The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on circular stapled haemorrhoidectomy.


Internal haemorrhoids develop when cushions of vascular tissue in the anus undergo pathological change. These cushions have an important role in maintaining continence as they function, along with the internal anal sphincter, to allow the complete closure of the anal canal. Haemorrhoids may cause bleeding, faecal soiling, itching, and occasionally pain. The prevalence of haemorrhoids is estimated at between 4% and 34%.

Circular stapled rectal haemorrhoidectomy reduces the size of internal haemorrhoids by interrupting their blood supply, reducing the available rectal mucosa with the potential to prolapse. Whereas conventional surgical haemorrhoidectomy involves excision of haemorrhoidal tissue, anoderm and perianal skin, stapled haemorrhoidectomy simply excises an annulus of rectal mucosa above the haemorrhoids.

After dilatation of the anal canal, a purse string suture is placed four centimetres above the dentate line. Subsequently, a circular stapler is introduced transanally. The anvil of the device is positioned proximal to the purse-string and the suture is tied down on to the anvil. Retraction of the suture pulls the attached rectal mucosa into the stapler. Closure of the anvil and firing of the stapler simultaneously excises a ring of mucosa proximal to the haemorrhoid(s), thus interrupting the blood supply, but maintaining continuity of the rectal mucosa.

Coding and clinical classification codes for this guidance.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.