Haemorrhoidal disease is one of the most common benign anorectal conditions, with a lifetime risk of up to 39% in the general population (1). Among the available surgical options, the Milligan & Morgan three-pedicle haemorrhoidectomy remains the gold standard for advanced (Goligher grade III–IV) or recurrent disease, providing durable symptom relief and low recurrence rates (2). However, this technique is also associated with significant postoperative morbidity, including pain, bleeding, urinary retention, and delayed functional recovery, factors that have traditionally limited its suitability for outpatient care (3).

Until the early 2010s, three-pedicle haemorrhoidectomy was performed exclusively as an inpatient procedure in most French institutions, including ours. Concerns over pain during the first bowel movement, bleeding risk, and urological complications largely dictated this cautious approach. A pivotal moment came in 2011 with the publication of national recommendations by the French Society of Digestive Surgery, which endorsed the feasibility and safety of performing excisional haemorrhoidectomy in an ambulatory setting (4). At the same time, the French Regional Health Agency (ARS) initiated a strong policy encouraging the development of ambulatory surgery across specialties.

In 2014, our team contributed to the development of national recommendations by the French Society of Coloproctology (SNFCP) supporting outpatient care for selected proctologic procedures, laying the foundation for institutional change (5). Consequently, in 2015 we began offering outpatient haemorrhoidectomy, supported by the implementation of a dedicated multimodal pain-management protocol. This included a preoperative nurse consultation, early scheduling to allow extended postoperative monitoring if needed, preoperative paracetamol, intraoperative pudendal nerve block with ropivacaine (6), routine intraoperative nonsteroidal anti-inflammatory drugs (NSAIDs), and systematic postoperative prescription of paracetamol, tramadol, and paracetamol–codeine. In parallel, we established a structured follow-up system to reassure patients and detect early complications (7, 8). A first prospective evaluation of this strategy, published in 2017, showed high satisfaction and acceptable complication rates in the initial cohort of 50 outpatient haemorrhoidectomy patients (9).

Building on these findings, this study aims to evaluate patient satisfaction with outpatient three-pedicle haemorrhoidectomy and to identify key factors, particularly those related to quality of information and organisational structure, that influence perception.

During the 12-month study period, a total of 392 patients underwent three-pedicle haemorrhoidectomy, of whom 292 (74%) were operated on in the outpatient setting. Two patients refused to have their data processed and 176 patients (60%) completed the satisfaction questionnaire. The mean age was 52 ± 12 years, and 64% of respondents were male (Table 1).

Our study demonstrates that outpatient three-pedicle haemorrhoidectomy is both feasible and well tolerated by the vast majority of patients when integrated into a structured, multidisciplinary perioperative care pathway. We observed this among a typical population of patients with haemorrhoidal disease, which is particularly interesting given that one might assume that satisfied patients would not have seen fit to respond to the questionnaire we sent them. Furthermore, institutional data showed an increase in the proportion of haemorrhoidectomies performed on an outpatient basis. From 0% in 2014, this figure rose progressively to 95% by 2025, reflecting the structured implementation of multimodal pain management and organisational optimization in our department for these patients. This is particularly noteworthy given the long-standing perception of the Milligan-Morgan three-pedicle haemorrhoidectomy as too painful or risky for ambulatory settings. Previous literature has documented concerns related to postoperative pain, urinary retention, and secondary bleeding as barriers to same-day discharge. Our findings support more recent evidence that, when carefully implemented, outpatient excisional haemorrhoidectomy can be performed without increased morbidity or a decline in patient satisfaction (9, 12–14).

Pain management remains a cornerstone of this transformation. Our institutional multimodal analgesic protocol, combining preoperative education, pre-emptive paracetamol, intraoperative pudendal nerve block with ropivacaine, intra- and perioperative NSAIDs, and postoperative prescriptions, enabled same-day discharge with acceptable pain control and low readmission rates. These findings align with high-level evidence showing that pudendal nerve blocks significantly reduce early postoperative pain and opioid consumption, while perioperative NSAIDs contribute to overall analgesic effectiveness (6, 15–17). Importantly, this approach aligns with enhanced recovery after surgery (ERAS) principles, which emphasise multimodal analgesia and early mobilisation (18).

A distinctive element of our study lies in the detailed analysis of patient satisfaction determinants. Multivariate modelling revealed that insufficient preoperative explanations, whether by the surgeon or the anaesthetist, were independent predictors of dissatisfaction. These findings mirror prospective studies in colorectal and general surgery, which consistently report that clear expectation-setting, comprehensive perioperative counselling, and accessible postoperative contact points improve satisfaction and reduce unplanned consultations (7, 19–21). Interestingly, while complications occurred in nearly one-third of our cohort, they were not the strongest predictor of dissatisfaction. This suggests that patients are more willing to accept complications when they feel adequately informed and supported.

A substantial proportion of patients contacted healthcare providers or returned for unscheduled consultations after discharge. These events likely reflect a combination of expected reassurance-seeking behaviour and symptom-related concerns rather than severe postoperative morbidity, particularly within the context of the French healthcare system. Within an outpatient care model, such contacts were anticipated and facilitated through structured accessibility to nursing and surgical teams, which may represent a strength of the pathway rather than a failure of outpatient management.

Among postoperative complications, faecal impaction was particularly distressing and often triggered emergency consultations. This observation is in line with smaller series and ambulatory proctology audits reporting that constipation-related events, although rarely serious, are disproportionately impactful on patient experience (22–24). Structured postoperative dietary guidance, early laxative prescription, and proactive follow-up may mitigate these events.

Another notable finding was the influence of sex on patient perceptions. Female patients were significantly more likely to report that they would not choose outpatient care again. While the reasons for this are multifactorial, hypotheses include differing pain perception, greater preoperative anxiety, or different postoperative social support structures. The literature on gender differences in surgical satisfaction is mixed, with some studies showing no association and others suggesting that women report lower satisfaction in high-discomfort procedures (25, 26). This highlights the need for tailored preoperative counselling that addresses patient-specific concerns.

From an institutional standpoint, our experience illustrates the role of organisation and culture in driving sustainable change. Since the introduction of our dedicated outpatient pathway in 2015, supported by clear analgesic protocols, coordinated scheduling, and structured follow-up, outpatient rates have risen steadily to reach 95% in 2025. This transition was gradual, relying on iterative protocol refinements, interdisciplinary engagement, and continuous monitoring of outcomes. Crucially, this shift did not result in increased postoperative morbidity or a decline in satisfaction, confirming that cultural change can be achieved without compromising safety. Our findings have broader implications for other centres aiming to expand their ambulatory proctology services. They underline that success is not solely dependent on surgical technique but requires investment in preoperative patient education, multidisciplinary coordination, and robust postoperative support systems. These elements are increasingly recognised in surgical quality frameworks as being as important as intraoperative performance.

Our study has some limitations. Its retrospective design limits causal inference and is susceptible to information bias. Additionally, this is a single-centre study conducted in the largest and most active proctology unit in France, which may limit external generalisability. This work was also carried out during the first wave of COVID-19; in this particular context, it did not modify our hospitalisation procedures, and it is difficult to say whether it had any impact on patients' feelings about having their surgery performed on an outpatient basis. Furthermore, postoperative complications were not classified using a standardized severity grading system (such as Clavien–Dindo), which limits the precise assessment of their clinical impact and comparability with other series. On the other hand, the size of the cohort, the maturity of the outpatient pathway, and the reproducibility of the organisational model strengthen the relevance of our findings for similar high-volume centres. Finally, although economic outcomes represent an important dimension of ambulatory surgery, the present study was not designed to assess costs or resource utilisation, which were therefore not analysed.