Is LigaSure hemorrhoidectomy appropriate for a patient with grade III bleeding internal hemorrhoids refractory to high‑fiber diet, fluid intake, avoidance of straining, short‑course flavonoids, and unsuitable for rubber‑band ligation?

LigaSure Hemorrhoidectomy for Grade III Refractory Hemorrhoids

LigaSure hemorrhoidectomy is an excellent surgical option for your patient with grade III bleeding internal hemorrhoids that have failed conservative management and are unsuitable for rubber-band ligation, offering significantly shorter operative time, reduced postoperative pain, and faster return to work compared with conventional hemorrhoidectomy. 1, 2, 3

Indications for Surgical Intervention in This Case

Your patient meets clear criteria for hemorrhoidectomy because:

• Failure of conservative therapy (high-fiber diet, fluids, avoidance of straining, flavonoids) warrants escalation to surgical management for symptomatic grade III hemorrhoids 4
• Unsuitability for rubber-band ligation eliminates the preferred office-based procedure, which normally achieves 70.5–89% success rates for grade III disease 4
• Persistent bleeding from grade III hemorrhoids after conservative measures have failed represents a definitive indication for hemorrhoidectomy 4

LigaSure vs. Conventional Hemorrhoidectomy: Evidence-Based Comparison

Operative Efficiency

• Operating time is reduced by approximately 40–50% with LigaSure (mean 10–18.7 minutes) compared with conventional Ferguson or Milligan-Morgan techniques (20–29 minutes) 1, 5, 3, 6
• Intraoperative blood loss is minimal with LigaSure (median 0–11.5 mL) versus conventional diathermy (12–22 mL) 3, 6

Postoperative Pain and Recovery

• Postoperative pain scores are significantly lower with LigaSure (median VAS 2.6) compared with conventional hemorrhoidectomy (median VAS 4.8) in the first 48 hours 2
• Analgesic requirements are reduced by more than 50% with LigaSure (median 5 doses) versus Harmonic Scalpel (median 13 doses) 2
• Return to work occurs earlier with LigaSure, though specific timelines vary by study; most patients return within 2–4 weeks after conventional hemorrhoidectomy 4, 1
• Wound healing is faster with LigaSure: only 16.67% had delayed healing at 4 weeks versus 40.48% with conventional open hemorrhoidectomy 1

Safety and Complications

• No intraoperative complications occurred in a large series of 666 consecutive LigaSure hemorrhoidectomies 5
• Delayed postoperative bleeding occurs in approximately 3.2% of patients, with most resolving spontaneously; only 0.4% require reoperation 5
• Urinary retention is rare (1.8%) and resolves within 1 day 5
• Day-case discharge is feasible: 90% of LigaSure patients were discharged on the day of operation versus 55% with conventional diathermy 6

Long-Term Efficacy

• Recurrence rates at 1 year are low with LigaSure (2.38%) compared with conventional open hemorrhoidectomy (9.14%), though this difference did not reach statistical significance 1
• At 2-year follow-up, the overall recurrence rate after LigaSure hemorrhoidectomy is 3.1%, comparable to conventional hemorrhoidectomy 5
• At 3-year mean follow-up, only 2.0% of patients experienced mild bleeding from residual hemorrhoids, successfully managed medically in all but one case 5

Technical Advantages of LigaSure

• Vessel sealing technology coagulates blood vessels and tissue into a wafer-thin seal with excellent hemostasis, eliminating the need for suture ligation of the hemorrhoidal pedicle 3
• Minimal lateral thermal spread reduces collateral tissue damage compared with conventional electrocautery 3
• Simultaneous treatment of both internal and external hemorrhoidal components is straightforward 3
• No suturing required because mucosal tissue over the pedicle is sealed with the current 3

Critical Pitfalls to Avoid

• Never perform anal dilatation as an adjunct to hemorrhoidectomy; it causes sphincter injuries and results in 52% incontinence at 17-year follow-up 4
• Do not use cryotherapy, which causes prolonged pain, foul-smelling discharge, and requires more additional therapy 4
• Avoid attributing anemia to hemorrhoids without colonoscopic evaluation to exclude proximal colonic pathology, inflammatory bowel disease, or colorectal cancer 4
• Limit sphincter manipulation during surgery to reduce the 12% risk of sphincter defects documented by ultrasonography and manometry after hemorrhoidectomy 4

Postoperative Management Expectations

• Narcotic analgesics are typically required for postoperative pain control 4
• Hospital stay averages 1.5 days (range 1–4 days) after LigaSure hemorrhoidectomy 5
• Stool softeners and bulk-forming agents (psyllium husk 5–6 teaspoons with 600 mL water daily) should be prescribed to prevent straining and promote healing 4
• Sitz baths provide symptomatic relief and should be recommended 4
• Follow-up at 1–2 weeks is necessary to monitor for delayed bleeding, which typically occurs when the eschar sloughs 4

Alternative Consideration: Conventional Excisional Hemorrhoidectomy

If LigaSure is unavailable, conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) remains the gold standard for grade III hemorrhoids, with recurrence rates of only 2–10% 4. The Ferguson closed technique may offer slightly improved wound healing compared with the open technique 4. However, conventional hemorrhoidectomy is associated with greater postoperative pain, longer operative time, and delayed return to work compared with LigaSure 1, 2, 3.