Table 1.

Overview of treatment options for second and third-degree hemorrhoids

Degree of hemorrhoids	Treatment option	Pros	Cons	Comments
2nd degree	Rubber band ligation (RBL)	“Easy-to-do”	Significant pain if placed below dentate line)	Frequently used as first-line treatment [24]
		Feasible in outpatient clinic	Minor bleeding may be experienced with potential for more significant bleeding	Not recommended under warfarin/clopidogrel (increased bleeding risk) [27]
		Easy to repeat if needed, short-term success rate 70% [28]		Meta-analysis shows superiority compared to sclerotherapy [28]
2nd degree	Injection sclerotherapy	”Easy-to-do”	Recent studies show poor long-term outcomes [31,32]	Limited role in today’s practice
		Feasible in outpatient clinic
		Short-term benefits especially for bleeding hemorrhoids
3rd degree	Open (Milligan-Morgan) hemorrhoidectomy	“Easy-to-teach” procedure	Limited number of hemorrhoids can be resected – danger of stenosis (< 5%) [65]	Good long-term results (low recurrence rates) [39]
		Good long-term results [39]	Reports of postoperative inconti- nence [39]	Equivalent results to closed technique [41]
		Quicker compared to closed technique [42]	Postoperative pain	Still a viable option for 3rd degree hemorrhoids
			Secondary bleeding in up to 5% of patients [62]
3rd degree	Closed (Ferguson) hemorrhoidectomy	“Easy-to-teach” procedure	Longer procedure compared to open technique	Good long-term results (low recurrence rates) [39]
		Faster wound healing compared to open [42]	Postoperative pain	Equivalent results to open technique (potential advantages see pros) [41]
		Lower risk of bleeding compared to open	Secondary bleeding in up to 5% of patients [62]	Still a viable option for 3rd degree hemorrhoids
		Lower risk of stenosis as no secondary healing of big open wounds [43]	Reports of postoperative incontinence [39]
3rd degree	Ligasure hemorrhoidectomy	Short operating time	Expensive equipment	In authors opinion – not to be recommended as standard use (cost/benefit ratio)
		Low volumes of blood loss
		Lower pain scores than formal hemorrhoidectomy in first postoperative week [45]
3rd degree	Stapled hemorrhoidopexy (PPH)	Quick procedure	Higher recurrence rate compared to formal hemorrhoidectomy (especially for 4th degree hemorrhoids) [73-74]	Patient selection critical in this procedure (e.g., caution in previous urge symptoms)
		Reduction in analgesic requirement, shorter hospital stay, quicker recovery (compared to formal hemorrhoidectomy) [69-71]	Rare but potential serious complications like pelvic sepsis, accidental vaginal stapling	Placement (height and depth) of pursestring suture crucial in order to avoid potentially serious complications
			Possibility of postoperative “urge”/”tenesmus” symptoms [77-79]	”Tenesmus”/”urge” symptoms can be severe, can require removal of metallic staplers
3rd degree	Transanal Haemorrhoidal Dearterialisation (HAL)	Minimal postoperative pain, quick recovery time, easily doable as day procedure [83-84]	High postoperative recurrence rates reported (up to 30% at 1-year postoperation) [88]	Newer technique, nonexcisional, aims to interrupt arterial bloodflow to
		Good treatment option for pa- tients under blood thinners – bleeding risk seems not increased [87]		Hemorrhoidal plexus
				HubBLe-Trial: multiple RBL showed similar treatment efficacy as HAL, in addition less pain and shorter procedure in RBL. Authors question cost-effectivity for HAL [88]
				Might have a role in anticoagulated pa- tients/patients who do not want a formal hemorrhoidectomy and who recur after RBL [89]