The aim of this study was to compare ligation-anopexy and pile suture for treatment of 3ed 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 I underwent ligation-anopexy and group II underwent pile suture. Operating time, post operative pain, time off work, 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 ±11.2 years. The operative time for group I was 18.3 ±4.12 minutes versus 22.8 ±7.1 minutes in group II. The mean follow up for group I was 13.73 ±2.12 months while for group II it was14.21 ±2.26 months. Follow up showed that mean visual analog scale for pain in pile suture group was significantly higher at 1st post-operative day (2.43 ±0.94 vs 4.97 ±1.65) and at the 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 occurred in four patients in group II, Temporary anal spasm occurred in three patients in group I and two patients in 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.