Dr. Solon Gonçalves Souza Menezes
Professor of Surgery — FAMED UFU · Robotic Surgery Certification (Intuitive / Albert Einstein Hospital) · Practices at Hospital UMC and Hospital Mater Dei Santa Genoveva, Uberlândia, Brazil · +55 (34) 99341-0915
Hemorrhoids are normal structures of the anal canal — cushions of blood vessels and supporting tissue that help with continence. Hemorrhoidal disease arises when these cushions dilate, slide or become inflamed, causing bright red bleeding with bowel movements, a bulge, itching, moisture and, during thrombosis attacks, intense pain. Internal hemorrhoids lie above the dentate line and are classified into four grades according to prolapse: grade I (no prolapse), II (prolapse that reduces on its own), III (reduced by hand) and IV (cannot be reduced). External hemorrhoids lie below the line, covered by sensitive skin, and are the cause of pain in thrombosis. The digestive tract surgeon treats anorectal diseases — hemorrhoids, anal fissure and anal fistula — as part of the specialty.
The guideline of the American Society of Colon and Rectal Surgeons (ASCRS 2024) organizes treatment in steps. The first is always clinical: fiber, water, correction of bowel habits and sitz baths (strong recommendation). For grade I and II hemorrhoids — and selected grade III cases — that do not improve, office procedures resolve most cases, and rubber band ligation is the most effective of them. Hemorrhoidectomy (surgical removal of the hemorrhoidal cushions, by the open Milligan-Morgan or closed Ferguson techniques) is reserved for grade III and IV hemorrhoids, symptomatic external hemorrhoids and mixed cases — it is the technique with the lowest recurrence, but also the most painful afterwards.
Between these two extremes lies laser hemorrhoidoplasty: through a small puncture in the skin, a laser fiber is introduced into the hemorrhoidal cushion and the energy causes the tissue to shrink and scar, without cutting the mucosa. It is a minimally invasive technique, performed as day surgery, and Dr. Solon Gonçalves offers it when indicated — symptomatic internal hemorrhoids of grades II and III. What the evidence shows, honestly: the meta-analyses of randomized trials (17 trials, 1,196 patients; 9 trials, 661 patients) found less pain, less bleeding, less urinary retention and a return to work about 12 days earlier compared with conventional hemorrhoidectomy. On the other hand, recurrence is the Achilles heel of the laser: in a double-blind trial, 10% of laser-treated patients needed further treatment within a year, versus 0% after hemorrhoidectomy; at 5 years, 29% versus 24% (a non-significant difference); and a systematic review found more recurrence with the laser than with open surgery.
The choice is therefore individual: for those with grade II or III hemorrhoids who prioritize a fast recovery with less pain, the laser is a good option, knowing that there is a higher chance of needing further treatment over the years; for grade IV hemorrhoids, large external components or recurrences, hemorrhoidectomy remains the reference. It is worth noting that the ASCRS 2024 guideline does not yet cover the laser — the technique is recent, and long-term studies are few. Dr. Solon practices at Hospital UMC and Hospital Mater Dei Santa Genoveva in Uberlândia, Brazil, and discusses the alternatives with each patient based on the proctological examination.
Book a consultationThe right treatment for each grade.
The choice follows the ASCRS 2024 guideline and the evidence on the laser, and is defined at the proctological examination, which includes anoscopy. Anal bleeding in people over 45 or with risk factors also requires a colonoscopy, to rule out other causes.
Grades I and II
Clinical treatment (fiber, water, bowel habits, sitz baths) and, if it persists, office procedures — rubber band ligation is the most effective. Laser hemorrhoidoplasty is an alternative in grade II: in a randomized trial, it had less pain and bleeding in the first two weeks than ligation, with equal recurrence at one year.
Grade III
Laser hemorrhoidoplasty or hemorrhoidectomy, depending on the size of the cushions and the patient's priority — less pain and faster return (laser) or lower recurrence (hemorrhoidectomy). Rubber band ligation can resolve selected cases.
Grade IV and external hemorrhoids
Hemorrhoidectomy (Milligan-Morgan or Ferguson), with a strong recommendation from the ASCRS. The laser alone is not indicated in grade IV — the consensus of the technique's own users only admits it combined with other techniques, by experienced surgeons, with a higher risk of recurrence.
Hemorrhoidal thrombosis
An attack of intense pain with a hard lump: in the first 72 hours it can be treated by removing the clot or the cushion; after that, clinical treatment usually resolves it, and definitive surgery is discussed later.
Laser, ligation and hemorrhoidectomy: a comparison with the published numbers.
The table summarizes the results of the randomized trials and meta-analyses cited in the references. All numbers are averages of groups of patients; recurrence, in particular, varies with the grade of the disease and with the surgeon's technique.
| Aspect | Rubber band ligation | Laser hemorrhoidoplasty | Hemorrhoidectomy |
|---|---|---|---|
| Main indication | Grades I and II; selected III | Internal grades II and III | Grades III and IV, external and mixed |
| Where it is done | Office, no anesthesia | Day surgery, with anesthesia | Hospital, with anesthesia |
| Postoperative pain | Mild | Less than hemorrhoidectomy (pain score about 2.5 points lower on day 1) | The most intense, for 1 to 2 weeks |
| Postoperative bleeding | Low | Less than hemorrhoidectomy (OR 0.16) | More frequent |
| Return to activities | Immediate | About 12 days earlier than hemorrhoidectomy; 15 days in the Vilnius trial | About 30 days in the same trial |
| Recurrence | May require repeated sessions | 10% at 1 year and 29% at 5 years in the Vilnius trial; 21.6% at 25 months in a grade III cohort; a review points to more recurrence than open surgery | 0% at 1 year and 24% at 5 years in the Vilnius trial; 8.1% at 25 months in the cohort |
| Specific complications | Pain, late bleeding | External hemorrhoid thrombosis (up to 4–10%), bleeding (0–7.6%) | Urinary retention, anal stenosis, late bleeding |
On a phone, drag the table sideways to see all the columns.
What to expect before and after surgery.
Preoperative preparation
The consultation includes the proctological examination with anoscopy, which defines the grade and the presence of an external component. Colonoscopy is requested when there is bleeding in patients over 45, anemia, a change in bowel habits or a family history of colorectal cancer. For procedures under anesthesia, blood tests and an anesthetic assessment are requested; fasting, simple bowel cleansing (usually a small enema) and suspension of anticoagulants under guidance are advised.
Recovery and postoperative care
After the laser, most patients go home the same day, with mild to moderate pain controlled by common painkillers; thrombosis of an external hemorrhoid, when it occurs, can cause more intense pain for a few days. After hemorrhoidectomy, pain is more significant in the first two weeks and requires scheduled analgesia, sitz baths and care with bowel habits — fiber, water and mild laxatives prevent hard stools. Small amounts of bleeding with bowel movements are expected during healing, which takes 3 to 6 weeks after hemorrhoidectomy. Return to work ranges from a few days (ligation, laser) to 2 to 4 weeks (hemorrhoidectomy).
What can happen, technique by technique.
No hemorrhoid treatment is free of recurrence or complications. The numbers below come from the meta-analyses and trials cited in the references.
- Recurrence — the most important point in the choice: lower with hemorrhoidectomy; higher with the laser in long-term studies (29% at 5 years in the Vilnius trial; 34% at 5.4 years in a Swiss series; 21.6% at 25 months in grade III). Rubber band ligation may need repeating.
- Pain — intense after hemorrhoidectomy, for 1 to 2 weeks; less after the laser and ligation, but the laser can cause external hemorrhoid thrombosis (up to 4% to 10%), with pain comparable to conventional surgery in those cases.
- Bleeding — late (between day 7 and day 14) after hemorrhoidectomy or ligation; after the laser, reported between 0% and 7.6%.
- Urinary retention — transient, more common after hemorrhoidectomy.
- Anal stenosis — scar narrowing, rare, more associated with extensive hemorrhoidectomy (the laser showed less stenosis in the meta-analyses).
- Incontinence — rare with all techniques; no difference between laser and hemorrhoidectomy in the meta-analyses.
- Infection and fistula — rare; a Swiss series reported 18% of complications after the laser, including two fistulas, which reinforces the need for careful indication.
Common questions about this procedure.
When do hemorrhoids need surgery?+
When clinical treatment and office procedures do not resolve them, when there is grade III or IV prolapse, a symptomatic external component or repeated thrombosis attacks. Persistent bleeding with anemia is also an indication. Most grade I and II hemorrhoids do not need surgery.
Is laser hemorrhoid surgery better?+
It is better in one respect and worse in another. The meta-analyses of randomized trials show less pain, less bleeding and a return to work about 12 days earlier than with hemorrhoidectomy. On the other hand, recurrence is higher: 10% at one year versus 0% for hemorrhoidectomy in a double-blind trial, and 29% versus 24% at 5 years. It is a good option for grades II and III when the patient accepts this trade-off; it does not replace hemorrhoidectomy in grade IV.
Does laser hemorrhoid surgery hurt? How long is the recovery?+
Pain is mild to moderate in most cases and controlled with common painkillers; return to activities takes an average of 15 days in the Vilnius trial, versus 30 days after hemorrhoidectomy. If thrombosis of an external hemorrhoid occurs — a complication described in up to 4% to 10% of cases —, pain can be stronger for a few days.
Is hemorrhoid surgery dangerous?+
It is not a life-threatening operation, but it has possible complications: late bleeding, urinary retention, intense pain (hemorrhoidectomy), external thrombosis (laser) and, rarely, stenosis, infection or incontinence. Choosing the right technique for the grade of the disease is what reduces these risks most.
What is the difference between open (Milligan-Morgan) and closed (Ferguson) hemorrhoidectomy?+
In the open technique, the wound left by removing the cushion is left to heal on its own; in the closed technique, it is sutured. Both are excisional techniques with similar long-term results and low recurrence; postoperative pain is similar. The choice depends on the case and the surgeon's preference.
Is it normal to bleed after hemorrhoid surgery?+
Small amounts of bleeding with bowel movements are expected during healing, for a few weeks. Heavy bleeding, with clots, or bleeding between day 7 and day 14 (when the scab comes off) must be reported immediately — it is rare, but may require assessment.
How many days of sick leave for hemorrhoid surgery?+
After rubber band ligation, generally none or a few days; after the laser, about one to two weeks; after hemorrhoidectomy, two to four weeks, depending on the occupation. Sick leave is defined individually.
Can hemorrhoids be cured?+
The hemorrhoidal cushions are normal structures, so what is treated is the disease — the prolapse, the bleeding and the attacks. All techniques have some recurrence over the years, lowest with hemorrhoidectomy. Keeping the bowels regular, with fiber and water, is part of the treatment for life.
Can hemorrhoids turn into cancer?+
Hemorrhoids do not turn into cancer. The concern is a different one: anal bleeding may be attributed to hemorrhoids and hide a tumor of the rectum or colon. That is why bleeding in people over 45, with anemia, a change in bowel habits or a family history requires a colonoscopy before any treatment.
Is the surgery done under general anesthesia?+
Laser procedures and hemorrhoidectomy are performed under spinal or general anesthesia, according to the anesthetic assessment, as day surgery or with one night in hospital. Rubber band ligation is done in the office, without anesthesia.
Inflamed hemorrhoids: what to do during an attack?+
Warm sitz baths, painkillers, ointments for a limited time and soft stools (fiber, water, mild laxative) relieve most attacks. Very intense pain with a hard lump suggests thrombosis: in the first 72 hours, removal of the clot brings quick relief; seek assessment.
Do you operate through the SUS, the Brazilian public health system?+
I do operate through the SUS. I am a Professor of Surgery at the School of Medicine of the Federal University of Uberlândia and I operate on patients at the university hospital, HC-UFU. The route, however, does not go through my private practice: to be operated on through the SUS you must go to the health post or Basic Health Unit nearest your home, be assessed by a doctor and, if surgery is indicated, be placed in your municipality's regulation queue. The surgeon does not choose who gets operated on through the SUS — the queue is followed strictly, according to SUS rules.
Hospital facilities in Uberlândia, Brazil.
Hospital Mater Dei Santa Genoveva
Av. Vasconcelos Costa, 967 — Martins, Uberlândia-MG
Open in Google Maps →Content reviewed by Dr. Solon Gonçalves Souza Menezes — CRM-MG 79366, RQE 60355 (GI Surgery), RQE 44656 (General Surgery). Professor of Surgery at FAMED-UFU and Supervisor of the General Surgery Medical Residency Program at HC-UFU. ORCID. Last reviewed: October/2026.
- Hawkins AT, Davis BR, Bhama AR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024;67(5):614-623. doi:10.1097/DCR.0000000000003276
- Cheng PL, Chen CC, Chen JS, et al. Diode laser hemorrhoidoplasty versus conventional Milligan-Morgan and Ferguson hemorrhoidectomy for symptomatic hemorrhoids: Meta-analysis. Asian J Surg. 2024;47(11):4681-4690. doi:10.1016/j.asjsur.2024.04.156
- Wee IJY, Koo CH, Seow-En I, et al. Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for grade II/III hemorrhoids: a systematic review and meta-analysis. Ann Coloproctol. 2023;39(1):3-10. doi:10.3393/ac.2022.00598.0085
- Lie H, Caesarini EF, Purnama AA, et al. Laser hemorrhoidoplasty for hemorrhoidal disease: a systematic review and meta-analysis. Lasers Med Sci. 2022;37(9):3621-3630. doi:10.1007/s10103-022-03643-8
- Li Z, Wu J, Brown NKD, et al. A systematic review comparing the efficacy of 980 nm vs. 1470 nm wavelengths in laser hemorrhoidoplasty. Int J Colorectal Dis. 2024;39(1):117. doi:10.1007/s00384-024-04690-z
- Poskus T, Danys D, Makunaite G, et al. Results of the double-blind randomized controlled trial comparing laser hemorrhoidoplasty with sutured mucopexy and excisional hemorrhoidectomy. Int J Colorectal Dis. 2020;35(3):481-490. doi:10.1007/s00384-019-03460-6
- Makunaite G, Grinys A, Danys D, et al. Five-Year Follow-up of the Double-Blinded Randomized Controlled Trial Comparing Laser Hemorrhoidoplasty With Sutured Mucopexy and Excisional Hemorrhoidectomy. Dis Colon Rectum. 2026;69(10):2484-2491. doi:10.1097/DCR.0000000000004372
- Gambardella C, Brusciano L, Brillantino A, et al. Mid-term efficacy and postoperative wound management of laser hemorrhoidoplasty (LHP) vs conventional excisional hemorrhoidectomy in grade III hemorrhoidal disease: the twisting trend. Langenbecks Arch Surg. 2023;408(1):140. doi:10.1007/s00423-023-02879-4
- Faes S, Pratsinis M, Hasler-Gehrer S, et al. Short- and long-term outcomes of laser haemorrhoidoplasty for grade II–III haemorrhoidal disease. Colorectal Dis. 2019;21(6):689-696. doi:10.1111/codi.14572
- Jin L, Qin K, Wu R, et al. Laser hemorrhoidoplasty vs. rubber band ligation: a randomized trial comparing 2 mini-invasive treatment for grade II hemorrhoids. BMC Surg. 2024;24(1):164. doi:10.1186/s12893-024-02425-z
- Ambe PC, et al. Best clinical practice recommendations for the management of symptomatic hemorrhoids via laser hemorrhoidoplasty: the LHP recommendations. Tech Coloproctol. 2024;29(1):2. doi:10.1007/s10151-024-03022-1