What are the pros and cons of LASER (Light Amplification by Stimulated Emission of Radiation) hemorrhoidoplasty for an adult patient with a history of hemorrhoids?

LASER Hemorrhoidoplasty: Pros and Cons

LASER hemorrhoidoplasty offers significant advantages over conventional hemorrhoidectomy in terms of reduced postoperative pain, faster recovery, and lower complication rates, but carries a concerning 34% long-term recurrence rate that limits its use primarily to grade II-III hemorrhoids without major prolapse. 1

Advantages of LASER Hemorrhoidoplasty

Pain Reduction

• Postoperative pain is dramatically lower compared to conventional hemorrhoidectomy, with a mean reduction of 2.07 points on the visual analogue scale on day 1, and 74% of patients reporting minimal pain (VAS 0-1) within 24 hours. 1, 2
• Pain scores remain significantly lower at 12 hours (3.8 vs 6.81), 24 hours (2.6 vs 4.6), and 1 week (0.46 vs 0.88) compared to stapler hemorrhoidopexy. 3
• Analgesic requirements are substantially reduced, with a mean difference of 4.88 mg morphine equivalents and 2.25 fewer days of analgesic use. 2

Operative Advantages

• Operative time is 12.42 minutes shorter on average compared to conventional hemorrhoidectomy (28.6 minutes vs 36.2 minutes for stapler technique). 4, 3
• Blood loss is significantly reduced by 16.43 ml compared to conventional techniques (6.42 ml vs 12.6 ml for stapler). 4, 3
• The procedure is minimally invasive with less aggression to the anoderm and anal canal mucosa. 5

Recovery and Complications

• Hospital stay is reduced by approximately 10 hours (18.36 hours vs 28.40 hours for stapler hemorrhoidopexy). 3
• Return to work occurs 9.03 days earlier compared to conventional hemorrhoidectomy. 2
• Postoperative bleeding/hemorrhage risk is dramatically lower (OR: 0.16,95% CI: 0.10-0.28). 4
• Anal stenosis risk is significantly reduced (OR: 0.14,95% CI: 0.03-0.65). 4
• Risk of incontinence and sphincter injury is almost non-existent, unlike conventional hemorrhoidectomy which carries up to 12% risk of sphincter defects. 6, 5

Disadvantages and Limitations

High Recurrence Rate

• The most significant drawback is a 34% recurrence rate at 5-year follow-up, with median time to recurrence of 21 months (range 0.2-6 years). 1
• This recurrence rate is substantially higher than conventional excisional hemorrhoidectomy's 2-10% recurrence rate. 6, 7

Complications

• Minor postoperative complications occur in 18% of patients, including perianal thrombosis, perianal eczema, local bleeding, and anal fissure. 1
• Serious complications (Clavien-Dindo grade IIIb) occur in 6% of patients, including fistula formation (two cases) and incontinence (one case). 1
• Minimal bleeding occurs in 28% of patients, with significant bleeding requiring readmission in approximately 9.5% of cases. 5
• Residual skin tags persist in 28.5% of patients. 5
• Subcutaneous fistula formation occurs in 9.5% of cases. 5

Limited Indications

• LASER hemorrhoidoplasty should be used primarily for grade II-III hemorrhoids without major prolapse, as it is less effective for grade IV disease. 5
• The technique is not recommended for thrombosed external hemorrhoids, which require complete excision within 72 hours or conservative management. 6
• Conventional excisional hemorrhoidectomy remains the most effective treatment for grade III-IV hemorrhoids, particularly when mixed internal and external components are present. 6, 7

Clinical Decision Algorithm

For Grade II-III hemorrhoids without major prolapse:

• LASER hemorrhoidoplasty is the preferred initial surgical option when conservative management (fiber, fluids, rubber band ligation) has failed. 6, 5
• Patients must be counseled about the 34% long-term recurrence risk and accept potential need for repeat intervention. 1

For Grade IV hemorrhoids or mixed internal/external disease:

• Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan) remains the gold standard, with only 2-10% recurrence despite higher postoperative pain. 6, 7

For thrombosed external hemorrhoids:

• LASER hemorrhoidoplasty is not indicated; complete surgical excision within 72 hours or conservative management with topical nifedipine/lidocaine is recommended. 6

Critical Pitfalls to Avoid

• Never use LASER hemorrhoidoplasty for grade IV hemorrhoids with significant prolapse, as inadequate tissue removal leads to high recurrence rates. 5
• Do not assume LASER hemorrhoidoplasty provides equivalent long-term efficacy to conventional hemorrhoidectomy—the 34% recurrence rate at 5 years is clinically significant. 1
• Avoid LASER hemorrhoidoplasty in patients who cannot accept the possibility of repeat intervention, as one-third will experience recurrence. 1
• Do not perform LASER hemorrhoidoplasty on patients with portal hypertension or cirrhosis, as these may represent anorectal varices requiring different management. 6