In a patient with grade III internal hemorrhoids and a concurrent anal fissure, should I perform a Ligasure (bipolar vessel‑sealing) hemorrhoidectomy or a 1470‑nm diode laser hemorrhoidectomy?

Ligasure Hemorrhoidectomy for Grade III Hemorrhoids with Concurrent Anal Fissure

For a patient with grade III internal hemorrhoids and a concurrent anal fissure, I recommend performing Ligasure hemorrhoidectomy combined with lateral internal sphincterotomy (if the fissure is chronic) in a single operative setting, rather than laser hemorrhoidoplasty. 1, 2

Rationale for Ligasure Over Laser

Superior Long-Term Efficacy

• Ligasure hemorrhoidectomy has a significantly lower recurrence rate (2-10%) compared to laser hemorrhoidoplasty (9.4-22%) at 12-month follow-up 1, 3, 4
• The American Gastroenterological Association confirms that conventional excisional hemorrhoidectomy (which includes Ligasure technique) is the most effective treatment for grade III hemorrhoids with recurrence rates of only 2-10% 1, 2
• In the largest comparative study, laser hemorrhoidoplasty showed 22% recurrence versus only 6% with Ligasure at one year 3

Ability to Address Concurrent Fissure

• Concomitant anorectal conditions requiring surgery justify combined surgical intervention, and Ligasure allows you to perform both hemorrhoidectomy and sphincterotomy in one setting 1
• Laser hemorrhoidoplasty does not provide adequate access or technique for addressing the anal fissure simultaneously 1
• The American Society of Colon and Rectal Surgeons recommends performing lateral internal sphincterotomy for chronic fissure and addressing hemorrhoids in the same operative setting, with success rates of 90-98% 1

Comparable Safety Profile

• Sphincter defects occur in up to 12% of patients after hemorrhoidectomy regardless of technique (conventional, diathermy, or Ligasure), so the sphincter injury risk is equivalent 5
• Ligasure showed no significant difference in pain scores compared to conventional techniques in randomized trials 5
• In an 18-year experience with 1,454 patients, Ligasure hemorrhoidectomy demonstrated only 2.1% early complication rate and 5.3% long-term complication rate 6

Short-Term Trade-offs (Acceptable Given Superior Long-Term Outcomes)

Postoperative Pain

• Laser hemorrhoidoplasty does produce less immediate postoperative pain: VAS scores of 2.4 on day 1 versus 6.2 with Ligasure 3
• However, this pain difference is manageable with narcotic analgesics and resolves within 2-4 weeks 1, 2
• The pain advantage of laser does not justify accepting a 3-4 fold higher recurrence rate 3, 4

Return to Work

• Laser patients return to work faster: median 2.3 days versus 4.6 days with Ligasure 3
• Most Ligasure patients return to work within 2-4 weeks, which is acceptable for definitive treatment 2

Operative Time

• Laser procedures are faster (mean operating time shorter, p<0.001) 3
• However, Ligasure mean operating time is only 14.3 minutes in experienced hands, so the difference is clinically insignificant 6

Specific Surgical Approach for Your Patient

Step 1: Determine Fissure Chronicity

• If the fissure is acute (<8 weeks duration), initiate conservative management first with dietary modifications, increased fiber and water intake, topical 0.3% nifedipine with 1.5% lidocaine, and pain control 1
• If the fissure is chronic (>8 weeks) and has failed 8 weeks of conservative therapy, proceed with combined surgery 1

Step 2: Combined Surgical Technique

• Perform Ligasure hemorrhoidectomy using Ferguson (closed) technique, which may offer slightly improved wound healing 1
• Add limited lateral internal sphincterotomy for the chronic fissure, using minimal cutting to reduce incontinence risk 1
• The combined approach achieves 90-98% success rates with only 2-10% recurrence 1

Step 3: Critical Technical Points

• Never perform aggressive sphincterotomy, as hemorrhoidectomy alone carries up to 12% risk of sphincter defects; excessive sphincter division increases incontinence rather than reducing it 1, 5
• Avoid excessive retraction with extensive dilation of the anal canal, which is the primary mechanism of sphincter injury and incontinence (2-12% rate) 5
• Never perform anal dilatation as an adjunct, as it causes 52% incontinence rate at long-term follow-up 1, 5

Techniques to Absolutely Avoid

• Do not perform laser hemorrhoidoplasty in this scenario because it cannot adequately address the concurrent fissure and has unacceptably high recurrence rates 1, 3, 4
• Never use stapled hemorrhoidopexy, as it does not address external hemorrhoid components and the patient was not consented for this technique 1
• Do not use cryotherapy, as it causes prolonged pain, foul-smelling discharge, and requires more additional therapy 1

Postoperative Management

• Emphasize high-fiber diet (25-30 g/day) and adequate hydration to prevent constipation and straining, which could compromise healing of both surgical sites 1
• Provide narcotic analgesics as needed, with most patients requiring them for 2-4 weeks 2
• Monitor for urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%) 2
• 90.2% of Ligasure patients can be treated in day surgery regimen with mean operating time of 14.3 minutes 6

Common Pitfall to Avoid

Never proceed with sphincterotomy while ignoring grade III bleeding hemorrhoids, as this leaves the patient with ongoing bleeding and prolapse requiring a second procedure 1. The concurrent pathology demands combined definitive treatment to avoid subjecting the patient to multiple operations.