SURGICAL MANAGEMENT OF HEMORRHOIDS: CURRENT APPROACHES AND ADVANCEMENTS

Hemorrhoidal disease, a common vascular pathology of the anorectal region, presents variably from asymptomatic cushions to severe prolapse and bleeding, affecting 4.4-36.4% of adults worldwide, with higher rates in Western populations due to low-fiber diets, inactivity, and rising obesity. When conservative measures—such as ≥30 g/day fiber intake, phlebotonics (e.g., diosmin), and office procedures like rubber band ligation (RBL) or infrared coagulation (IRC)—fail, especially for Goligher grades III-IV with persistent prolapse, surgery is indicated to relieve symptoms, restore anatomy, and improve health-related quality of life (HRQoL).

This systematic review, based on peer-reviewed studies from 2023 to mid-2025, highlights the shift from traditional excisional hemorrhoidectomy to minimally invasive options, aiming to reduce postoperative pain, recovery time, and complications like stenosis or incontinence. Key techniques include Milligan-Morgan/Ferguson excisions, stapled hemorrhoidopexy (SH/PPH), transanal hemorrhoidal dearterialization (THD) with Doppler-guided ligation and mucopexy, laser hemorrhoidoplasty (LHP) using 980-1470 nm lasers, radiofrequency ablation (RFA), and ALTA sclerotherapy hybrids with selective excision.

Meta-analyses and RCTs from PubMed Central and Cochrane confirm excisional methods offer superior longevity with 1-5% recurrence at 36-60 months (95% CI: 0.8-4.2%), but at costs of high VAS pain (6.5-8.5) and 21-35 day recovery. Minimally invasive approaches like THD and LHP lower VAS to 1.5-4.0, enable 3-12 day reintegration, and keep complications <5% (e.g., urinary retention OR 0.45, 95% CI 0.32-0.64), though recurrence rises to 8-18%. Adjuncts such as LigaSure, harmonic scalpels, robotics, and AI planning cut bleeding by 40-60% and procedure time by 15-25%.

Challenges include inconsistent reporting, limited long-term data (>24 months) for hybrids, and costs (e.g., $1,500-3,500 for THD) hindering access in low-resource areas. The review recommends patient-specific algorithms incorporating comorbidities, grading, and expertise to maximize benefits and minimize risks. Future directions involve bioengineered agents, microbiome-based prevention, and large RCTs to strengthen guidelines, potentially easing the >$1.2 billion annual U.S. economic burden.