Hemorrhoids, commonly known as piles, are severely swollen veins that have formed in the lower rectum or the anus. They are of two types: internal and external. Internal ones develop within the rectum and are usually painless. They can lead to rectal bleeding. They may also prolapse, which is when the hemorrhoids come out through the anus.

On the other hand, the skin beneath the anus is home to external hemorrhoids, which can cause swelling, pain, and itching. ^{1, 2} Risk factors include pregnancy, family history, aging, obesity, low-fiber diet, sedentary lifestyle, heavy lifting, and chronic constipation or diarrhea. ^{3, 4} Studies show that nearly 5% of the global population suffers from symptomatic hemorrhoids, with higher prevalences in developed countries. ⁵ People suffering from hemorrhoids complain of factors such as pain, discomfort, itching, and even bleeding, which makes it difficult for them to carry out their daily activities as well as social life. This may lead to physical and psychological problems such as anxiety and depression because they tend to feel embarrassed. ⁶ The Goligher grading system classifies internal hemorrhoids into four grades based on prolapse severity. Grade I is asymptomatic, while Grade II prolapses after bowel movements but reduces spontaneously. Grade III requires manual reduction, and Grade IV remains prolapsed. ⁷ Treatment varies by severity. Early-stage cases are managed with lifestyle modifications and analgesics. ⁸ Minimally invasive procedures like sclerotherapy, infrared photocoagulation, and rubber band ligation are options for advanced cases. ⁹ Severe or chronic hemorrhoids often require surgery, primarily conventional or stapled hemorrhoidectomy. ¹⁰ In conventional hemorrhoidectomy, the hemorrhagic tissues are removed under local, regional, or general anesthesia during the surgery. It may be done using a laser or a scalpel with the wound either sutured or left open. It’s found to be effective for Grade III and IV hemorrhoids but is associated with significant postoperative pain and a lengthy recovery period of two to six weeks. ¹¹ In contrast, stapled hemorrhoidectomy, which uses a circular stapler to remove extra tissue and realign hemorrhoids while under general anesthesia, has a greater recurrence rate but is less painful and heals more quickly. ^{12, 13} The classical technique, introduced in 1993, treats hemorrhoidal disease through stapled hemorrhoidopexy, a less invasive alternative to traditional hemorrhoidectomy. It offers better pain control and patient comfort but carries risks of complications like bleeding and sepsis. Since 2002, over 130 studies have reported these risks, emphasizing the need for careful comparison with conventional hemorrhoidectomy. ¹⁴

The choice between conventional and stapled hemorrhoidectomy remains challenging due to variations in pain levels, recovery time. Limited and mostly outdated studies have explored this topic, with none conducted in Iraq, leaving a gap in understanding patient outcomes and long-term effectiveness in our clinical setting.

This research aims to compare the outcomes between stapled and conventional hemorrhoidectomy techniques by evaluating postoperative pain, recovery time, and complications. The study seeks to provide evidence-based data to guide surgical decision-making and optimize treatment selection for patients requiring hemorrhoid surgery in our clinical setting.

This study is a retrospective analysis of prospectively collected data from two centers: AL-Kafeel Hospital and Safeer Al-Hussain Hospital in Karbala, Iraq. The aim was to compare the outcomes and complications of conventional hemorrhoidectomy and stapled hemorrhoidectomy.

In this retrospective study involving 114 participants, 50 (43%) were in the classical group, while 64 (56%) were in the stapled group. Among both groups, 35 participants (30%) were female, and 79 (69%) were male. The mean age of the classical group was 42 years, while the mean age of the stapled group was 43 years. The age distribution among the study groups followed a normal distribution, and there was no statistically significant difference in age between the groups, see Table 1. Age was categorized into multiple groups for analytical purposes. At baseline, the stapled group exhibited a higher proportion of fourth-degree cases than those with third-degree cases, as can be seen in Table 2 and Figure 1.

Regarding the preoperative presentations, the preoperative mass was the predominant feature in the clinical presentation for both groups. This mass may be associated with bleeding or pain. The proportions of hemorrhoid severity varied between the two groups. The majority of participants presented with third-degree hemorrhoids, with 92% in the classical group compared to 64% in the stapled group, see Figure 2. While in postoperative complications, a significant difference was observed in postoperative pain, bleeding (p = 0.001), and wound infection (p = 0.01). In the classical group, additional complications included anal stenosis. Notably, all cases of postoperative wound infection occurred in females (n = 5). In contrast, no such complications were observed in the stapled group, see Table 3, Figure 3 and Table 4. All instances of postoperative bleeding in the stapled group were reported in males ( Table 5).

Our findings show differences in results between stapled and conventional hemorrhoidectomy operations. The results showed less postoperative pain and fewer complications.

The mean (SD) of age in our cohort was 42.52 (11.56) and 43.55 (13.89) in the classical and stapled groups, respectively, which is slightly higher than the mean age reported in a prior cohort, 40.05 years (SD = 10.88) and 39.5 years (SD = 9.82) in the classical and stapled groups, respectively. ¹⁵

Regarding gender distribution, our classical group had a relatively balanced composition (52% male, 48% female), whereas the stapled group had a significantly higher proportion of males (82% male, 17% female). This differs from the findings of Sachin et al. (2017), where the male-to-female ratios were 66% male, 34% female in the conventional group and 54% male and 46% female in the stapled group. ¹⁵

The type of anesthesia used was spinal in 54% of patients who underwent classical hemorrhoidectomy and general anesthesia in 92% of stapled hemorrhoidectomy patients. However, the significantly lower postoperative pain in the stapled hemorrhoidectomy group (p < 0.001) aligns with previous studies, which attribute this to the preservation of the anoderm and perianal skin innervation. ^{12, 13} Conventional hemorrhoidectomy involves excising hemorrhoidal tissue, leading to an open wound that remains exposed to irritation from stool passage, causing prolonged discomfort. ¹¹ In contrast, stapled hemorrhoidectomy repositions rather than removes tissue. ^{12, 13} This could be due to minimized nerve disruption and inflammatory response, which may explain the shorter recovery period observed in our cohort.

In contrast, studies reported severe postoperative pain as one of the most common complications, ^{14, 16, 17} Still, it was powerfully explained by the incorrect indication for surgery or surgical technique or pre-existing comorbidities. ^{14, 17} However, other studies have shown that stapled hemorrhoidectomy reduces hospitalization length and lowers the need for postoperative analgesics. ^{18– 20}

Our study confirmed that wound infection anal stenosis were exclusively seen in the conventional hemorrhoidectomy group (p < 0.05), which are common complications known to be associated with conventional hemorrhoidectomy. ^{21, 22} This may be due to open wounds being prone to bacterial colonization, tissue fibrosis, and subsequent scarring. ²³

There were no notable distinctions between males and females in most of the postoperative complications. Interestingly, our results showed a higher rate of wound infections in females (p = 0.02) and anal stenosis in males (p = 0.004). The reason for this disparity is unclear but may be linked to anatomical variations in pelvic floor structure, wound healing response, and hormonal influences.

In our study, the mean surgical duration was 28.1 ± 11.72 minutes in the classical group and 29.3 ± 7.82 minutes in the stapled group, with significantly longer times in females (P < 0.001). Similarly, there was no significant difference in operative time (P = 0.082) or blood loss (P = 0.117), but shorter hospital stays in the stapled group (P < 0.001) (19). Conversely, Toppo et al. (2023) found shorter operative times for stapled (28.71 ± 7.25 min) vs. open hemorrhoidectomy (36.51 ± 9.16 min) ²⁴ gender disparity in our classical group underscores the importance of considering patient demographics when evaluating surgical outcomes.

Although the stapled hemorrhoidectomy technique is generally considered safer with a lower complication rate, It has been linked to a higher chance of incontinence and higher recurrence rates, as confirmed by previous studies. ^{19, 25, 26} This suggests that while the stapled technique may offer short-term benefits in terms of safety, long-term outcomes should be carefully considered, particularly in high-risk populations. A national study, for instance, found that advanced age combined with comorbidities significantly increased postoperative risks in hemorrhoidectomy patients. ²⁷ Further, a study linked complications like pain, bleeding, and stricture to pre-existing conditions, highlighting the need for careful patient assessment. ¹⁷

This study demonstrates that stapled hemorrhoidectomy is better than conventional hemorrhoidectomy in that it causes less postoperative pain, fewer complications, and faster recovery. The high recurrence rate is problematic. These findings suggest that surgical management should be tailored based on disease severity and patient preference. Further studies with more extensive series and longer follow-ups are required to validate these observations and guide the optimal surgical treatment for hemorrhoidal disease.

Ethical approval was taken from the “Research Unite at Karbala Health Directorate” in February 2025. No approval number was provided. Patient confidentiality was maintained throughout the study. This study was conducted in accordance with the ethical standards of the Declaration of Helsinki.

Written informed consent was obtained from each patient at time of data collection.

This retrospective study has not been preregistered at any site previously, as retrospective registration is not permitted.