Does LigaSure Reduce Sphincter Injury Risk During Hemorrhoidectomy?
LigaSure hemorrhoidectomy does not reduce the risk of sphincter (neuromuscular) injury compared to conventional techniques. The available evidence demonstrates that LigaSure primarily reduces operating time and postoperative pain, but no studies have documented any protective effect on sphincter integrity 1, 2, 3, 4, 5.
Evidence on Sphincter Injury Risk
Baseline Sphincter Injury Rates
- Up to 12% of patients develop sphincter defects (documented by ultrasonography and anorectal manometry) after hemorrhoidectomy, regardless of the surgical technique used 6, 7.
- These defects result from excessive tissue retraction or anal dilation during surgery, not from the energy device employed for tissue dissection 8.
- The incidence of postoperative incontinence ranges from 2-12% across all hemorrhoidectomy techniques 6.
LigaSure-Specific Safety Data
- No randomized trials comparing LigaSure to conventional diathermy have reported sphincter injury as an outcome measure 1, 2, 3, 4, 5.
- Cleveland Clinic incontinence scores showed no significant difference between LigaSure and conventional diathermy groups in the only study that assessed continence 1.
- The mechanism of LigaSure (vessel sealing through collagen fusion) addresses hemostasis and tissue division but does not alter the surgical dissection plane or sphincter manipulation required during hemorrhoidectomy 1, 2.
What LigaSure Actually Improves
Proven Benefits
- Operating time reduction: LigaSure reduces mean operative time from 20-34 minutes to 10-15 minutes (P < 0.001 across all trials) 1, 2, 3, 4.
- Intraoperative blood loss: Median blood loss decreases from 12-22 mL to 0-5 mL (P < 0.001) 2, 3.
- Postoperative pain: Significantly lower pain scores on postoperative days 1-2 and at first defecation (P < 0.001 to P < 0.05) 1, 3, 4, 5.
- Hospital stay: More patients achieve same-day discharge (18/20 vs 11/20, P < 0.05) 2.
No Impact on Sphincter Protection
- The dissection technique and extent of sphincter manipulation remain identical whether using LigaSure or conventional diathermy 1, 3.
- Sphincter injury prevention depends on avoiding excessive anal dilation (which causes 52% long-term incontinence) and limiting sphincter retraction, not on the energy modality 6, 8.
Critical Surgical Technique Factors That Actually Prevent Sphincter Injury
Techniques to Avoid
- Never perform anal dilation as an adjunct to hemorrhoidectomy—this causes sphincter injuries and 52% incontinence at 17-year follow-up 6.
- Avoid excessive retraction of the anal canal during dissection, as this directly damages sphincter fibers 8.
- Do not extend dissection beyond the hemorrhoidal tissue into the sphincter muscle 6.
Protective Measures
- Maintain the dissection plane between hemorrhoidal tissue and internal sphincter regardless of energy device used 3.
- Limit the number of hemorrhoidal columns excised in a single session to reduce cumulative sphincter trauma 6.
- Consider adding lateral internal sphincterotomy only when treating concurrent chronic anal fissure, as this paradoxically reduces urinary retention (a marker of sphincter spasm) but must be performed with minimal cutting to avoid incontinence 6, 8.
Clinical Bottom Line
LigaSure is a superior energy device for hemorrhoidectomy because it reduces operative time, blood loss, and postoperative pain—but it offers no protection against sphincter injury 1, 2, 3, 4, 5. Sphincter preservation depends entirely on meticulous surgical technique: avoiding anal dilation, minimizing sphincter retraction, and maintaining the correct dissection plane 6, 8. The 12% baseline sphincter defect rate remains constant across all energy modalities 6, 7.
Post-Operative Monitoring for Sphincter Injury
- Assess for fecal soiling or urgency at 1-2 week follow-up, as these indicate sphincter dysfunction 7.
- Any new fecal incontinence symptoms warrant anorectal manometry and endoanal ultrasound to document sphincter defects 6.
- Anal stenosis (occurring in 0-6% of cases) may mask sphincter injury initially, so long-term follow-up beyond 6 months is essential 6.