Currently, multiple operations are available for the treat-ment of symptomatic haemorrhoids, and no method isuniversally accepted as superior to the others. The opera-tive approach is often tailored to the individual patientdepending on the surgeon’s preference and experience.Ideally, the surgical procedure for the treatment of haem-orrhoids should be a technique able to provide long-termrelief of symptoms whilst being economical, safe, easy toperform and well tolerated by patients. In recent years, wehave seen a shift towards less invasive procedures mostlyaimed at avoiding or minimizing postoperative pain. Newtechniques such as stapled haemorrhoidopexy (SH) anddoppler-guided haemorrhoidal artery ligation (DGHAL)also known as transanal haemorrhoidal artery ligation(THD) have now become widely accepted for the treatmentof symptomatic haemorrhoids. Both SH and DGHAL havethe advantage of not leaving wounds in the anal canalwhich improves convalescence by reducing postoperativediscomfort. The expected reduction in postoperative painmakes these procedures appealing to the patients, andindeed, their short-term benefits compared to conventionalsurgery have been clearly demonstrated in prospectivecomparative trials and/or observational studies [1–3].However, the real innovation introduced by these proce-dures is the fact that they aim to treat the symptoms whilstnot excising the diseased tissue, as in conventional haem-orrhoidectomy (CH), but by restoring the normal anatomyand correcting the physiology of the haemorrhoidal plexus.This means that the long-term benefits are potentially byfar more important than the short-term ones. With that inmind, the question is whether they actually work andwhether any of these new modalities of treatment issuperior to the other. In this issue of techniques in colo-proctology, Avital et al. [4] showed that pain is signifi-cantly lower in the DGHAL group during the first 24 h, atthe time of the first bowel movement, and at 1 week afterthe operation. However, in this study, a mucopexy inassociation with the DGHAL was never performed. Itcould be argued that performing a plication of the rectalmucosa may improve outcomes but may also lead to morepostoperative pain. Two different prospective trials com-paring SH to THD with rectal mucopexy as standard haveshown less pain and earlier recovery following the THDprocedure [5, 6]. However, reduced postoperative painalthough important is not a measure of success for whichsafety and effectiveness remain the main benchmarks. Todate, there are only a very few other studies comparing thetwo techniques directly and only one reporting results at arelatively long follow-up. Based on the evidence availablefrom comparative studies, these procedures have demon-strated to be equally effective. In Avital et al.’s [4] study,18% of patients in the DGHAL group suffered fromongoing haemorrhoidal symptoms whilst only 3% of thepatients in the SH group did. This reflected in a highernumber of patients requiring further intervention in theDGHAL group. However, once again it could be arguedthat the patients in the DGHAL group did not receive anymucopexy and this may have certainly influenced theoutcome. Indeed, in the prospective trials where rectalmucopexy was used as a standard part of the THD proce-dure, the improvement of symptoms was similar in bothgroups [5, 6]. In the few comparative studies available, onemajor complication was reported following SH whilst nonewere encountered in the DGHAL patients [6]. Outsidethese studies, a significant number of major complications