Hemorrhoidectomy - making sense of the surgical options

Table 1 Classification of internal hemorrhoids

Grade	Definition
I	Normal appearance externally, bleeding but not prolapsing
II	Anal cushions prolapse on straining but reduces spontaneously
III	Anal cushions prolapse on straining or exertion and require manual reduction
IV	Permanent prolapse, irreducible

Table 2 Results for grade II hemorrhoids

Methods	Mean operating time (min)	Return to work (d)	Recurrence at < 1 yr	Recurrence at > 1 yr	Post-op bleeding	ARU	Fistula	Anal stricture
DGHAL	NR	NR	5.3-6.7[9,44]	12[44]	2.2[9]	0[9]	0[9]	NR
SH	NR	NR	NR	NR	NR	NR	NR	NR
CH	NR	NR	NR	NR	NR	NR	NR	NR
CH + LigaSure	NR	NR	NR	NR	NR	NR	NR	NR

DGHAL: Doppler-guided hemorrhoidal artery ligation; SH: Stapler hemorrhoidectomy; CH: Conventional hemorrhoidectomy; ARU: Acute urinary retention; NR: Not recorded.

Table 3 Results for grade III hemorrhoids

Methods	Mean operating time (min)	Return to work (d)	Recurrence at < 1 yr (%)	Recurrence at>1 yr (%)	Post-op bleeding (%)	ARU (%)	Fistula (%)	Anal stricture (%)
DGHAL	19[45]	NR	13-13.5[9,44]	18-31[44,45]	0-6.8[9,45]	1[9]	0-0.5[9,45]	NR
SH	21-31[45,47-49]	6-7.9[47,48]	7.5[47]	3-25.6[45,47,49,55]	0-9.1[45,47-49]	1.6-17.5[45,47]	0[49]	1.3-2.6[48,49]
CH	35-42.36[47-49]	10.2-15[47,48]	5[47]	0-17.5[47,49,55]	1.7-7.5[47-49]	40[47]	2.5[49]	0[48,49]

DGHAL: Doppler-guided hemorrhoidal artery ligation; SH: Stapler hemorrhoidectomy; CH: Conventional hemorrhoidectomy; ARU: Acute urinary retention; NR: Not recorded.

Table 4 Results for grade IV hemorrhoids

Methods	Mean operating time (min)	Return to work (d)	Recurrence at < 1 yr (%)	Recurrence at> 1 yr (%)	Post-op bleeding (%)	ARU (%)	Fistula (%)	Anal stricture (%)
DGHAL	NR	NR	59.3[9]	NR	3.7[9]	3.7[9]	0[9]	NR
DGHAL + RAR	35[51]	NR	NR	9[51]	4[51]	NR	NR	NR
SH	24[52]	NR	NR	50-53.3[52,55]	0[52]	NR	NR	NR
CH	27.4-39[52,53]	16.4[53]	NR	0-6.25[52,53,55]	6.25-11[52,53]	0[53]	NR	NR
CH + LigaSure	22.3[53]	12.2[53]	NR	0[53]	4[53]	4[53]	NR	NR

DGHAL: Doppler-guided hemorrhoidal artery ligation; SH: Stapler hemorrhoidectomy; CH: Conventional hemorrhoidectomy; ARU: Acute urinary retention; NR: Not recorded; RAR: Rectoanal repair.

Table 5 Summary of recommendations

	Small hemorrhoids	Large hemorrhoids	Isolated hemorrhoids	Circumferential hemorrhoids
Grade II	Ligation	DGHAL	Ligation	SH
Grade III	DGHAL	CH/SH	CH	SH
Grade IV	CH	CH	CH	CH/SH

DGHAL: Doppler guided hemorrhoidal artery ligation; SH: Stapler hemorrhoidectomy; CH: Conventional hemorrhoidectomy.