Excisional hemorrhoidectomy is often referred to as the “gold standard” for the treatment of hemorrhoids when it comes to control of symptoms [8]. A large retrospective case series of 693 patients who underwent EH (Ferguson closed technique) for grade III and IV hemorrhoids reported a recurrence rate of 1 % and 3 % at 1 and 2 years [9]. When compared to other surgical techniques such as PPH, a meta-analysis demonstrated that patients undergoing EH were significantly less likely to complain of ongoing hemorrhoidal symptoms than those who underwent PPH (6 trials, 388 patients, OR 0.52, 95 % CI, 0.3–0.91; p = 0.02) [10]. DGHAL has also been shown to have a high recurrence rate with 31 % of patients having symptoms within the subsequent 5 years [11]. Conversely, a recent clinical trial comparing EH to DGHAL with mucopexy demonstrated no difference in symptoms including pain and bleeding at 2 years post-procedure [12].

RBL has also been shown to control symptoms for many individuals, but to a lesser extent. A retrospective study of 701 patients showed an overall success rate (alleviation of symptoms) of 70 % [13]. When only patients with grade III hemorrhoids were included, the success rate decreased to 59 %. Three studies were identified that compared outcomes of EH directly to RBL. Murie et al. evaluated 100 patients with either grade II or III hemorrhoids and randomized them to EH or RBL [14]. Of the 56 patients with grade III hemorrhoids, 97 % of patients undergoing EH had no symptoms of prolapse at 1 year compared to 70 % in the RBL group (p = 0.04). When adding in the patients with grade II hemorrhoids, 86 % of EH patients had no bleeding at 1 year compared to 74 % in the RBL group (p = 0.28).

Lewis et al. compared EH with anal dilatation, RBL and cryotherapy [15]. Of the 26 patients undergoing EH, 100 % had fewer symptoms and 65 % had no symptoms at 1 year, as opposed to 67 % and 13 % for RBL. In the long-term (6 months–5 years) 100 % of EH patients had fewer symptoms and 86 % had no symptoms. Only 40 % of RBL patients had fewer symptoms and 23 % were symptom free. No patients in the EH group required further treatment compared to 80 % in the RBL group.

A systematic review of the two aforementioned trials demonstrated greater efficacy for EH over RBL for the treatment of grade III hemorrhoids (2 trials, 116 patients, RR 1.23, 95 % CI 1.0–1.5, p = 0.01). However, this difference was not seen with grade II hemorrhoids (1 trial, 32 patients, RR 1.07, 95 % CI 0.9–1.2, p = 0.32) [16].

A 2011 study randomized 100 patients with grade II/III hemorrhoids to EH or RBL [17]. Of the grade III patients (38 patients), 12.5 % of the EH group experienced recurrent prolapse symptoms after 6 months compared to 50 % in the RBL group. Although no statistical analysis was included in the study, post-hoc analysis reveals this is a statistically significant finding (p = 0.03). Consistent with the systematic review is the finding that RBL leads to better results with grade II hemorrhoids compared to grade III (77 % vs. 50 % without prolapse at 6 months, respectively).

In a comparison of PPH with RBL, there was a significant decrease in the percentage of patients experiencing the symptoms of bleeding from hemorrhoids at 2-weeks post-procedure in the PPH group (27 % vs. 68 %, p < 0.005). This difference was not seen for prolapse, pruritis, or wound discharge [18]. By 2 months, there was no difference in symptoms experienced in either group.

We did not identify any published results comparing DGHAL to RBL. However, there is currently a multi-center randomized controlled trial that has been completed comparing these two interventions for grade II and III hemorrhoids, with results pending [19].

A systematic review of trials comparing EH to RBL for grade II/III hemorrhoids (including Murie and Lewis, et al.) demonstrated significantly more patients that underwent EH experienced post-operative pain (3 trials, 212 patients, RR 1.94, 95 % CI 1.62–2.33, p < 0.001) [16]. There was no statistically significant difference in other postoperative complications such as urinary retention, hemorrhage, or anal stenosis. A meta-analysis of the same three trials revealed similar results [5]. Gagloo et al. found 100 % of patients undergoing EH required postoperative analgesia compared to 20 % of patients after RBL [17]. Severe pain from RBL may result from placement of the band below the dentate line, which precludes the banding of external hemorrhoids [3].

While EH has been repeatedly shown to be associated with more postoperative pain than RBL, a recent Cochrane Review has demonstrated a significant decrease in pain when hemorrhoidectomy is performed with a LigaSure device [20]. Pain scores on the first post-operative day showed a WMD of −2.07 (10 studies, 835 patients, CI −2.77−1.38). There was no relevant difference in other postoperative complications. A study comparing DGHAL with mucopexy to EH demonstrated no significant difference in post-operative pain scores up to 2 weeks [12].

In a comparison of PPH with RBL, PPH was associated with a higher maximal pain score at discharge (5 vs 2, p < 0.001) and at 2 weeks (5 vs 0, p < 0.001). However, by 2 months, no patient in either group complained of pain. There was no difference in other complications such as urinary retention, bleeding, anal stenosis, or change in continence. However, his study was not sufficiently powered for these endpoints [18].