What is the procedure and protocol for a patient undergoing Laser Hemorrhoidopexy (LHP) for hemorrhoid treatment?

Laser Hemorrhoidoplasty (LHP) Procedure and Protocol

Laser Entry Point and Technique

The laser fiber should be inserted submucosally into the hemorrhoidal tissue at the apex of each hemorrhoidal column, positioned approximately 2-3 cm proximal to the dentate line, using a 1470-nm diode laser with energy delivery of up to 250 J per hemorrhoid. 1

Specific Technical Parameters

• Laser specifications: Use a 1470-nm diode laser with a 1.85 mm optical fiber for the procedure 2
• Power settings: Set laser power at 8-10 W with 1-3 second pulses 2
• Energy delivery: Deliver up to 250 J of energy per individual hemorrhoid 1
• Tissue penetration depth: Each laser application creates a coagulation zone of approximately 4 mm in depth 2
• Spacing between applications: Initiate subsequent coagulation points approximately 5 mm from the previous application to avoid overlapping thermal injury 2

Entry Point Location

• Position the fiber insertion point at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerve afferents are absent above the anal transition zone 3
• The procedure is performed circumferentially, treating all hemorrhoidal columns in a single session 1
• Insert the fiber submucosally into the hemorrhoidal tissue, targeting the terminal branches of hemorrhoidal arteries 4

Patient Selection Criteria

LHP is indicated for symptomatic grade II-III hemorrhoids with minimal to mild rectal mucosal prolapse. 5, 6

• Grade II-III hemorrhoids are the ideal candidates for this procedure 5, 1, 6
• Patients with grade IV hemorrhoids or mixed internal/external disease should undergo conventional excisional hemorrhoidectomy instead, which has a recurrence rate of only 2-10% 3
• Thrombosed external hemorrhoids presenting within 72 hours require surgical excision under local anesthesia rather than LHP 3

Preoperative Preparation

• Perform anoscopy to confirm hemorrhoid grade and rule out other anorectal pathology 3
• Never attribute anemia or significant bleeding to hemorrhoids without colonoscopy, as anemia from hemorrhoids is rare (0.5 patients/100,000 population) 3
• Verify that anal pain is actually from hemorrhoids, as uncomplicated internal hemorrhoids generally do not cause severe pain 7
• The procedure can be performed under local anesthesia in an ambulatory setting 6

Operative Technique Details

• Mean operative time: 15-28 minutes 4, 1
• Average blood loss: 6.42 ml 4
• The procedure involves no cutting or excision of tissue 4
• Laser energy causes shrinkage of hemorrhoidal piles through thermal coagulation of terminal hemorrhoidal artery branches 4

Postoperative Management Protocol

Immediate Postoperative Period (First 24 Hours)

• Mean hospital stay: 18-22 hours 4
• Postoperative pain scores (VAS) are extremely low:
  • At 12 hours: mean 2-3.8 4, 5
  • At 24 hours: mean 2.6 4
• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for symptomatic relief 7
• Prescribe bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to prevent straining 7

Early Recovery (First Week)

• Patients return to daily activity within 2-15 days, significantly faster than conventional hemorrhoidectomy (30 days) 5, 1
• Pain at 1 week: mean VAS 0.46 4
• Early complication rate: 2.4% within first week 4
• No special anal hygienic measures required 5

Long-Term Follow-Up

• Recurrence rates: 0-10% at 6-12 months follow-up 5, 1, 6
• Symptom resolution (pain, bleeding, pruritus) occurs in 75-80% of patients 6
• Complete downgrading of hemorrhoid size typically occurs 3-7 months post-procedure 6

Critical Advantages Over Alternative Procedures

LHP demonstrates significantly less postoperative pain and faster recovery compared to both stapled hemorrhoidopexy and excisional hemorrhoidectomy, though it has a higher recurrence rate (10%) than excisional hemorrhoidectomy (0%). 1

• Compared to stapled hemorrhoidopexy: Less pain (VAS 3.8 vs 6.81 at 12 hours), shorter hospital stay (18 vs 28 hours), fewer complications (2.4% vs 16.7%) 4
• Compared to excisional hemorrhoidectomy: Less pain, faster return to work (15 vs 30 days), but higher recurrence rate (10% vs 0%) 1
• Compared to sutured mucopexy: Lower recurrence rate (10% vs 22%), faster return to activity (15 vs 22 days) 1

Important Contraindications and Pitfalls

• Do not use LHP for grade IV hemorrhoids - these require conventional excisional hemorrhoidectomy 3
• Avoid LHP for acutely thrombosed or incarcerated hemorrhoids - these require either excision or hemorrhoidectomy 3
• Never perform LHP on immunocompromised patients with acute thrombosed hemorrhoids due to risk of necrotizing pelvic sepsis 3
• Do not use this technique for mixed internal/external hemorrhoids with significant external component - surgical hemorrhoidectomy is indicated 3