Patients may undergo hemorrhoidal operations in the outpatient clinic, day surgery suite, or inpatient operating room. The preoperative care will vary slightly, but will generally have the same components. Full medical evaluation should be performed to ensure safety of anesthesia. A preoperative bowel prep is usually prescribed and may range from an enema or suppository to evacuate the rectum to a more complete prep with one or two doses of magnesium citrate followed by enemas the evening prior to and morning of the operation. All patients undergoing procedures in the operating room should not eat of drink anything after midnight. Antibiotics are administered prior to incision and should generally be targeted toward the normal colonic flora.

The patient may be placed in the lateral decubitus, jackknife, or high lithotomy position. Office procedures under local anesthetics are best served by the decubitus or jackknife approach, while either jackknife or high lithotomy may be used in the operating room. In the jackknife position, care needs to be taken to avoid pressure on facial structures. In high lithotomy, the patient’s heels are placed in soft stirrups. Care should be taken to avoid pressure on the heels and calves. Choice of anesthesia involves extent of the planned procedure, patient anxiety and pain, likelihood of additional pathology, anesthetic risk, and patient preference. Local anesthesia alone may be used for simple procedures, but conscious sedation, spinal anesthesia, or general anesthesia with laryngeal mask or endotracheal tube may be needed for more complicated hemorrhoid treatment. In general, deep anesthesia is preferred when performing operations in the anal canal. This prevents the patient from straining against the anal speculum and traumatizing the sphincter mechanism. Preparation of the anus and perianal region should be performed with a full betadine scrub.

Injection of a sclerosing agent may be used to treat first, second and third degree hemorrhoids. One to five ml of sclerosing agent (5 % phenol in oil, ethanolamine, quinine urea, hypertonic saline, or aluminum potassium sulfate with tannic acid [ALTA]) is injected into the submucosa of each hemorrhoid [7]. The resultant ulceration and scarring prevent prolapse. Care should be taken in the anterior direction to inject superficially. The prostate or periprostatic venous plexus may be injured with deep injection [2, 6].

Either through an endoscope or using an anoscope, the tip of a fiberoptic probe is placed at the tip of the hemorrhoidal pedicle and infrared radiation is used to coagulate the underlying vascular plexus. This treatment is only suited for first and minor second degree hemorrhoids [2, 6, 7].

Doppler-guided laser photocoagulation (Hemorrhoid Laser Procedure, or HeLP) is a newer system of more targeted photocoagulation. Doppler ultrasound is used to identify the branches of the superior hemorrhoidal artery feeding into the hemorrhoidal plexuses about 3 cm above the dentate line, and a laser system is then used to coagulate the vascular supply. A small randomized controlled trial between HeLP and rubber band ligation demonstrated better postoperative pain control and more frequent resolution of symptoms at 6 months with HeLP as well as improved patient satisfaction [8]. Long-term follow up of this method is still needed [7].

Rubber-band ligation is best suited for first, second, and few third degree hemorrhoids. A Cochrane review comparing rubber band ligation to excisional hemorrhoidectomy concluded that this should be the initial treatment of choice for symptomatic grade 2 hemorrhoids, although higher-grade hemorrhoids respond better to surgical excision [9]. Rubber-band ligation involves the application of a rubber band to the mucosa above the hemorrhoidal tissue and 1–2 cm above the dentate line to include the feeding vessel of the hemorrhoid within the band. This causes necrosis of the captured tissue, ulceration and scarring, which prevents prolapse or bleeding. A slotted anoscope or anal speculum is inserted the hemorrhoidal tissue is allowed to protrude into the slot. Rubber-bands may be applied by a suction or non-suction device. The mucosa just above the hemorrhoidal cushion is either grasped with a clamp or suctioned into the tip of the banding device. The pre-loaded band is then deployed by squeezing the trigger on the device. The band must be employed above the dentate line to ensure that no sensate mucosa is included. Immediate and postoperative pain are indications of inclusion of this mucosa and removal of the bands may be necessary [2, 6].