Hemorrhoid disease is a common entity, with a worldwide prevalence of up to 27.9%. It is estimated that more than 50% of the population will experience symptoms from hemorrhoids within their lifetime.
Symptomatic hemorrhoids that have failed conservative medical management can be managed in a variety of ways, depending on their size and symptomatology. The gold standard is a traditional hemorrhoidectomy; however, this is plagued with severe postoperative pain and other complications such as urinary retention, bleeding, anal stenosis, and chronic fissure. Other nonexcisional treatments cause similar issues with pain and are associated with high recurrence rates.
Laser was first described for use in hemorrhoid disease over 30 years ago, but only utilized recently. There are 2 main laser approaches to hemorrhoidal disease. A laser hemorrhoidoplasty (LH) involves an incision at the base of hemorrhoid, via which the hemorrhoidal tissue is coagulated using the laser probe. A hemorrhoidal laser procedure utilizes a Doppler ultrasound probe to identify the terminal branches of the superior rectal artery, which are coagulated with laser energy.
The procedure is usually performed under general anesthetic in lithotomy position. It involved the use of an anal retractor to identify the hemorrhoidal pedicles.
A small incision İs made at the anoderm adjacent to the hemorrhoidal pedicle to allow the passage of the laser probe (1.8 mm). Using a small artery forceps, a plane between the internal anal sphincter and hemorrhoid tissue İs bluntly dissected via this stab incision to form a tract for laser probe to pass into the hemorrhoid tissue.
The hemorrhoid tissue is coagulated using a 12-W, 1,470-nm diode laser system by neoLaser via a Biopsy Bell 14 G cannula (neoLaser). The laser probe is advanced into the hemorrhoidal tissue and moved in and out to target the entire bulk of tissue. This laser probe delivers single 3-second pulses in a radial trajectory, emitting energy over a 5 to 6-mm field. The laser beam is considered a divergent beam, where the laser energy dissipates and causes no damage to surrounding normal tissue.
Post hemorrhoidectomy pain is the commonest problem associated with the surgical techniques. The other early complications are urinary retention (20%), bleeding (secondary or reactionary) (3–6%) and subcutaneous abscess (1%). The long-term complications include anal fissure (1% -3%), anal stenosis (1%), incontinence (1%), fistula (1%) and recurrence of hemorrhoids.
On the other hand, Literature suggests that laser hemorrhoidoplasty is more suitable for lower-grade hemorrhoids (grade II and III) with low rates of recurrence. Laser hemorrhoidoplasty has shown to have minimal intraoperative and postoperative complications, and low rates of recurrence for those with grade II and III hemorrhoids, this procedure is likely to be safe in moderate hemorrhoidal disease.
A systematic review by Longchamp et al. highlights that the recurrence rate of hemorrhoids after laser hemorrhoidoplasty ranges from 0% to 11% after 1 year for this cohort, and Faes et al.’s 2019 prospective study in Switzerland with grade II to III hemorrhoids undergoing laser hemorrhoidoplasty estimates the 5-year recurrence to be 36%.
A systematic review in 2021 found that laser treatment universally reported low postoperative pain scores as well as satisfactory symptom relief and recurrence rates on long-term follow-up.
A randomized controlled trial of 121 patients in 2019, comparing laser hemorrhoidoplasty with excisional hemorrhoidectomy found that laser hemorrhoidoplasty was significantly less painful than excisional hemorrhoidectomy and associated with earlier return to regular activity.
In summary, laser hemorrhoidoplasty procedure is more preferred in comparison with conventional open surgical hemorrhoidectomy. Postoperative pain is significantly lesser in laser procedure compared with surgical procedure (p<0.05). Duration time is significantly shorter in laser procedure
Prepared and summarized by Abdulcabbar Kartal, MD, Colorectal Surgeon
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