Haemorrhoid Removal Surgery (Haemorrhoidectomy) Waiting Times Update

Find out about the latest waiting times and length of hospital stay for Haemorrhoidectomy with Dr Foster Health

Haemorrhoid removal surgery summary

Haemorrhoids - commonly known as piles - are swollen blood vessels (veins) which develop inside and/or outside the anus. If they become infected, they can cause pain and discomfort and may need to be removed surgically.

Haemorrhoidectomy is the surgical procedure to remove haemorrhoids. A number of different surgical procedures exist to remove haemorrhoids and each have their advantages and disadvantages.

Who gets haemorrhoids?

Haemorrhoids are extremely common, with about half of the population experiencing them at some time.

What are the symptoms of haemorrhoids?

1. Bright red blood spots in the toilet or on the toilet paper
2. Itchiness and discomfort around the anus
3. A hard lump near the anus
4. Mucus discharge after passing a stool
5. Pain while passing a stool
6. Feeling of incomplete evacuation of your bowels

What causes haemorrhoids?

1. Pregnancy increases abdominal pressure on pelvic blood vessels ⁽¹⁾
2. Ageing reduces the efficiency of the circulation ⁽²⁾
3. Lack of dietary fibre can cause constipation and straining ⁽³⁾
4. Being overweight or obese ⁽⁴⁾

How are haemorrhoids diagnosed?

Your GP will examine you to check for external swollen blood vessels around your anus. S/he may ask you if your stools contain blood or mucus and enquire about your bowel habits.

For internal haemorrhoids, an internal digital examination may be performed - the doctor will put on a latex glove and use a finger to feel inside the rectum.

Your GP may also check for other conditions which may have similar symptoms, such as inflammatory bowel disease and bowel cancer, both of which are much less common than haemorrhoids.

If you are 50 years or older and have noticed a change in your bowel habits, such as regular constipation or diarrhoea, you should see your doctor.

If your haemorrhoids are bleeding and infected, then your GP may refer you to a consultant that specialises in colorectal surgery.

There are two types of haemorrhoids:

1. Internal haemorrhoids - these occur inside the anus
2. External haemorrhoids - these appear outside the anus

Haemorrhoids are also classified by the degree of prolapse (dropping outside the anus), their size and if they are infected ⁽⁵⁾:

1. First degree haemorrhoids bleed but do not prolapse
2. Second degree haemorrhoids prolapse on straining and then reduce (go back inside the anus)
3. Third degree haemorrhoids prolapse on straining and do not reduce and may require manual reduction (pushed back inside the anus)
4. Fourth degree prolapsed haemorrhoids are trapped outside the anus and may become strangulated/ infected

How are haemorrhoids treated?

Minor haemorrhoids do not require medical treatment and may disappear on their own.

Creams and suppositories can treat minor haemorrhoids. These over-the-counter medicines contain an anaesthetic to ease painful symptoms, allowing bowel movements to pass more easily.

Laxatives can help reduce constipation and the accompanying straining that can lead to haemorrhoids. Other remedies work by bulking-up or softening the stools, while others cause the bowel to contract more forcefully. However, they are not suitable for long-term or regular use.

Non-surgical treatments for low grade haemorrhoids include:

1. Band ligation - a small rubber band is placed at the base of the haemorrhoid with an applicator. This cuts off the blood supply so that the haemorrhoid eventually falls off leaving a shallow ulcer that heals up
2. Cryotherapy - freezing the haemorrhoids to shrink them
3. Sclerotherapy - injecting a chemical into the problem haemorrhoids to shrink them

Surgical removal of haemorrhoids

Haemorrhoidectomy - surgical removal of the piles under general anaesthetic - may be necessary if the haemorrhoids are large and strangulated and there is regular bleeding, infection or blood clots passed during a bowel movement.

The consultant colorectal surgeon will remove the problem haemorrhoids using one of two different methods depending on the severity of your haemorrhoids and your general health:

1. Milligan-Morgan Haemorrhoidectomy (MMH) - is the 'gold standard' procedure to remove problem haemorrhoids. MMH is usually used to treat second-degree haemorrhoids (too large for band ligation) and more severe cases. The haemorrhoids are surgically removed (excised) and the incisions sutured and dressed. The haemorrhoids can also be removed using diathermy (high frequency electric current). Performed as a day case, MMH is the most commonly performed type of haemorrhoidectomy ⁽⁶⁾ as there is less likelihood that the haemorrhoids will return. However, post-operative pain is associated with MMH.
2. Stapled Haemorrhoidopexy (SH) - involves stapling the problem haemorrhoids into their original position and removing excess haemorrhoidal tissue. A specially designed circular knife staples and removes the tissue with the haemorrhoids on it in one action. SH is associated with less post-operative pain and shorter recovery compared with MMH ⁽⁷⁾. However, SH is associated with a higher risk of haemorrhoid recurrence and prolapse compared with MMH ⁽⁶⁾.

Waiting times for haemorrhoidectomy

Government targets have gone some way to reducing waiting times, especially for high-volume procedures, such as haemorrhoidectomy. Dr Foster Health data shows that waiting times for haemorrhoidectomy have been falling year on year in all Strategic Health Authorities (SHA) since 2006/7:

Figure 1: Waiting times for Haemorrhoidectomy by Strategic Health Authority

Hospital length of stay for haemorrhoidectomy

The following graph (figure 2) shows you the average length of stay in hospital after haemorrhoidectomy according to age group. Haemorrhoid removal surgery is generally a day case, which means you will probably not need to stay overnight in a hospital.

Figure 2: Haemorrhoidectomy: Spells & Day Case Rate by Age Group

Inpatient spell: a patient's stay in hospital consists of at least one finished consultant episode (period of care under one consultant/team)

Figure 2 shows that as patients get older they are more likely to stay in hospital for longer after a haemorrhoidectomy procedure.

New developments in haemorrhoid removal surgery

As conventional haemorrhoidectomy techniques tend to be associated with post-operative pain and reoccurrence of haemorrhoids, new techniques have been developed to diminish these complications.

If you decide to go privately, you should make sure that your insurance covers these types of procedures.

Clinical studies assessing long-term outcomes among these newer procedures are ongoing and new treatments may continue to evolve.

These newer procedures may not be available at all NHS or Private Hospitals:

Doppler-guided haemorrhoidal artery ligation - a minimally-invasive and relatively painless surgical method for the treatment of haemorrhoids.

"Doppler ultrasound" is an instrument (similar to the ultrasound used to take images of the unborn baby) that detects blood flow in the six branches of the rectal artery that send blood to haemorrhoidal tissue in the rectum and anus. The use of Doppler ultrasound allows surgeons to indentify accurately and tie off the blood supply to the problem haemorrhoids. Further internal stitches help prevent the haemorrhoids from prolapsing. Tying off the correct blood vessels shrinks the haemorrhoids, making it less likely that they will return.

By avoiding surgical incisions on the outside of the anus, recovery is less painful and can be performed as a day case ⁽⁸⁾. Another benefit of treating haemorrhoids using the Doppler-guided method is that the procedure can be performed with minimal sedation in about 20 minutes.

Ligasure - a new surgical device that fuses the blood vessels feeding the haemorrhoids together to form a permanent seal.

The advantage with Ligasure is that it does not leave behind stitches or dressings that can add to post-operative pain and slow recovery.

The Ligasure technique has been demonstrated to be superior to MMH or SH in terms of patient tolerance, but the long-term risk of recurrence of haemorrhoids has not been evaluated and needs more extensive clinical testing ⁽⁹⁾.