Haemorrhoidectomy (HE) and rubber band ligation (RBL) are equally effective especially in second-degree haemorrhoids. However, RBL is considered the first-line treatment in second-degree haemorrhoids since it is an outpatient procedure, it is cost effective, and takes the pressure off the surgical waiting list. Studies to evaluate comparative results of (RBL) and haemorrhoidectomy for second- or third-degree primary haemorrhoids are numerous. The diagnosis of haemorrhoids is primarily based on the proctoscopic examination. Each patient should subjected to sigmoidoscopy to exclude other lesion higher up in rectosigmoid. Although RBL is not as effective as haemorrhoidectomy in third-degree haemorrhoid, it does improve bleeding and prolapse and is highly recommended for patients who are unfit for surgery or have concurrent disease that contraindicates anaesthesia. RBL should be considered as the first-line treatment for second-degree haemorrhoid. However, in the third-degree haemorrhoids, haemorrhoidectomy achieves better results, and RBL is recommend as the first-line treatment for those patients in whom there is contraindication for surgery or anaesthesia.
For grade 3 haemorrhoids (prolapse requiring manual reduction) no prolapse was reported in 50 % of patients following RBL compared with 87.5 % following haemorrhoidectomy, improvement in prolapse following RBL in 28 % compare to 12.5 % after haemorrhoidectomy and no change in 21 % in RBL group compared to 0 % in Haemorrhoidectomy group. These findings suggest that RBL is not as effective as haemorrhoidectomy in the treatment of large haemorrhoid requiring manual reduction (grade 3). Lewis et al.  report that cryotherapy and RBL are unsuitable for treatment of large prolapsing haemorrhoids; however, they may be considered as cost-effective and acceptable treatment in short term, but in long term some patients will develop recurrence, requiring haemorrhoidectomy.
In our series, patient assessment of treatment modality showed that 64 % reported RBL as excellent modality compared with 70 % following haemorrhoidectomy, 20 % were moderately satisfied with RBL compared with 20 % following haemorrhoidectomy and 16 % reported no improvement in RBL group compared with 10 % following haemorrhoidectomy. These findings correlate well with those of Murie et al.  and Bayer et al. . However, Cheng et al.  reported that 96 % patients were cured at 1 year following haemorrhoidectomy compared with 83 % following RBL. Almost similar findings were observed by Steinberg  and MacRae and Mcleod .
In our study, 100 % patients required postoperative analgesia following haemorrhoidectomy compared with 20 % patients requiring analgesia following RBL, which correlate well with the study of O’Regan et al.  and Wienert .
RBL is associated with fever complications and less pain than haemorrhoidectomy. Haemorrhoidectomy is often a painful procedure, involving a hospital stay of 5–10 days with additional time off work of 2–6 weeks. Furthermore, it is not without complications such as secondary haemorrhage, stenosis, or incontinence .
RBL is associated with fever complications and less pain than haemorrhoidectomy. Haemorrhoidectomy is often a painful procedure, involving a hospital stay of 5–10 days with additional time off work of 2–6 weeks. Furthermore, it is not without complications such as secondary haemorrhage, stenosis, or incontinence
Summary and Conclusion
· Haemorrhoidectomy and RBL are equally effective, especially in second-degree haemorrhoids; however, haemorrhoidectomy that aims to excise most of the haemorrhoid plexus of veins produces lasting results. But patients who suffer persistent and severe recurrent symptoms after RBL can be treated by further RBL.
· Haemorrhoidectomy is a painful procedure that involves hospital stay of 5–10 days with an additional time off work of 2–6 weeks and is associated with complications such as secondary haemorrhage, stenosis, or incontinence.
· RBL is safe, pain-free procedure, does not involve anaesthesia, and is an outpatient procedure. Patients report back to work soon after the procedure.
· By restoring to the policy of RBL as the first choice in second-degree haemorrhoids, many a hospital beds can be saved for more sick patients and it can take pressure off the surgical waiting lists.
· RBL, although not as effective as haemorrhoidectomy, in third-degree haemorrhoids does improve bleeding and prolapse. Hence, it is highly recommended for patients who are unfit for surgery or have concurrent disease which contraindicates anaesthesia.
We support the view that RBL should be considered the first-line treatment in second-degree haemorrhoids. However, in the third-degree haemorrhoids, haemorrhoidectomy achieves better results and RBL is recommended as the first-line of treatment for those patients in whom their is contraindication for surgery or anaesthesia.