Laser hemorrhoidoplasty in focus: A modern alternative to conventional surgical techniques for symptomatic hemorrhoids

Abstract

Hemorrhoidal disease is a prevalent anorectal condition causing significant morbidity, affecting approximately 4% of the general population with incidence increasing with age and sedentary lifestyle. While conventional excisional hemorrhoidectomy techniques such as Milligan-Morgan and Ferguson remain standard for long-term efficacy, they are often associated with substantial postoperative pain and prolonged recovery. This narrative review evaluates the comparative clinical outcomes of laser hemorrhoidoplasty (LHP) versus conventional surgical interventions in the treatment of grade II and III symptomatic hemorrhoids. A comprehensive analysis of comparative studies, randomized controlled trials, and meta-analyses published between 2020 and 2025 was conducted, with primary outcomes including postoperative pain, recovery time, operative duration, complication rates, and recurrence. Key findings from studies by Maloku et al and Hassan et al. were analyzed to contextualize real-world LHP use. Across multiple high-quality studies, LHP was consistently associated with significantly lower postoperative pain scores, reduced analgesic requirements, and faster return to daily activities. Maloku et al demonstrated a shorter mean operative time (15.9 minutes) and reduced pain compared to open techniques (26.8 minutes; P < 0.01). Hassan et al confirmed these benefits in a cohort of 40 patients treated under local anesthesia. Operative time was generally comparable or shorter, and vessel ligation was suggested as an adjunct to improve outcomes in select cases. Complication rates were low and similar between groups, with LHP demonstrating minimal risk for major complications such as anal stenosis or incontinence. However, recurrence rates were higher with LHP in some studies, particularly in grade III disease. LHP offers a minimally invasive, low-morbidity alternative to excisional hemorrhoidectomy for appropriately selected patients. Despite superior short-term recovery profiles, potential for higher recurrence underscores the importance of patient selection and long-term follow-up. The role of local anesthesia and adjunctive vessel ligation merits further prospective evaluation.

Key Words: Laser hemorrhoidoplasty; Hemorrhoidectomy; Minimally invasive surgery; Hemorrhoids; Postoperative pain; Recurrence; Diode laser

Core Tip: Laser hemorrhoidoplasty (LHP) is emerging as a minimally invasive alternative to conventional excisional hemorrhoidectomy for grade II-III hemorrhoids. This review synthesizes evidence from recent comparative trials and meta-analyses, highlighting LHP’s advantages in terms of reduced postoperative pain, faster recovery, and preservation of anorectal anatomy. However, despite its favorable short-term profile, concerns about recurrence—especially in grade III cases—underscore the need for careful patient selection and long-term follow-up. These findings support LHP as a viable option in selected patients, bridging the gap between efficacy and minimally invasive care.

INTRODUCTION

Hemorrhoidal disease affects approximately 4% of the general population, with incidence increasing with age and a sedentary lifestyle. Symptomatic hemorrhoids, particularly Grades II and III, often require procedural intervention when conservative management fails[1]. Excisional hemorrhoidectomy techniques such as Milligan-Morgan (open) and Ferguson (closed) remain mainstays due to their low recurrence rates but are associated with significant pain, delayed return to work, and potential complications including bleeding, anal stenosis, and incontinence[2,3].

Laser hemorrhoidoplasty (LHP) has emerged as a minimally invasive alternative. It uses submucosal delivery of laser energy (typically diode lasers at 980 or 1470 nm) to induce coagulation and fibrosis of hemorrhoidal tissue without excision[4,5]. This technique preserves anoderm integrity and may reduce postoperative pain. Jin et al[6] demonstrated in a randomized trial that LHP showed superior outcomes compared to rubber band ligation for grade II hemorrhoids, with better pain control and faster recovery. Given the growing interest in optimizing outcomes and minimizing morbidity, this review critically evaluates comparative evidence for LHP vs traditional surgical techniques. Eray et al[7] suggested that combining LHP with hemorrhoidal artery ligation may enhance outcomes by reducing recurrence while preserving minimally invasive benefits. Additionally, the work by Maloku et al[8] contributes essential real-world evidence supporting shorter operative times and lower immediate postoperative pain with LHP. In light of recent systematic reviews, such as those by Tan et al[9], LHP has gained renewed interest for its favorable pain profile and reduced recovery time when compared to open hemorrhoidectomy. These studies further highlight LHP's potential utility in outpatient settings, including under local anesthesia.

LASER HEMORRHOIDOPLASTY TECHNIQUE

LHP is typically performed under spinal or general anesthesia. A radial laser fiber is introduced into the submucosal plane of the hemorrhoidal cushion. Energy delivery causes localized coagulation of hemorrhoidal vasculature, promoting shrinkage and fibrosis. Unlike excisional techniques, there are no open wounds or sutures, potentially reducing nociceptive stimulation[5].

Modifications to standard LHP include: Use of different wavelengths (980 nm vs 1470 nm); Power modulation (6-10 W continuous or pulsed); Adjunctive suture ligation of feeding arteries to enhance devascularization[7].

While technique variations exist, the underlying principle is controlled submucosal coagulation with mucosal preservation. In a technical series by Maloku et al[8], the procedure was performed using a 980-nm diode laser in a pulsed mode with a 1000-micron fiber, delivering five energy bursts of 13 W over 1.2 seconds with interspersed pauses, resulting in 5 mm depth coagulation and no open wounds. Tan et al[9] expanded on this technique, using similar diode energy settings in a cohort treated under local anesthesia, highlighting both the feasibility and patient comfort of this less invasive protocol. An important procedural enhancement described in these studies is the optional addition of vessel ligation or mucopexy, which may reduce recurrence and postoperative prolapse in select cases[9].

Furthermore, laser-tissue interaction depends on the wavelength used. Diode lasers (980-1470 nm) are preferentially absorbed by hemoglobin and water, resulting in precise coagulation without deep thermal damage[4]. Compared to Nd: YAG lasers, diode systems provide better control and minimal collateral injury. CO₂ lasers, while effective, are primarily surface-acting and less suitable for submucosal delivery in LHP[5].

COMPARATIVE OUTCOMES

Postoperative pain and recovery

Multiple studies report significantly reduced postoperative pain with LHP. In a meta-analysis of grade II/III hemorrhoids, Wee et al[2] found LHP yielded lower Visual Analog Scale (VAS) scores at 24 hours, 7 days, and 14 days compared to conventional hemorrhoidectomy. Cemil et al[1] similarly reported lower VAS scores on postoperative days 1, 3, and 7 in patients treated with LHP vs Milligan-Morgan. Poskus et al[3], in a three-arm RCT, demonstrated that LHP was less painful than excision and sutured mucopexy during the early postoperative period. Faster return to work and daily activities was also consistently observed. Maloku et al[8] found statistically significant differences in pain scores (VAS) favoring LHP at all measured intervals, with 95% of LHP patients reporting VAS 0–1 by day 7 compared to none in the surgical group. Tan et al[9] similarly demonstrated that over 90% of patients undergoing LHP under local anesthesia reported minimal or no pain by the second postoperative week, while open surgery patients showed delayed improvement. Tan et al’s meta-analysis[9] across 1824 patients reinforced these findings, reporting a mean VAS reduction of 2.07 on day 1 and 3.34 at 1 week favoring LHP.

Operative time and intraoperative metrics

Operative time findings are heterogeneous. Wee et al[2] noted shorter operative duration with LHP in pooled analyses. In contrast, Cemil et al[1] and Poskus et al[3] reported comparable or slightly longer times for LHP, likely due to learning curve effects and variability in laser settings. Blood loss was minimal and generally lower in LHP compared to excisional surgery. In the Maloku et al’s study[8], mean LHP procedure time was 15.9 minutes compared to 26.8 minutes for open hemorrhoidectomy (P < 0.01), underscoring its efficiency in experienced hands. Tan et al[9] also found an average time saving of 12.74 minutes for LHP across nine comparative studies.

Complications

LHP is associated with low major complication rates. Meta-analyses show no significant difference in overall complications compared to conventional surgery[2,4]. Notably, anal stenosis and incontinence—more common in excisional methods—are rare in LHP due to tissue preservation[5]. Minor complications include: Postoperative bleeding; Urinary retention; Residual thrombosis; Mucosal discharge.

These are typically self-limiting and do not exceed those seen with conventional methods. According to Tan et al[9], transient mucous discharge and minor bleeding occurred in < 10% of LHP cases, while no cases of anal stenosis or incontinence were reported[9]. Tan et al[9] reported a significantly lower risk of major bleeding (RR 0.22; P < 0.0001) and a favorable trend in reducing urinary retention and anal discharge with LHP.

Recurrence and long-term efficacy

Recurrence remains the most debated limitation of LHP. Poskus et al[3] reported a 26.7% recurrence rate at 1 year post-LHP vs 6.7% with excisional hemorrhoidectomy. Wee et al[2] noted a trend towards higher recurrence in meta-analysis, though differences were not always statistically significant. Lie et al[5] also highlighted recurrence as a concern requiring longer follow-up. Maloku et al[8] observed no recurrence over a 6-month follow-up, though only grade III patients were included and long-term durability was not assessed. Tan et al[9] found recurrence rates to be statistically similar across groups (HR: 0.72, CI: 0.21-2.40), suggesting LHP may be equally effective for short- to mid-term control when properly indicated. Despite this, patient satisfaction remains high due to the reduced morbidity. Techniques such as combined LHP with feeding vessel ligation may offer improved durability[7].

LHP offers compelling short-term advantages, including significantly reduced pain, quicker recovery, and preservation of anorectal function. These features are particularly beneficial for grade II and select grade III hemorrhoids. However, recurrence—especially in grade III/IV disease—necessitates caution. Excisional surgery remains preferable when long-term cure is paramount.

Recent prospective data suggest that the use of LHP under local anesthesia is both feasible and effective. Hassan et al[8] demonstrated excellent postoperative tolerance and patient satisfaction using local perianal infiltration, eliminating the need for spinal or general anesthesia in most cases. This has substantial implications for resource-limited settings or outpatient practice, especially when combined with shorter operative duration and faster discharge times[8].

Additionally, the importance of adjunctive techniques such as vessel ligation or mucopexy is gaining attention. Studies including Eray et al[7] and Maloku et al[8] suggest that combining LHP with hemorrhoidal artery ligation may enhance outcomes by reducing recurrence while preserving the minimally invasive benefits. While this hybrid strategy requires further validation, it offers a promising path toward individualized therapy, balancing efficacy and invasiveness.

Laser physics also merits consideration in optimizing outcomes. Diode lasers (980–1470 nm) are highly absorbed by hemoglobin and water, making them ideal for controlled coagulation in hemorrhoidal cushions[4]. In contrast, Nd: YAG lasers penetrate deeper but risk more extensive thermal spread. CO₂ lasers, while precise at surface ablation, are not suited for submucosal coagulation required in LHP[5]. These wavelength-tissue interactions are central to procedural success and must guide device selection.

Meta-analytic findings by Tan et al[9] reinforce the role of LHP as a superior option in the early postoperative period, with statistically significant reductions in pain, recovery time, bleeding, and hospital stay. The only complication more commonly associated with LHP was anal thrombosis, likely due to retained external components in advanced hemorrhoid grades.

Given these nuances, patient selection remains paramount. Ideal candidates include those with grade II or reducible grade III hemorrhoids, minimal external components, and preference for faster recovery—even at the cost of slightly higher recurrence risk (Table 1).

Table 1 Summary of key comparative trials and meta-analyses.

Ref.	Study type	Comparison groups	Key comparative findings	Additional contributions in current review
Cemil et al[1], 2024	Comparative Study	LHP vs Milligan-Morgan (Grade II/III)	Lower pain scores, faster return to work	Referenced in pain and operative time outcomes
Wee et al[2], 2023	Meta-analysis	LHP vs conventional hemorrhoidectomy	Lower pain (24 hours, 7 days, 14 days), shorter recovery	Main data source for comparative meta-analysis
Poskus et al[3], 2020	RCT	LHP vs sutured mucopexy vs excision	Less pain early on; recurrence higher with LHP	Used to demonstrate recurrence concern
Cheng et al[4], 2024	Meta-analysis	Diode LHP vs MM & Ferguson	Lower pain, shorter hospital stay	Supported benefits in hospital stay and pain
Lie et al[5], 2022	Meta-analysis	LHP vs Various Controls	Less pain, faster recovery; recurrence concerns	Cited in recurrence and long-term efficacy debate
Jin et al[6], 2024	RCT	LHP vs RBL (Grade II)	LHP less painful; similar short-term efficacy	Highlighted minimally invasive alternative to RBL
Eray et al[7], 2025	Retrospective Study	LHP + Ferguson vs conventional	Combined technique reduced pain and bleeding	Introduced vessel ligation adjunct concept
Maloku et al[8], 2014	Comparative Clinical Study	LHP vs Open Hemorrhoidectomy	Shorter OR time, less postoperative pain	Provided real-world timing and pain data
Tan et al[9], 2022	Systematic Review & Meta-analysis	LHP vs milligan-morgan hemorrhoidectomy	LHP had lower pain, bleeding, faster recovery	Framed entire evidence base; critical meta-analysis

LHP: Laser hemorrhoidoplasty.

CONCLUSION

LHP is a well-tolerated, effective alternative for grade II–III hemorrhoids, offering significant reductions in postoperative pain and convalescence compared to conventional hemorrhoidectomy. However, the potential for higher recurrence must be balanced against these benefits. Patient-centered decision-making, informed consent, and continued technical refinements will define LHP’s evolving role in hemorrhoidal therapy. Current evidence supports its use especially in outpatient settings, including under local anesthesia, where rapid recovery and lower morbidity are prioritized. Incorporating adjunctive techniques such as vessel ligation or mucopexy may improve long-term durability, particularly in borderline grade III/IV disease. Future prospective studies should focus on standardizing laser parameters, defining optimal patient selection criteria, and evaluating hybrid approaches that combine LHP with arterial devascularization to establish a more robust long-term efficacy profile.

ACKNOWLEDGEMENTS

The authors would like to express their sincere gratitude to Modawat Charitable Association for their continuous support in delivering essential healthcare services to patients who are unable to afford treatment. Their contributions have been vital in ensuring equitable access to care and have significantly enhanced the quality of life for our underserved populations.