Internal Hemorrhoid Band Ligation Technique

Updated: Nov 05, 2020
  • Author: Assaad M Soweid, MD, FACG, FASGE; Chief Editor: Vikram Kate, MBBS, PhD, MS, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, FFST(Ed), MAMS, MASCRS  more...
  • Print

Approach Considerations

Hemorrhoid band ligation (HBL) can be performed in an office setting and may not require anesthesia. [15] Technically, it can be performed in an antegrade and/or retroflexed position by using disposable single or multishot devices. [9]  An endoscope is used to grasp hemorrhoidal tissue, and elastic bands are then applied. [27] Submucosal scarring prevents subsequent hemorrhoidal tissue formation. [8]

Grade I, grade II, and select grade III internal hemorrhoids can be treated with office-based procedures such as infrared coagulation, sclerotherapy, and HBL; HBL is generally the most popular and effective office-based treatment. [4, 28] Grade III and grade IV can be treated surgically, especially if thrombosed.


Internal Hemorrhoid Banding

Once the symptomatic internal hemorrhoids have been identified, a forceps applicator can be used to apply the rubber bands down to the neck of the hemorrhoids, 5 mm above the dentate line, to avoid thrombosis. [27]

An alternative technique involves the use of an endoscopic suction ligator. [27] The bands are deployed by suction via the biopsy channel of the endoscope. That fewer treatment sessions are needed but adequate ligation is still achieved suggests the efficacy of this technique. A single-handed nonendoscopic ligating device (KilRoid, Astra Tech, AB, Molndal, Sweden) is currently used and has shown excellent results. [29]

Another available technique is the vacuum suction band ligator, [27] in which the ligator is attached to wall suction. The advantage of this technique is that it can be performed without assistance; the operator can hold the ligator to apply the rubber bands with one hand and the anoscope with the other. [29]

Traditionally, a reusable rigid banding device and an anoscope had been used. Various newer single-shot and multishot disposable devices became available for endoscopic HBL, including the Steigmann-Goff banding device (C.R. Bard, Inc, Murray Hill, NJ), CRH-O'Regan Disposable Hemorrhoid Banding System (CRH Medical Corp, Kirkland, WA), 4 Shooter (Cook Medical, Winston-Salem, NC), and Short Shot Hemorrhoidal Multiband Ligator (Cook Medical).

These ligating devices can be used to place rubber bands in the antegrade and/or retroflexed position. [9] Many experienced endoscopists prefer banding in the retroflexed position (see the images below) with a diagnostic endoscope because the dentate line is more easily identified in this position and treatments are better tolerated with the smaller-caliber endoscope.

Endoscopic view of post-banding of the internal he Endoscopic view of post-banding of the internal hemorrhoids.
Post-band ligation with retroflexed view. Post-band ligation with retroflexed view.
Grade II internal hemorrhoids Grade II internal hemorrhoids

Prolapsed internal hemorrhoids are first manually reduced and then visualized via the anoscope or endoscope. Protruding tissue is gently drawn into the banding device with a forceps (traditional device) or with suction (much as in variceal band ligation). If a patient experiences pain with suctioning, the band release should not be performed at that location, and an area farther above the dentate line should then be identified and resuctioned.

An average of three or four bands are placed during each session. Treatments are repeated at 4- to 6-week intervals until symptoms are controlled and all internal hemorrhoid segments are reduced to grade I or 0. Ulcerations are usually noted at the site of the previous band ligation after the banded hemorrhoidal tissue sloughs off.



Pain is the most frequent complication following HBL. [30] It has been reported in approximately 8% of patients and results from anal spasm or misapplication of bands below the dentate line. [31]  

Other potential complications include the following [12] :

  • Hemorrhoidal thrombosis (hemorrhoids distal to the rubber band ligation site)
  • Delayed hemorrhage (due to band dislodgment within 2-4 days or ulceration around 5-7 days after the procedure)
  • Localized infection or abscess (manifesting as persistent anorectal pain, fever, or foul-smelling rectal drainage)
  • Sepsis
  • Urinary retention