Do Ligasure (electrosurgical instrument) hemorrhoidectomy, fistulotomy, and fissurectomy cause anal sphincter injuries?

Risk of Sphincter Injuries with Ligasure Hemorrhoidectomy, Fistulotomy, and Fissurectomy

All three procedures carry risk of sphincter injury, but the risk varies substantially: hemorrhoidectomy (including Ligasure technique) causes sphincter defects in up to 12% of patients, fistulotomy causes virtually universal internal sphincter injury with reversal of normal anal canal pressure gradients in 89% of patients, while fissurectomy with anoplasty demonstrates the lowest risk with only 7% developing clinically significant incontinence. 1, 2, 3

Hemorrhoidectomy (Including Ligasure Technique)

Sphincter Injury Risk Profile

• Sphincter defects occur in up to 12% of patients after hemorrhoidectomy, documented by ultrasonography and anal manometry, regardless of the specific technique used (conventional scissors, diathermy, or Ligasure). 1

• The American Gastroenterological Association reports that incontinence rates range from 2-12% following hemorrhoidectomy, with the primary mechanism being excessive retraction and extensive dilation of the anal canal during the procedure. 1

• Ligasure (bipolar diathermy device) showed no significant difference in pain scores compared to conventional techniques in randomized trials, but the guideline does not indicate that it reduces sphincter injury rates compared to other hemorrhoidectomy methods. 1

Mechanism of Injury

• The use of excessive retraction with extensive dilation of the anal canal is probably responsible for sphincter injury and incontinence following hemorrhoidectomy. 1

• Smooth muscle fibers (potentially from the internal anal sphincter) have been detected in hemorrhoidectomy specimens, and fragmentation of the internal sphincter was noted in 14% of patients in histologic studies. 1

Critical Pitfall to Avoid

• Never perform lateral internal sphincterotomy as an adjunct to hemorrhoidectomy, as randomized studies have shown an increase in incontinence rather than benefit. 1

• Anal dilatation should never be performed due to a 52% incontinence rate at 17-year follow-up and documented sphincter injuries. 1, 4

Fistulotomy

Sphincter Injury Risk Profile

• Fistulotomy causes the highest rate of sphincter injury among these three procedures, with incontinence after fistulotomy characterized by virtually universal presence of internal sphincter injury. 2

• The internal sphincter is almost universally injured in a pattern specific to the underlying procedure, with the distal high-pressure zone typically affected. 2

• Reversal of the normal resting pressure gradient of the anal canal occurs in 89% of patients following fistulotomy, indicating significant functional sphincter disruption. 2

Pattern of Injury

• One-third of patients develop a related surgical external sphincter injury from the fistulotomy procedure itself. 2

• The distal resting pressure is typically reduced, with maximum squeeze pressure remaining normal in only 52% of patients. 2

Sphincter-Sparing Alternative

• Fistulotomy with end-to-end primary sphincteroplasty (cutting the sphincter but immediately repairing it) shows a 95.8% success rate with only 11.6% developing de novo post-defecation soiling at mean 29-month follow-up. 5

• However, patients with recurrent fistula after previous fistula surgery have a 5-fold increased probability of impaired continence (relative risk 5.00,95% CI 1.45-17.27) with this technique. 5

Fissurectomy

Sphincter Injury Risk Profile

• Fissurectomy with anoplasty demonstrates the lowest sphincter injury risk, with de novo clinically significant anal incontinence (Wexner score >5) affecting only 7% of patients at 1-year follow-up. 3

• There was a nonsignificant increase in the Wexner anal incontinence score from 1/20 to 2/20 at 1 year, indicating minimal functional impact. 3

• Notably, presurgical incontinence disappeared in 15% of patients following fissurectomy, suggesting the procedure may actually improve continence in some cases. 3

Why Fissurectomy is Safer

• Fissurectomy is specifically designed as a sphincter-sparing technique to avoid the irreversible anal incontinence risk associated with lateral internal sphincterotomy. 6, 3

• The technique achieves 100% healing rate at median 7.5 weeks with no recurrences at 1 year, demonstrating that sphincter preservation does not compromise efficacy. 3

Comparison to Sphincterotomy

• Lateral internal sphincterotomy (LIS) carries risk of irreversible anal incontinence, which is why fissurectomy combined with anoplasty is preferred in some countries despite LIS being the gold standard in English-speaking nations. 6

Clinical Algorithm for Minimizing Sphincter Injury

For hemorrhoidectomy:

• Avoid excessive retraction and extensive anal canal dilation during the procedure 1
• Never add lateral internal sphincterotomy as an adjunct 1
• Never perform anal dilatation 1

For fistula treatment:

• Consider sphincter-sparing procedures (LIFT, fistula plug) for complex fistulae involving significant sphincter 7
• If fistulotomy is necessary, consider immediate primary sphincteroplasty to reduce incontinence risk 5
• Exercise extreme caution in patients with prior fistula surgery (5-fold increased incontinence risk) 5

For fissure treatment:

• Fissurectomy with anoplasty should be the preferred surgical approach over lateral internal sphincterotomy when sphincter preservation is a priority 3
• Reserve sphincterotomy for cases where fissurectomy has failed 6