What are the advantages and risks of Laser Hemorrhoidectomy + Laser Fissurectomy versus traditional methods for a patient with Grade 2 hemorrhoids and chronic anal fissure, particularly considering the risk of fecal incontinence and suitability for a patient with tight sphincter tone?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 4, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Laser Fissurectomy vs. Traditional Lateral Internal Sphincterotomy for Chronic Anal Fissure with Grade 2 Hemorrhoids

For a patient with Grade 2 hemorrhoids and chronic anal fissure, traditional lateral internal sphincterotomy (LIS) combined with conventional hemorrhoidectomy remains the gold standard with superior long-term outcomes, despite laser techniques offering less immediate postoperative pain. 1, 2

Advantages of Laser Fissurectomy Over Traditional LIS

Pain and Recovery Profile

  • Laser fissurectomy demonstrates significantly lower postoperative pain, with 74% of patients reporting minimal pain (VAS 0-1) at day 1, increasing to 100% by day 60, compared to traditional sphincterotomy which typically requires narcotic analgesics for 2-4 weeks 3, 2
  • Pain reduction is progressive and substantial with laser therapy, decreasing from a mean VAS score of 4.1 preoperatively to 0.1 by day 60 postoperatively 3
  • Laser procedures are performed on an outpatient basis with local anesthesia, avoiding the need for general anesthesia required by traditional techniques 3, 4

Tissue Preservation Benefits

  • Laser fissurectomy causes less aggression to the anoderm and anal canal mucosa compared to conventional excision, resulting in lower morbidity 5
  • The technique removes fibrotic and granulation tissue while stimulating submucosal regeneration through fractional laser mode, promoting natural healing 4

Success Rates and Recurrence Rates

Laser Fissurectomy Outcomes

  • Short-term success is excellent with 92% of fissures healing completely within 4 weeks in combined procedures 6
  • However, long-term data reveals significant limitations: laser hemorrhoidoplasty (which would be combined with laser fissurectomy) shows a 34% recurrence rate at 5-year follow-up, with median time to recurrence of 21 months 7
  • Minor complications occur in 7.9% of laser fissure patients, including hemorrhoidal thrombosis (2.6%), skin tags (2.6%), and treatment failure (2.6%) 3

Traditional LIS Outcomes

  • Lateral internal sphincterotomy achieves 90-98% success rates for chronic anal fissures with significantly lower long-term recurrence 1
  • When combined with hemorrhoidectomy for concurrent conditions, conventional excisional hemorrhoidectomy demonstrates recurrence rates of only 2-10% 1, 2
  • All fissures heal completely within 4 weeks when LIS is combined with stapled hemorrhoidopexy, with no fissure recurrence observed during follow-up 6

Risk of Fecal Incontinence: Critical Comparison

Laser Fissurectomy Incontinence Risk

  • Laser fissurectomy shows NO significant change in fecal continence at 60-day follow-up, with zero incontinence reported in the primary laser fissure study 3
  • The risk of incontinence is almost non-existent with laser hemorrhoidoplasty techniques 5
  • However, one study reported 1 case of Clavien-Dindo grade IIIb incontinence among 50 patients (2%) treated with laser hemorrhoidoplasty 7

Traditional LIS Incontinence Risk

  • Incontinence rates following hemorrhoidectomy range from 2-12%, with sphincter defects documented in up to 12% of patients by ultrasonography and anal manometry 8, 2
  • The primary mechanism is excessive retraction and extensive dilation of the anal canal during conventional procedures 8
  • When LIS is performed as an adjunct to hemorrhoidectomy, randomized studies show an INCREASE in incontinence rather than benefit 8
  • Critical technical point: performing a limited, controlled sphincterotomy rather than excessive sphincter division is key to reducing incontinence risk 1

Definitive Recommendation on Incontinence Risk

Laser fissurectomy has demonstrably lower risk of fecal incontinence (0-2%) compared to traditional LIS combined with hemorrhoidectomy (2-12%). 3, 8

Suitability for Tight Sphincter Tone

When Laser is Appropriate

  • Laser fissurectomy is particularly suitable for patients with tight sphincter tone because it does not mechanically divide the sphincter muscle, instead using thermal energy to remove fibrotic tissue and stimulate healing 4
  • The technique creates eight full-thickness spots through the sphincter without interrupting its continuity, effectively reducing hypertonicity while preserving structural integrity 4
  • For Grade 2 hemorrhoids specifically, laser hemorrhoidoplasty is considered a minimally invasive alternative with minimal risk of stenosis or incontinence 5

When Traditional Sphincterotomy is More Indicated

  • Traditional LIS is more definitively indicated when the chronic fissure has failed 8 weeks of conservative therapy (including topical calcium channel blockers like 0.3% nifedipine with 1.5% lidocaine) 1
  • For Grade 3-4 hemorrhoids with chronic fissure, conventional excisional hemorrhoidectomy combined with limited LIS provides superior long-term outcomes despite higher immediate morbidity 1, 2
  • Sphincterotomy directly addresses the underlying pathophysiology of elevated anal sphincter pressure that causes chronic fissures 1

Clinical Decision Algorithm for Your Case

For Grade 2 hemorrhoids with chronic anal fissure and tight sphincter tone:

  1. If the fissure is truly chronic (>8 weeks) and has failed conservative therapy: Traditional LIS combined with rubber band ligation or conventional hemorrhoidectomy offers superior long-term cure rates (90-98% vs 66% at 5 years) 1, 7

  2. If minimizing immediate postoperative pain and incontinence risk is the absolute priority: Laser fissurectomy + laser hemorrhoidoplasty is reasonable, accepting the 34% recurrence rate at 5 years 7, 3

  3. If the fissure is acute (<8 weeks) or you haven't tried conservative therapy: Delay surgery and trial topical 0.3% nifedipine with 1.5% lidocaine for 8 weeks first 1

Critical Pitfalls to Avoid

  • Never perform anal dilatation as an adjunct to either procedure - it causes sphincter injuries and 52% incontinence rate at long-term follow-up 8, 2
  • Never add LIS as an adjunct to hemorrhoidectomy - randomized studies show this increases incontinence rather than providing benefit 8
  • Do not assume laser therapy is definitively superior - while it offers less immediate pain, the 34% long-term recurrence rate is substantially higher than traditional techniques 7
  • Avoid excessive sphincter division if choosing traditional LIS - limit to "minimal cutting" to reduce incontinence risk, especially when combined with hemorrhoidectomy 1
  • Do not use laser hemorrhoidoplasty for Grade 3-4 hemorrhoids with major prolapse - it is best suited for Grade 2-3 without significant prolapse 5

References

1
Guideline

Management of Hemorrhoids

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Surgical Management of Hemorrhoids

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

6
Research

Stapled haemorrhoidopexy for haemorrhoids in combination with lateral internal sphincterotomy for fissure-in-ano.

European surgical research. Europaische chirurgische Forschung. Recherches chirurgicales europeennes, 2005

7
Research

Short- and long-term outcomes of laser haemorrhoidoplasty for grade II-III haemorrhoidal disease.

Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland, 2019

8
Guideline

Risk of Sphincter Injuries with Anorectal Procedures

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Related Questions

Can a patient with a history of anal fissure and grade 3 hemorrhoids, who underwent fissureectomy, lateral sphincterotomy, and internal hemorrhoidectomy, regain close to baseline bowel function if no incontinence is observed?
Can sphincter guarding tension persist indefinitely in a middle-aged adult with a history of anal fissure and grade 3 hemorrhoids who has undergone transanal fistulotomy without pelvic care therapy treatment?
Can a hemorrhoidectomy be considered medically necessary in a patient with a history of lateral sphincterotomy, who has developed a fistula, despite the fistula not being advised as a risk, and is outside the 2-year window for malpractice suits?
Does thinning of the perianal skin increase the risk of anal fissures?
What is the best approach for a patient with a history of lateral sphincterotomy (surgical incision of the anal sphincter) who has developed a fistula and now requires a hemorrhoidectomy, considering they were not previously advised of the risks associated with hemorrhoidectomy?
What is the best management approach for a 30-year-old male with a history of alcoholism, hypertension, orthostatic hypotension, erectile dysfunction, and sleep disturbances, who is currently being treated with bupropion (Wellbutrin) and naltrexone (Revia)?
What are the treatment options for a patient with chronic swallowing difficulties?
Can I prescribe ibuprofen (400mg every 6 hours for 3-4 days) and dextromethorphan for a cough, and for how many days, in a patient without gastrointestinal issues or kidney disease?
What is the comprehensive management plan for a child with chronic kidney disease (CKD)?
Is Botulinum toxin (Botox) injection into the internal anal sphincter a reasonable treatment option for a patient with chronic anal fissure and tight sphincter tone who has had partial relief with stool softeners for 22 months?
What is the diagnosis and management plan for a patient with impaired lung function, as indicated by abnormal pulmonary function test results, including a low FEV1%FVC ratio and other parameters suggestive of obstructive and restrictive lung disease components?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question