<p>This study aimed to evaluate the efficacy and the safety of Doppler-guided hemorrhoid artery ligation (DG-HAL) and tissue-selecting technique (TST) in patients with grade III/IV hemorrhoids. We conducted a retrospective analysis of 251 patients with grade III/IV hemorrhoids between January 2019 and January 2021. Among them, 119 patients had received TST, and the remaining 132 patients received DG-HAL. We collected and compared clinical characteristics of both groups, including post-operative visual analog scale (VAS) for pain, post-operative bleeding, post-operative defecation, urinary retention, and recurrence rate (prolapse and bleeding). The VAS pain score of the first post-operative defecation and at the post-operative day (POD)1 and 2 for the DG-HAL group was lower than those for the TST group (<i>P</i> = 0.006 and <i>P</i> = 0.029). The incidence of post-operative complications (including bleeding, urinary retention and sensation of rectal tenesmus) in the DG-HAL group was lower than that in the TST group (<i>P</i> = 0.021, <i>P</i> = 0.035 and <i>P</i> = 0.047). At follow-up by telephone or outpatient 3&#xa0;years after surgery, the recurrence rate (prolapse) was lower in the TST group than in the DG-HAL group (<i>P</i> = 0.013). Subgroup analysis showed a higher prolapse recurrence rate in grade IV patients than grade III patients after DG-HAL (<i>P</i> = 0.013). DG-HAL had fewer complications, lower bleeding rates, and less early post-operative pain but showed a higher recurrence rate than TST at the 3-year follow-up, especially in grade IV patients.</p>