Updates in Surgery

https://doi.org/10.1007/s13304-019-00694-5

ORIGINAL ARTICLE

Postoperative discomfort and pain in the management

of hemorrhoidal disease: laser hemorrhoidoplasty, a minimal invasive
treatment of symptomatic hemorrhoids
Luigi Brusciano1   · Claudio Gambardella1,2 · Gianmattia Terracciano1 · Giorgia Gualtieri1 ·
Michele Schiano di Visconte3 · Salvatore Tolone1 · Gianmattia del Genio1 · Ludovico Docimo1

Received: 29 August 2019 / Accepted: 16 November 2019

© Italian Society of Surgery (SIC) 2019

Abstract
Hemorrhoidal disease (HD) treatment still remains controversial. In fact, despite many surgical progresses, postoperative
pain, and discomfort remain the major weaknesses. Laser hemorrhoidoplasty (LHP) is a minimal invasive procedure for HD
treatment determining the shrinkage of the hemorrhoidal piles by diode laser. The aim of the current study is to analyze the
feasibility and efficacy of LHP in patients with II–III degrees hemorrhoids. Consecutive patients with II–III degree hemor-
rhoids were enrolled in the study and underwent an LHP treatment using a 1470-nm diode laser. Operative time, postopera-
tive pain and complications, resolution of symptoms, and length of return to daily activity were prospectively evaluated.
Recurrence of prolapsed hemorrhoid or symptoms at a minimum follow-up of 6 months was evaluated. Fifty patients (28
males and 22 females) were enrolled in the study. No significant intraoperative complications occurred. Postoperative pain
score (at 12, 18, and 24 h postoperatively), evaluated through visual analogue scale, was extremely low (mean value 2). No
postoperative spontaneous bleeding occurred. The 100% of our population came back to daily activity 2 days after surgery.
At a mean follow-up period of 8.6 months, we reported a recurrence rate of 0%. LHP demonstrated a large efficacy in selected
patients. The greatest strength points were low postoperative pain, the presence of slightly significant peri-anal wounds, no
special anal hygienic measures and low surgical time. Thus, resulting in a negligible postoperative discomfort, LHP could
be considered a painless and minimal invasive technique in the treatment of HD.

Keywords  Hemorrhoidal disease · Laser hemorrhoidoplasty · Postoperative pain · Postoperative discomfort

Introduction

Hemorrhoidal disease (HD) is a widespread anorectal condi-

tion affecting millions of people around the world and repre-
Electronic supplementary material  The online version of this senting a major medical and socioeconomic issue, severely
article (https​://doi.org/10.1007/s1330​4-019-00694​-5) contains influencing patients’ quality of life [1, 2]. Hemorrhoids or
supplementary material, which is available to authorized users. hemorrhoidal columns are submucosal cushions containing
venules, arterioles and smooth muscle fibers. They, along
Luigi Brusciano and Claudio Gambardella contributed equally to
the paper. with the internal anal sphincter, are essential in the main-
tenance of continence by providing soft-tissue support and
* Ludovico Docimo keeping the anal canal closed tightly [2]. HD surgical treat-
[email protected]
ment is mostly required when the patient complains bleeding
1
University of Study of Campania “Luigi Vanvitelli”, via and prolapse (spontaneously or manually reducible). Sur-
Luigi Pansini n° 5, 80131 Naples, Italy gical treatment choice still remains controversial. In fact,
2
Department of Cardiothoracic Sciences, School of Medicine, despite many modifications and progress in the HD surgical
University of Campania “Luigi Vanvitelli”, Naples, Italy techniques, postoperative pain and discomfort, daily activity
3
“S. Maria dei Battuti” Hospital, Conegliano, Conegliano, TV, limitation, serous–mucous discharge, and recurrence remain
Italy the major weaknesses [1]. Nowadays, the resective approach,

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 Updates in Surgery

open (Milligan–Morgan) or closed (Ferguson), leads to a low assessed. Inclusion criteria were age ≥ 16 years, a sympto-
recurrence rate, but postoperative pain and discomfort are matic HD of II and III degree according to the Goligher’s
not negligible. On the other hand, the suspensive approaches classification and failure of conservative medical treatment,
have been burdened by a high recurrence rate, and despite an American Society of Anesthesiologists (ASA) physical
a low postoperative pain and discomfort, though being status of grade I or II [9–12]. Exclusion criteria were acutely
frequently associated to new symptoms onset (defecatory thrombosed hemorrhoids, patients affected by IBD involving
urgency, unbearable pain, and tenesmus) [3, 4]. rectum or anus, patients previously surgically treated for HD
Currently, patients undergoing a surgical intervention for and the inability to complete study protocol. All subjects
HD could experience variable intensity of pain depending were preoperatively assessed during a specialized coloproc-
on the adopted technique, postoperative bleeding, possible tology evaluation in a teaching Hospital [13, 14]. A clinical
incontinence to flatus or liquid feces, delayed return to daily examination, comprehensive of an anorectal digital evalu-
activity (> 5 days), and, in case of Milligan–Morgan tech- ation followed by anoscopy, was performed in all patients
nique, continuous serous discharge for the presence of surgi- and information on bowel function; pregnancies, episiotomy,
cal wounds, that could require qualified assistance (nursing previous surgery, and associated diseases were recorded.
and relative care) [5]. Before surgery, all patients underwent laboratory tests,
Moreover, other possible complications after hemor- chest X-ray, ECG examination, and cardiological counseling.
rhoidal surgery such as urinary retention in case of spinal Preoperatively, all patients underwent a pancolonscopy to
anesthesia (20.1%), bleeding (secondary or reactionary) exclude the presence of colic neoformations or inflamma-
(2.4–6%), and subcutaneous abscess (0.5%) should not be tory bowel disease. Patients underwent an LHP treatment
neglected. The long-term complications include anal fissure using a 1470-nm diode laser ­(Biolitec® Jena, Germany). All
(1–2.6%), anal stenosis (1%), incontinence (0.4%), fistula surgical procedures were performed by the same surgeon
(0.5%) and recurrence of hemorrhoids [6–8]. (LB), experienced in coloproctological surgery, assisted
Therefore, for the fear of postoperative pain and compli- by a skilled collaborative team. All patients were detailed
cations, mildly symptomatic patients often hesitate and delay informed about the study protocol, the surgical interven-
undergoing to surgical treatment for this benign disease. tion, and the unknown long-term results of the technique
Laser hemorrhoidoplasty (LHP) is a new minimal inva- and signed a written informed consent. The local ethical
sive and painless procedure for day-surgery treatment of committee approved the study protocol (370/18).
symptomatic hemorrhoids determining the shrinkage of the
hemorrhoidal piles by mean of a diode laser [2, 9]. The com- Operative technique
monly used laser energy in medicine are carbon dioxide,
argon, and Nd:YAG. The laser beam causes tissue shrinkage In lithotomy position, a bilateral pudendal nerve locore-
and degeneration at different depths depending on the laser gional block was performed by administration of ropiv-
power and the duration of laser light application. acaine (10 ml for each side). A deep sedation, obtained by
The aim of the current study is to analyze the feasibility propofol (2.0 mg/kg i.v.) and associated with the use of a
and efficacy of LHP in patients with II–III degrees hemor- laryngeal mask was performed. Antibiotic prophylaxis with
rhoids, reporting our initial experience with this minimal ceftriaxone (2 g i.v.) was administered. A skin microincision
invasive treatment, focusing on the patients’ postoperative of 3 mm was made about 1–1.5 cm of distance from the
pain and discomfort (in terms of analgesic need and time of anal verge at the base of each hemorrhoidal node. The probe
returning to daily activity). (1.85 mm of diameter) was driven through the incision in
the submucosal tissue until reaching the area underneath the
distal rectal mucosa (Fig. 1). Then, 10–12 effective pulses
Materials and methods (adjusted to resective node dimensions), 8 W per 3 s each,
of approximately 24 Joule using a 1470-nm diode laser gen-
Study design erator ­(LEONARDO® DUAL 45 B ­ iolitec® Jena, Germany)
were fired. Half of them were fired in the submucosal tissue,
This study is reported according to the Strengthening and the others in the intra-nodal compartment determining
the Reporting of Observational Studies in Epidemiology the shrinkage of the hemorrhoidal piles (Supplementary
(STROBE) statement for cohort studies [10]. Between May Video 1). The anal wounds were left open. At the end of
2018 and October 2018, consecutive adult patients affected the procedure, an anal tampon was positioned. After 12 h
by II–III degrees symptomatic HD referred to our referral the anal tampon was removed, and patients were discharged
center of coloproctology (Master of pelvi-perineal rehabili- the day after surgical operation, in case of no postoperative
tation and Master of coloproctology) at University of Study complications, presence of a tolerable pain ≤ 5 with VAS
of Campania “Luigi Vanvitelli” of Naples were prospectively score, and tolerance to oral feeding.

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Updates in Surgery

Table 1  Baseline characteristic of the patients

Characteristics Study group (n = 50)

Age (years) 42 ± 12.6

Gender 28 Males (56%)
22 Females (44%)
Preoperative symptoms
 1. Bleeding 50 (100%)
 2. Pain 33 (66%)
 3. Prolapsed hemorrhoids 45 (90%)
Hemorrhoid grade
 II 5 (10%)
 III 45 (90%)
Number of columns
 2 8 (16%)
 3 42 (84%)
Fig. 1  Probe (1.85  mm of diameter) was driven through the anal
verge minincision (1 cm) in the submucosal tissue until reaching the
area underneath the distal rectal mucosa

(28 females and 22 males) were finally enrolled in the

Outcome measures current study. All patients had symptomatic grade II–III
HD. Mean age was 42 ± 12.6 years (range 22–70 years).
Mean operative time was evaluated in minutes. Postoperative Age and sex ratio, preoperative symptoms, hemorrhoid
pain was considered as the main outcome and was evaluated grades, and number of treated hemorrhoidal columns are
with the visual analogue scale (VAS) at 6 and 12 h, and 1, 3, detailed in Table 1. No significant intraoperative compli-
7, 14, and 28 postoperative days. The need of analgesics after cations occurred. Intraoperative mean time was 14 min.
discharge was evaluated at days 1, 3, 7, 14, and 21. Eventual Mean hospitalization was 2 days (one night). Postopera-
bleeding was evaluated at days 1, 3, 7, 14, andd 21; it was clas- tive pain score evaluated through the visual analogue scale
sified as follows: spontaneous, post-defecatory, or no evidence (VAS), was extremely low, with the eventual administra-
of bleeding. Sero-mucous discharge was also evaluated at days tion of only NSAIDs on request. In detail, in the early
1, 3, 7, 10, 14, and 21. Fecal and gas incontinence was assessed postoperative time (0–24 h) and the first 3 days after sur-
using the Cleveland clinic incontinence score for fecal inconti- gery a mean VAS value of 2 (range 0–3) was recorded,
nence at days 1, 3, 7, 10, 14, and 21 [15]. Time needed to come while in the subsequent days, the VAS value decreased to
back to daily activity was also evaluated and expressed in days. 0 (Fig. 2). The dose of postoperative administered analge-
One month after surgery, all patients were asked whether or sics and the number of patients who used analgesics after
not they would repeat the procedure in case of persistence or discharge was low (Fig. 2). No patients suffered of spon-
recurrence of the disease. The presence of recurrence and of taneous bleeding after surgery, while 32 patients (60%)
any postoperative complications at a minimum follow-up time experienced a post-defecatory bleeding the day 1 after sur-
of 6 months was assessed. gery, and 15 patients (30%) on postoperative day 3. From
the 7th postoperative day, no bleeding event occurred in
Statistical analysis our cohort (Fig. 3). No patients experienced sero-mucous
discharge for the absence of open surgical wounds and
Data were analyzed using the statistical package for social no patients reported fecal incontinence (mean Cleveland
sciences (SPSS, version 16.0, Chicago, IL, USA). Qualita- clinic incontinence score was 0) in the follow-up period.
tive data are expressed as per cents, and quantitative data are Twenty patients (40%) and the 100% of our population
expressed as the means. came back to daily activity 1 day and 2 days after surgery,
respectively (Fig.  4). Considering our limited popula-
tion and follow-up length, no patients experienced post-
Results operative local infection. At a mean follow-up period of
8.6 months, we reported a rate of recurrence of 0%.
Out of 60 consecutive patients affected by II–III degree All patients (50/50 patients) affirmatively answered to
HD, six refused the laser treatment, four presented a con- the hypothetic possibility of repeating the procedure in
comitant obstructive defecation syndrome. Fifty patients case of persistence or recurrence of the disease.

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 Updates in Surgery

25 3.5

3 3
20
2.6
2.5
2.3
15

VAS Score
2 2
Paents

1.8
1.5
10

1 1
5
0.5

0 0 0
Hour 3 Hour 6 Hour 12 Hour 24 Day 2 Day 3 Day 4

Analgesic Mean VAS Score

Fig. 2  Postoperative pain evaluation using VAS score and postoperative analgesic administrations

120%

100%

80%
Paents

60%

40%

20%

0%
Day 1 Day 3 Day 7 Day 14 Day 21
Spontaneus 0% 0% 0% 0% 0%
Aer defecaon 60% 30% 0% 0% 0%
No bleeding 40% 70% 100% 100% 100%

Spontaneus Aer defecaon No bleeding

Fig. 3  Postoperative spontaneous and post-defecation bleeding; no bleeding cases

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Updates in Surgery

Fig. 4  Return to daily activity 60

evaluation Ability to return daily acvies
Inability to return daily acvies

50

40

30

20

10

0
Day 0 Day 1 Day 2 Day 3

Discussion deep sedation assisted by laryngeal mask ventilation. Thus,

excluding the necessity of spinal or general anesthesia, the
Patients’ postoperative discomfort and pain represent the procedure can be safely performed even in unfit and aging
most feared and complained complications after surgical patients with several comorbidities. Healing and return to
hemorrhoidectomy. In response to the high request of pain- work activities are facilitate, because, unlike conventional
less treatments, in the recent years, we have assisted to the surgeries, there are no stitches for the presence of slightly
widespread of a broad spectrum of non-excisional and less significant wounds [16].
invasive techniques including stapled hemorrhoidopexy, To date, although the exciting and promising results, the
transanal hemorrhoidal dearterialization (THD), and hem- HD treatments by laser coagulation has been insufficiently
orrhoidal artery ligation (HAL) [16–18]. analyzed and further studies are needed to adequately assess
Since 2006, LHP has been introduced as an innovative its efficacy and, above all, its long-term results. The larg-
and alternative minimal-invasive technique in the treatment est reported series is the one of Jahanshahi et al. analyzing
of HD. [19] The concept of laser coagulation in the treat- the feasibility of LHP, with a lower wave length generator
ment of veins varicosity was borrowed by the endovenous (980 nm), in 368 patients affected by HD [20]. The Authors
ablation in vascular surgery [16]. The diode laser (wave- reported no case of recurrence at 1 year follow-up and a low
length = 1470 nm) penetrates up to 2 mm, determining a complication rate of 3.51%. Similar results were reached by
submucosal denaturation and a controlled shrinkage of the Maloku et al. on 20 patients treated by 980 nm diode laser
hemorrhoidal tissue. It is selectively and better adsorbed by coagulation [2]. Naderan et al. compared the efficacy of LHP
the hemoglobin, as compared to Nd:YAG laser, and con- treatment with 980 nm diode laser versus the conventional
sequently causes less damage to the surrounding tissue, Milligan–Morgan resection in 60 patients [9]. The authors
preventing any sphincteral lesions [16]. In addition, fibrotic reported similar results in the effectiveness of the two tech-
reconstruction generates new connective tissue, which niques, underlining the better results of LHP group in terms
ensures the full mucosa adherence to the underlying tissue. of postoperative pain and postoperative complications [9].
In the few reported papers, the laser ablation technique had Conversely, Giamundo et al. assessed that LHP technique is
short operative time, low postoperative pain and comparable associated with higher pain and bleeding compared to the
effectiveness in the treatment of HD to the respective and doppler assisted Hemorrhoid Laser Procedure (HeLP), but
more invasive techniques [9]. Another feature of paramount these conclusions were not supported by published data [21].
importance is the possibility to perform the procedure with To the best of our knowledge this is the largest series
a bilateral pudendal nerve locoregional block associated to a analyzing the use of Diode Laser with 1470 nm wavelength

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 Updates in Surgery

in the treatment of HD, in English Literature. Pain and recurrence, and in the 100% of cases (50/50 patients), the
postoperative discomfort are certainly the most important answer was affirmative, attesting a complete patients’ com-
symptoms complained after surgical treatment of HD. In pliance. Moreover, LHP does not alter the normal anatomy
our series, pain and postoperative discomfort outcome, our of anal canal and hemorrhoids allowing the possibility of
primary end-point, were extremely encouraging. In detail, in undergoing to a further more invasive surgical treatment in
the early postoperative time (0–24 h) and in the first 3 days a case of recurrence. Finally, it is an easy and reproducible
mean VAS value of 2 was recorded, while in the subsequent technique, with a short learning curve that allow the surgeon
days the VAS value decreased to 0, making the most feared to master the procedure after 3–5 cases [9].
drawback of the HD treatment completely manageable with Several authors have questioned about the excessive cost
mild analgesics. In our first experience we reported an excel- of the laser technique [21, 24]. Certainly, consistent with
lent resolution index of 100% (50/50). Considering a mini- the literature, the cost of LHP is significantly higher than
mum follow-up time of 6 months, no patients experienced the one of conventional Milligan–Morgan hemorrhoidec-
recurrence or persistence of HD. No case of spontaneous tomy by diathermy. In fact, purchasing, maintaining, and
bleeding after surgery occurred, while 32 patients (60%) recharging laser devices are expensive even if in our case
experienced a post-defecatory bleeding only the first day the diode laser generator was obtained as loan for use [9].
after surgery, and 15 patients (30%) on postoperative day 3, Nevertheless, it should be underlined that in case of use of
but in all cases the bleeding episodes disappeared from the radiofrequency or ultrasound coagulation, the cost for each
7th postoperative day. In detail, no patients required surgi- single disposable advanced hemostasis device is similar to
cal hemostasis, suggesting the hemostatic and coagulative the cost of the single disposable laser probe (approximately
effectiveness of the laser technique. Given the presence of 300€). Moreover, the laser procedure allows shorter hospi-
slightly significant incisions, no patients experienced sero- talization, shorter operative time and lower complications
mucous discharge, preventing the necessity of numerous rate guarantying a cost saving that should be investigated in
daily dressing by a qualified nurse or by a relative, as it further cost analysis studies.
often occurred after Milligan–Morgan procedure [22, 23]. The current study has certainly several limitations to
Moreover, the LHP procedure allows a quick return to work address. First, the small sample size, which precluded any
and to daily activity. In detail, in our series, twenty patients analysis of the effect of covariates and the evidence of rare
(40%) and the 100% of our population came back to daily complications. Moreover, we do not yet have long-term
activity 1 day and 2 days after surgery, respectively. During follow-up data after the procedure, as the present study was
our accurate postoperative clinical evaluations, we did not prospective and focused mainly on assessing LHP effective-
experience any significant and remarkable anal alteration ness and feasibility.
such as submucous abscesses and anal fissures, but only the
presence of a temporary hemorrhoidal piles hardening as
consequence of the laser shrinkage. Concerning the anal Conclusion
function, we recorded in all patients an excellent strength
and selectivity of the anal sphincter, probably due to the LHP is a minimal invasive, painless, safe and quick proce-
absence of intense postoperative pain. Therefore, we are dure that in our initial experience demonstrated large effi-
confident in excluding any early postoperative anal relevant cacy in patients affected by HD. Our preliminary data seems
anatomical and functional impairment. to suggest that the use of this technique provide a very low
Even though LHP does not suffer of the abovementioned pain and discomfort period with minimal need of analgesics
and well-known disadvantages of the resective and suspen- and wound care, electing it among the procedure suitable for
sive techniques, its actual drawback is the lack of long-term HD. However, there is a need of a longer follow-up period
results reported in literature. Therefore, it is worth to inform to verify long-term outcomes of these treatment for HD and
the patient about the possibility of its inefficacy and of recur- to compare this technique to the current conventional ones.
rence before the procedure, since literature is not conclusive
on this matter. Nevertheless, the complete absence of postop-
erative discomfort and pain probably widely overcomes the Author contributions  All authors contributed significantly to the pre-
sent research and reviewed the entire manuscript. LB participated sub-
latter limitation. Therefore, we reported our experience with stantially in conception, design and execution of the study and in the
a limited number of cases and with short follow-up period, analysis and interpretation of the data; also participated substantially
to emphasize the brightening and encouraging impact on in the drafting and editing of the manuscript. CG participated substan-
patients’ satisfaction (in terms of postoperative pain and tially in conception, design, and execution of the study and in the analy-
sis and interpretation of the data; also participated substantially in the
discomfort) more than to reach long-term conclusions. In drafting and editing of the manuscript. GT participated substantially in
our experience, the patients were asked about the possibility conception, design and execution of the study and in the analysis and
of repeating the procedure in case of disease persistence or interpretation of the data. GG participated substantially in conception,

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Updates in Surgery

design and execution of the study and in the analysis and interpreta- intra-hemorrhoidal coagulation and Milligan–Morgan hemorrhoid-
tion of the data. MSdV participated substantially in conception, design ectomy. J Invest Surg 30:325–331
and execution of the study and in the analysis and interpretation of the 10. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Van-
data. ST participated substantially in conception, design and execution denbroucke JP, Initiative STROBE (2014) The strengthening the
of the study and in the analysis and interpretation of the data. GdG reporting of observational studies in epidemiology (STROBE)
participated substantially in conception, design and execution of the statement: guidelines for reporting observational studies. Int J Surg
study and in the analysis and interpretation of the data. LD participated 12:1495–1499
substantially in conception, design and execution of the study and in 11. Goligher JC, Leacock AG, Brossy JJ (1955) The surgical anatomy
the analysis and interpretation of the data. of the anal canal. Br J Surg 43:51–61
12. Owens WD, Felts JA, Spitznagel EL Jr (1978) ASA physical sta-
Funding  This article did not receive sponsorship for publication. tusclassifications: a study of consistency of ratings. Anesthesiology
49:239–243
13. Brusciano L, Limongelli P, del Genio G, Sansone S, Rossetti G, Maf-
Availability of data and materials  The data sets used and/or analyzed
fettone V, Napoletano V, Sagnelli C, Amoroso A, Russo G, Pizza
during the current study are available from the XI Division of General,
F, Del Genio A (2007) Useful parameters helping proctologists to
Mini-invasive and Obesity Surgery—Master of Coloproctology and
identify patients with defaecatory disorders that may be treated with
Master of Pelvi-Perineal Rehabilitation. University of Study of Cam-
pelvic floor rehabilitation. Tech Coloproctol 11(1):45–50
pania “Luigi Vanvitelli” Naples, on reasonable request.
14. Brusciano L, Gambardella C, Tolone S, Del Genio G, Terracciano
G, Gualtieri G, Schiano di Visconte M, Docimo L (2019) An imagi-
Compliance with ethical standards  nary cuboid: chest, abdomen, vertebral column and perineum, differ-
ent parts of the same whole in the harmonic functioning of the pelvic
Conflict of interest  The authors declare that they have no competing floor. Tech Coloproctol. https​://doi.org/10.1007/s1015​1-019-01996​
interests. -x
15. Jorge JM, Wexner SD (1993) Etiology and management of fecal
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