomy?

There are different surgical techniques used to remove hemorrhoids. Depending on the procedure, general, regional, or local anesthesia may be used.

The type of hemorrhoid surgery used in a particular case depends on factors like the type of hemorrhoid involved and surgeon/patient preference.

Surgery for External Hemorrhoids

External hemorrhoids are located near the anus and often cause itching and bleeding. In some cases, an external hemorrhoid may become very painful, large, and/or thrombosed (when a clot forms inside of it) and require surgical removal.

When surgery is warranted, most external hemorrhoids are surgically cut out or excised. This is called a hemorrhoid excision.

Alternatively, an incisional hemorrhoidectomy may be performed for a thrombosed external hemorrhoid. With this type of surgery, a cut is made over the skin of the hemorrhoid. Just the clot (located within the hemorrhoid) is removed.

An incisional hemorrhoidectomy is less likely to be successful if a patient has been experiencing pain for more than 48 hours. In addition, if the incision is too small, blood can reaccumulate and form another clot inside the hemorrhoid.

Surgery for Internal Hemorrhoids

Internal hemorrhoids are located inside the rectum and are not typically visible. They usually cause painless rectal bleeding and are graded 1 to 4 based on their extent that the swollen tissue bulges out of the anus—what's known as prolapse.

For internal hemorrhoids, the whole hemorrhoid is usually cut out and removed. This is called a conventional hemorrhoidectomy. Based on the surgeon's preference, a scalpel, scissors, electrocautery (use of heat from an electric current to destroy tissue), or a more advanced device may be used to remove the hemorrhoid.

A procedure called a stapled hemorrhoidopexy may also be performed to remove internal hemorrhoids. With this technique, no incision is made. Instead, the hemorrhoid is lifted and stapled back into the anal canal using a special circular stapling device.

A stapled hemorrhoidopexy may result in less post-surgical pain than the conventional approach. However, with the former, the hemorrhoids are more likely to return.

An additional option for internal hemorrhoid removal is a surgical procedure called doppler-guided transanal hemorrhoidal artery ligation (HAL). The surgeon inserts a special tube called an anoscope a few inches into the anus to locate each hemorrhoid's arterial blood supply. This is called an anoscopy.

The blood supply is closed off in a process called ligation.

Contraindications

Any of the following may prevent you from being able to have a hemorrhoidectomy:

• Inability to control bowel movements, a.k.a. fecal incontinence
• Rectocele, a bulge in the vaginal wall
• Inflammatory bowel disease (e.g., Crohn's disease or ulcerative colitis)
• Portal hypertension with rectal varices
• Uncontrolled bleeding disorder

Potential Risks

Besides the general risks of surgery (e.g., bleeding, problems with anesthesia), there are specific risks associated with hemorrhoid surgery.

These risks depend on the type and extent of surgery being performed.

For example, risks associated with the surgical removal of a thrombosed external hemorrhoid include:

• Minor swelling
• Perianal abscess, a painful, red lump near the anus made up of bacteria and pus
• Internal sphincter injury

Risks associated with surgical removal of internal hemorrhoids include:

• Urinary retention
• Rectal perforation, when a hole forms in the rectum and sepsis (rare)
• Abscess (rare)
• Formation of a fistula, an abnormal tract between the anal or rectal canal and another area, like the vagina (rare)
• Fecal incontinence (rare)

Purpose of Hemorrhoid Surgery

The purpose of hemorrhoid surgery is to remove external or internal hemorrhoids.

That said, even though hemorrhoidectomy is the most effective and definitive treatment for hemorrhoids, it's linked to significantly more pain and complications than non-surgical therapies.

Therefore, the American Gastroenterological Association (AGA) advises that surgery only be considered for a specific and small group of individuals.

Potential candidates for hemorrhoidectomy generally include patients who:

• Have tried medical and non-operative hemorrhoid therapies without success, or who cannot tolerate them
• Have grade 3, grade 4, or mixed internal and external hemorrhoids that cause symptoms
• Have symptomatic hemorrhoids along with an associated anorectal condition that warrants surgery
• Prefer surgery and have discussed therapy options with their referring healthcare provider (e.g., primary care physician) and surgeon

When hemorrhoid surgery is scheduled, various pre-operative tests may need to be run, especially for patients undergoing general anesthesia.

Examples of such tests include:

• Blood tests like a complete blood count (CBC) and a coagulation panel
• Urinalysis
• Electrocardiogram (ECG)

How to Prepare

Once you are scheduled for hemorrhoid surgery, your surgeon will give you instructions on how to prepare.

Location

Hemorrhoid surgery is usually performed in a hospital, surgical center, or surgeon's office by a general surgeon or colon and rectal surgeon.

In select cases of suddenly occurring thrombosed external hemorrhoids that cause severe pain, surgery may be performed in an emergency room.

Food and Drink

On the day before surgery, you will likely be asked to eat a light, non-greasy breakfast and lunch.

After lunch, you will be asked to only drink clear liquids up until four hours prior to your surgery (at which point you cannot drink anything).  

Medications

You may be advised to stop taking certain medications several days prior to surgery. At the top of the list are those that increase your risk for bleeding, such as nonsteroidal anti-inflammatory drugs (NSAIDs).

You will also be instructed to undergo a cleansing bowel regimen prior to the procedure. Typically, your colon cleansing products can be purchased over the counter.

An example regimen may include the following:

• Drink one 10-ounce bottle of magnesium citrate in the afternoon on the day before your surgery. 
• Use a sodium phosphate enema in the evening prior to your surgery.
• Use a second sodium phosphate enema in the morning, approximately one hour prior to leaving for the hospital or surgical center.

Follow the specific instructions outlined by your healthcare provider.

What to Wear and Bring

On the day of your surgery, wear comfortable, loose-fitting clothes and avoid wearing makeup or nail polish. Leave all valuables, including jewelry, at home.

Make sure you bring your driver's license, insurance card, and a list of your medications.

If you are staying overnight in the hospital, pack a bag the night before your surgery.

In addition to personal care items (like a toothbrush and hairbrush) and comfort items (like a magazine or hand cream), be sure to pack:

• Any medical devices you use (e.g., eyeglasses or a CPAP machine for sleep apnea)
• Loose-fitting clothes to go home in, especially pants with an elastic waistband and cotton underwear

Someone will need to drive you home when you are discharged, so either plan for the person to accompany you to your surgery or to be on stand-by for your discharge.

Pre-Op Lifestyle Changes

You should stop smoking at least two weeks (and ideally six to eight weeks) before surgery, as smoking can impair wound healing.

What to Expect on the Day of Surgery

On the day of your hemorrhoid surgery, you will arrive at the hospital, surgical center, or office and check-in.

Before the Surgery

After checking in, you will be taken to a holding area where you will change into a hospital gown.

A surgical nurse will review your medication list, record your vitals (heart rate, blood pressure, etc.), and place an intravenous (IV) line into a vein in your arm.

You may receive an antibiotic through your IV at this time to help prevent post-operative infection. The IV will also be used for administering fluids and medications during and after surgery.

Your surgeon will then come to greet you and review the operation with you. They might perform an anoscopy while they are there to double-check the status of your hemorrhoids (e.g., location, volume, etc.).

From there, you will be wheeled into the operating room on a gurney where the anesthesia process and surgery will start.

During the Surgery

If general anesthesia is needed, the anesthesiologist will give you inhaled or intravenous medication to put you to sleep. Once asleep, a breathing tube called an endotracheal tube will be inserted down your throat to allow for mechanically-assisted breathing during the operation.

With regional anesthesia, the surgeon injects a numbing medication into your spine. You may feel a stinging sensation as the medication is being injected.

Local anesthesia also involves a numbing medication, but it is injected into the area around your anus. You will also probably be given a sedative to help you relax or fall asleep during the surgery.

Just as what's involved in delivering anesthesia differs depending on the technique being used, so do the steps that come next.

Here's one example. For a conventional internal hemorrhoidectomy, you can generally expect the following:

• Inspection: A surgical tool called a retractor is inserted into the anus and rectum to allow the surgeon to inspect the internal hemorrhoid.
• Access: The hemorrhoid is grasped with a small clamp and pulled away from the anal sphincter muscles.
• Excision: An elliptical- or diamond-shaped incision is made in the rectal tissue around the hemorrhoid. The hemorrhoid is cut away from the sphincter muscles. The swollen vein inside of it is tied off with a suture to prevent bleeding. The hemorrhoid is then removed. This step may be repeated if more than one hemorrhoid is present.
• Closure: The skin edges may be left open or closed with an absorbable suture. The anal area is covered with a dressing.

After the Surgery

A nurse will monitor your vital signs in the recovery room as you slowly wake up from general anesthesia or the sedative.

Since urinary retention is a potential complication of hemorrhoid surgery, you may be asked to urinate before being approved to go home (if a same-day surgery).

If you are staying in the hospital, you will be wheeled on a gurney to your hospital room.

Recovery

Recovery can take anywhere from one to six weeks, depending on the type and extent of your surgery.

As you recover at home or in the hospital, expect to experience pain and a sensation of anal fullness or tightness for the first week or so.

To ease your pain, your surgeon will advise the following:

• Take your pain medication as prescribed. This often includes an NSAID like Motrin (ibuprofen). An opioid may be given for more significant pain (although, opioids can cause constipation).
• Apply an ice pack, a bag of frozen peas, or a zipper bag filled with ice wrapped in a thin towel to your bottom (ask your surgeon for specific instructions on the timeline for icing).
• Take sitz baths for 15 to 20 minutes, three to four times per day.
• Drink at least eight glasses of water a day and take stool softeners as advised. Both can help you avoid constipation and worsening of your pain.

You can expect to have a bowel movement by the third day after your surgery.

It's important to follow up with your surgeon as advised. During these appointments, your surgeon will check your wound site, monitor for complications, access your pain, and remove any sutures (if applicable).

Wound Care

Mild bleeding and a yellow-red discharge from the anal area are common after surgery. Both may increase with bowel movements and activity.

Your surgeon will advise you to wear pads to monitor the drainage and to avoid soiling your underwear and pants.

You may also have a gauze dressing over your anal wound or some sort of packing in your anal area. Talk to your surgeon about when to remove this and how to change or replace it (if applicable and necessary).

Check with your surgeon, but you can probably shower the day after surgery. That said, you will want to avoid submerging your wound in a soapy bath for one week (sitz baths are OK).

If you have any stitches, they will dissolve around 10 to 14 days after surgery or be removed at one of your follow-up appointments.

Physical Activity

You will have specific activity guidelines to follow after surgery, such as:

• You can begin moving around the day after surgery and should be able to resume simple, light activities/chores. Use pain as your guide.
• You can drive when you are off all prescription pain medication.
• Avoid sitting for long periods of time. Use a soft cushion or pillow when doing so.
• Avoid heavy lifting or straining with bowel movements for at least five to seven days.

Long-Term Care

Besides keeping in touch with your surgeon as instructed, you will also want to adopt lifelong habits that will prevent hemorrhoids from forming again.

These habits include:

• Avoiding delaying bowel movements, straining, or sitting too long on the toilet
• Drinking six to eight glasses of water throughout the day
• Eating a high-fiber diet or taking fiber supplements (ideal fiber intake per day ranges from 19 to 38 grams, depending on age and gender)
• Staying active

If you are struggling with constipation, talk with your healthcare provider about taking an occasional laxative or using an enema.

Possible Future Surgeries

Future surgical interventions or medical therapies may be required if the hemorrhoid(s) recurs and/or if a complication from surgery develop.

Such complications might include anal stenosis or fecal incontinence.

A Word From Verywell

Most patients with symptomatic hemorrhoids notice that their discomfort and irritation eases within about a week or so of implementing conservative strategies—making surgery moot.

That said, if surgery is needed, know that it's often very effective. It will also require a commitment to your post-operative care.

If you are considering surgery for your hemorrhoids, please take your time talking with your healthcare provider about what the best surgical technique is for you. Also, remember to review potential risks, what type of anesthesia is being used, and any concerns or questions you have.

You want and deserve to be as informed and as comfortable as possible going into surgery.

Hemorrhoids Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

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