Background: Grade III hemorrhoidal disease may require operative management, particularly when associated with concomitant anorectal pathology. Doppler-guided hemorrhoidal artery ligation (HAL/THD) reduces arterial inflow, whereas excisional hemorrhoidectomy (Milligan–Morgan) remains a reference procedure for advanced prolapse and significant external components [1]. Case presentation: A 37-year-old patient with symptomatic grade III internal hemorrhoids and a chronic posterior anal fissure underwent a combined procedure: Doppler-guided HAL with figure-of-eight sutures at the principal pedicles (3, 5, 7, and 11 o’clock), followed by excisional hemorrhoidectomy of three piles using a Milligan–Morgan approach, with fissure excision included in the specimen. Intra-operative photographs illustrate exposure, disease appearance, and immediate postoperative aspect (Figures 1–2). Conclusion: This case highlights a tailored combined strategy in selected patients with grade III hemorrhoids and associated chronic fissure, aiming to address both vascular inflow and advanced prolapse/external components [1].