BACKGROUND Doppler-guided hemorrhoidal artery ligation is a minimally invasive technique for the treatment of symptomatic hemorrhoids that has been applied successfully for grade II and III hemorrhoids but is less effective for grade IV hemorrhoids. Development of a special proctoscope enabled the combination of hemorrhoidal artery ligation with transanal rectoanal repair (mucopexy), which serves to lift and then secure the protruding hemorrhoids in place. OBJECTIVE The purpose of this study was to describe our experience with this combined procedure in the treatment of grade IV hemorrhoids. METHODS Prospective observational study. METHODS Outpatient colorectal surgery unit. METHODS Consecutive patients with grade IV hemorrhoids treated from April 2006 to December 2008. METHODS Hemorrhoidal artery ligation-rectoanal repair. METHODS Operating time, number of ligations, number of mucopexies and associated procedures, and postoperative symptoms were recorded. Pain was graded on a visual analog scale. Follow-up was at 2, 6, and 12 months after surgery, and then annually. RESULTS A total of 100 consecutive patients (64 women, 36 men) with grade IV hemorrhoids were included. Preoperative symptoms were bleeding in 80 and pain in 71 patients; 19 patients had undergone previous surgical treatment for the disease. The mean operative time was 35 (range, 17-60) minutes, with a mean of 9 (range, 4-14) ligations placed per patient. Eighty-four patients were discharged on the day of the operation. Nine patients developed early postoperative complications: pain in 6, bleeding in 4, dyschezia in 1, and thrombosis of residual hemorrhoids in 3. Late complications occurred in 4 patients and were managed conservatively. Recurrence was observed in 9 patients (9%), with a mean follow-up of 34 (range, 14-42) months. CONCLUSIONS The 2 main weaknesses of the study were the lack of very long-term follow-up and the absence of a comparison with hemorrhoidectomy or hemorrhoidopexy. CONCLUSIONS Doppler-guided hemorrhoidal artery ligation with rectoanal repair is safe, easy to perform, and should be considered as an effective option for the treatment of grade IV hemorrhoids.