Hemorrhoids pp 485-492 | Cite as

Literature Data on Perioperative Management After Surgery for Hemorrhoids

  • Christopher Emmett
  • Mark Mercer-Jones
Reference work entry
Part of the Coloproctology book series (COLOPROCT, volume 2)


Excisional hemorrhoidectomy is a commonly performed procedure for symptomatic hemorrhoids. This term encompasses both “open” (Milligan-Morgan) and “closed” (Ferguson) hemorrhoidectomy techniques, as well as excisional procedures performed using surgical devices such as LigaSure™ and harmonic scalpel. These procedures pose certain challenges in the perioperative period, especially in the management of postoperative pain, bowel function, and wound healing. Traditionally, patients undergoing hemorrhoidectomy remained in hospital for up to a week postoperatively; however, in recent years, the procedure is increasingly being carried out as a day case operation.

A variety of strategies for reducing postoperative complications and improving postoperative pain have been suggested; usually, combinations of local anesthetic, oral medications, and topical therapies are employed with the aim of optimizing patients’ postoperative recovery, reducing hospital stay, and preventing readmission. This chapter aims to evaluate the current published evidence for postoperative management of patients undergoing excisional hemorrhoidectomy.


  1. Ala S, Saeedi M, Eshghi F, Mirzabeygi P (2008) Topical metronidazole can reduce pain after surgery and pain on defecation in postoperative hemorrhoidectomy. Dis Colon Rectum 51(2):235–238. Scholar
  2. Amorotti C, Mosca D, Trenti C, Pintaudi U (2003) Usefulness of lateral internal sphincterotomy combined with hemorrhoidectomy by the Milligan-Morgan’s technique: results of a prospective randomized trial. Chir Ital 55(6):879–886. Available at: Scholar
  3. Cheetham MJ, Phillips RKS (2001) Evidence-based practice in haemorrhoidectomy. Color Dis 3(2):126–134. Scholar
  4. Diana G, Guercio G, Cudia B, Ricotta C (2009) Internal sphincterotomy reduces postoperative pain after Milligan Morgan haemorrhoidectomy. BMC Surg 9:16.
  5. Gorfine SR, Onel E, Patou G, Krivokapic ZV (2011) Bupivacaine extended-release liposome injection for prolonged postsurgical analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial. Dis Colon Rectum 54(12):1552–1559. Scholar
  6. Gupta PJ (2008) Warm sitz bath does not reduce symptoms in posthaemorrhoidectomy period: a randomized, controlled study. ANZ J Surg 78(5):398–401. Scholar
  7. Haas E, Onel E, Miller H, Ragupathi M, White PF (2012) A double-blind, randomized, active-controlledstudy for post-hemorrhoidectomy pain management with liposome bupivacaine, a novel local analgesic formulation. Am Surg 78(5):574–581PubMedPubMedCentralGoogle Scholar
  8. Ho YH, Lee J, Salleh I, Leong A, Eu KW, Seow-Choen F (1998) Randomized controlled trial comparing same-day discharge with hospital stay following haemorrhoidectomy. Aust N Z J Surg 68(5):334–336. Available at: Scholar
  9. Ho YH, Tan M, Seow-Choen F (2000) Micronized purified flavonidic fraction compared favorably with rubber band ligation and fiber alone in the management of bleeding hemorrhoids: randomized controlled trial. Dis Colon Rectum 43(1):66–69. Scholar
  10. Hu D, Onel E, Singla N, Kramer WG, Hadzic A (2013) Pharmacokinetic profile of liposome bupivacaine injection following a single administration at the surgical site. Clin Drug Investig 33:109–115. Scholar
  11. Hunt L, Luck AJ, Rudkin G, Hewett PJ (1999) Day-case haemorrhoidectomy. Br J Surg 86(2):255–258. Scholar
  12. Hwang DY, Yoon SG, Kim HS, Lee JK, Kim KY (2003) Effect of 0.2 percent glyceryl trinitrate ointment on wound healing after a hemorrhoidectomy: results of a randomized, prospective, double-blind, placebo-controlled trial. Dis Colon Rectum 46(7):950–954. Scholar
  13. Johnson CD, Chir M, Budd J, Ward AJ (1987) Laxatives after hemorrhoidectomy. Dis Colon Rectum 30(10):780–781. Scholar
  14. Joshi GP, Neugebauer EAM (2010) Evidence-based management of pain after haemorrhoidectomy surgery. Br J Surg 97:1155–1168. Scholar
  15. Karanlik H, Akturk R, Camlica H, Asoglu O (2009) The effect of glyceryl trinitrate ointment on posthemorrhoidectomy pain and wound healing: results of a randomized, double-blind, placebo-controlled study. Dis Colon Rectum 52(2):280–285. Scholar
  16. Khubchandani IT (2002) Internal sphincterotomy with hemorrhoidectomy does not relieve pain: a prospective, randomized study. Dis Colon Rectum 45(11):1452–1457. Scholar
  17. Kilbride M, Morse M, Senagore A (1994) Transdermal fentanyl improves management of postoperative hemorrhoidectomy pain. Dis Colon Rectum 37(11):1070–1072. Scholar
  18. La Torre F, Nicolai AP (2004) Clinical use of micronized purified flavonoid fraction for treatment of symptoms after hemorrhoidectomy: results of a randomized, controlled, clinical trial. Dis Colon Rectum 47(5):704–710. Scholar
  19. London NJ, Bramley PD, Windle R (1987) Effect of four days of preoperative lactulose on posthaemorrhoidectomy pain: results of placebo controlled trial. Br Med J (Clin Res Ed) 295(6594):363–364. Scholar
  20. Luck AJ, Hewett PJ (2000) Ischiorectal fossa block decreases posthemorrhoidectomy pain: randomized, prospective, double-blind clinical trial. Dis. Colon Rectum 43(0012–3706):142–145. Available at: Scholar
  21. Lyons NJR, Cornille JB, Pathak S, Charters P, Daniels IR, Smart NJ (2017) Systematic review and meta-analysis of the role of metronidazole in post-haemorrhoidectomy pain relief. Color Dis 19:803–811. Scholar
  22. Lyseng-Williamson KA, Perry CM (2003) Micronised purified flavonoid fraction: a review of its use in chronic venous insufficiency, venous ulcers and haemorrhoids. Drugs 63:71–100. Scholar
  23. Marsh GD, Huddy SP, Rutter KP (1993) Bupivacaine infiltration after haemorrhoidectomy. J R Coll Surg Edinb 38(1):41–42. Available at: Scholar
  24. Morisaki H, Masuda J, Fukushima K, Iwao Y, Suzuki K, Matsushima M (1996) Wound infiltration with lidocaine prolongs postoperative analgesia after haemorrhoidectomy with spinal anaesthesia. Can J Anaesth 43(9):914–918. Scholar
  25. Naja Z, Ziade MF, Lönnqvist PA (2005) Nerve stimulator guided pudendal nerve block decreases posthemorrhoidectomy pain. Can J Anesth 52(1):62–68. Scholar
  26. Naja Z, El-Rajab M, Al-Tannir M, Ziade F, Zbibo R, Oweidat M, Lonnqvist PA (2006) Nerve stimulator guided pudendal nerve block versus general anesthesia for hemorrhoidectomy. Can J Anaesth 53(6):579–585. Scholar
  27. Ng SSM, Lee JFY, Cheung KY, Leung KL, Yiu RYC, Lau WY (2006) Pre-emptive analgesia and metronidazole on post-haemorrhoidectomy pain control. Surg Pract 10(3):102–105. Scholar
  28. Nicholson TJ, Armstrong D (2004) Topical metronidazole (10 percent) decreases Posthemorrhoidectomy pain and improves healing. Dis Colon Rectum 47(5):711–716. Scholar
  29. Patti R, Luigi AP, Matteo A, Sergio S, Pietro R, Calogero F, Gaetano DV (2006) Botulinum toxin vs. topical glyceryl trinitrate ointment for pain control in patients undergoing hemorrhoidectomy: a randomized trial. Dis Colon Rectum 49(11):1741–1748. Scholar
  30. Rahimi R, Abdollahi M (2012) A systematic review of the topical drugs for post hemorrhoidectomy pain. Int J Pharmacol 8(7):628–637. Scholar
  31. Rahimi M, Kazemeini AR, Pourtabatabaei N, Honarmand AR (2012) Comparison of topical anesthetic cream (EMLA) and diclofenac suppository for pain relief after hemorrhoidectomy: a randomized clinical trial. Surg Today 42(12):1201–1205. Scholar
  32. Rajabi M, Hosseinpour M, Jalalvand F, Afshar M, Moosavi G, Behdad S (2012) Ischiorectal block with bupivacaine for post hemorrhoidectomy pain. Kor J Pain 25(2):89–93. Scholar
  33. Ratnasingham K, Uzzaman M, Andreani SM, Light D, Patel B (2010) Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing. Int J Surg 8:606–611. Scholar
  34. Sammour T, Barazanchi AWH, Hill AG, Bonnet F, Fischer B, Joshi G, Kehlet H, Lirk P, Rawal N, Schug S, Van de Velde M, Vercauteren M (2017) Evidence-based Management of Pain after Excisional Haemorrhoidectomy Surgery: a PROSPECT review update. World J Surg 41:603–614. Scholar
  35. Shiau JM, Su HP, Chen HS, Hung KC, Lin SE, Tseng CC (2008) Use of a topical anesthetic cream (EMLA) to reduce pain after hemorrhoidectomy. Reg Anesth Pain Med 33(1):30–35. Scholar
  36. Sim HL, Tan KY (2014) Randomized single-blind clinical trial of intradermal methylene blue on pain reduction after open diathermy haemorrhoidectomy. Color Dis 16(8):O283. Scholar
  37. Singh B, Box B, Lindsey I, George B, Mortensen N, Cunningham C (2009) Botulinum toxin reduces anal spasm but has no effect on pain after haemorrhoidectomy. Color Dis 11(2):203–207. Scholar
  38. Tan KY, Sng KK, Tay KH, Lai JH, Eu KW (2006) Randomized clinical trial of 0.2 per cent glyceryl trinitrate ointment for wound healing and pain reduction after open diathermy haemorrhoidectomy. Br J Surg 93(12):1464–1468. Scholar
  39. Tejirian T, Abbas MA (2005) Sitz bath: where is the evidence? Scientific basis of a common practice. Dis Colon Rectum 48:2336–2340. Scholar
  40. Vinson-Bonnet B, Coltat JC, Fingerhut A, Bonnet F (2002) Local infiltration with ropivacaine improves immediate postoperative pain control after hemorrhoidal surgery. Dis Colon Rectum 45(1):104–108. Scholar
  41. Vinson-Bonnet B, Higuero T, Faucheron JL, Senejoux A, Pigot F, Siproudhis L (2015) Ambulatory haemorrhoidal surgery: systematic literature review and qualitative analysis. Int J Color Dis 30:437–445. Scholar
  42. Wanis KN, Emmerton-Coughlin HM, Coughlin S, Foley N, Vinden C (2017) Systemic metronidazole may not reduce posthemorrhoidectomy pain. Dis Colon Rectum 60:446–455CrossRefPubMedGoogle Scholar
  43. Wasvary HJ, Hain J, Mosed-Vogel M, Bendick P, Barkel DC, Klein SN (2001) Randomized, prospective, double-blind, placebo-controlled trial of effect of nitroglycerin ointment on pain after hemorrhoidectomy. Dis Colon Rectum 44(8):1069–1073. Available at:; Scholar
  44. Zuckermann M, Panconesi R, Scaricabarozzi I, Nava ML, Bechi P (1993) Clinical efficacy and tolerability of Nimesulide compared with naproxen in the treatment of Posthaemorrhoidectomy pain and inflammation. Drugs 46(1):177–179. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Queen Elizabeth HospitalGatesheadUK

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