The aim of this study is to compare ligation-anopexy and pile suture for treatment of 3rd and 4th degree hemorrhoidal disease. Patients and methods: 60 patients (28 females) complaining of symptoms of advanced hemorrhoidal disease were included in the study. Patients were divided into two groups, group A underwent ligation-anopexy and group B underwent pile suture. Operating time, post operative pain, time offwork, complications and recurrence of symptoms were analyzed. Results: Mean age in group I was 42.6 ±14.04 while in group II was 40.8±11.17 years.  The operative time for group I was 18.3 ±4.12 minutes versus 22.83 ±7.05 group II and mean follow up for group I was 13.73 ±2.12 while for group!! it was 14.21 ±2.26 months. Follow up showed that mean VAS pain in pile suture group was significantly higher at 1st post-operative day (2.43 ±0.94 vs 4.97 ±1.65) and atthe end of first week (0.43 ±0.63 vs1.07 ±1.17). Mean time needed for the patients to return to normal activity was slightly lower  in group I (5.3±  1.54 days) than in group II (6.90 ±2.14 days). Post-operative  complications  included thrombosis which occured in 4 patients of group II, temporary  anal spasm occured in three patients of group I and two patients of group II. Skin tags were the most common complication in both groups. The recurrence of symptoms was significantly higher after pile suture (16.7%) than after ligation­ anopexy (3.3%). Conclusion:  Anopexy  may  improve  complications  and  recurrence  rate  when  added  to ligation for treatment of advanced hemorrhoidal disease.