Laser haemorrhoidoplasty explained like an expert surgeon

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laser hemorrhoidoplasty systematic review guidelines 2024 2025

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PMID: 38762410

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PMID: 39048788

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https://pmc.ncbi.nlm.nih.gov/articles/PMC12572025

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diagram hemorrhoids anatomy internal external anal canal hemorrhoidal cushions

Laser haemorrhoidoplasty (LHP): the surgeon’s explanation

Laser haemorrhoidoplasty is a tissue-preserving operation for internal haemorrhoids. It does not cut out the haemorrhoidal cushions as in a conventional haemorrhoidectomy. Instead, a radial diode-laser fibre is placed into each haemorrhoidal cushion and delivers controlled thermal energy. This coagulates small vessels and causes collagen contraction, so the cushion shrinks, scars internally, and is pulled upward over the following weeks.

The aim is simple: reduce bleeding and prolapse while avoiding a large painful anoderm wound.

What problem is it designed to treat?

Haemorrhoids are normal vascular cushions in the anal canal. They become disease when they bleed, prolapse, soil, itch, thrombose, or cause troublesome symptoms. The key distinction is:

Internal haemorrhoids are above the dentate line and usually cause painless bleeding or prolapse.
External haemorrhoids/skin tags are below the dentate line and are sensitive.

LHP principally treats the internal vascular and submucosal component. It does not reliably remove a bulky external component, large fibrotic skin tags, or advanced fixed prolapse. Anoscopy is central to assessing the internal cushions and their relation to the dentate line. Sleisenger and Fordtran's Gastrointestinal and Liver Disease, p. 2670.

Best candidates

In experienced hands, LHP is most reasonable for:

Symptomatic grade II or selected grade III internal haemorrhoids
Bleeding with modest-to-moderate prolapse
Patients who value less postoperative pain and a faster return to activity
Those in whom preservation of anoderm and mucosa is desirable

It is less attractive when there is:

A large external haemorrhoidal component or significant skin tags
Grade IV, irreducible, strangulated, or markedly fibrotic prolapse
Coexistent anal pathology needing excision, such as a fissure, fistula, suspicious lesion, or major external disease
Unexplained rectal bleeding, iron-deficiency anaemia, altered bowel habit, or cancer risk without appropriate colorectal evaluation

A recent colorectal-surgery consensus describes LHP as an option for grade II and III disease, but advises added caution in grade IV disease and notes that external disease may still need excision. Taiwan consensus

How the operation is performed

Exact settings and instruments vary by platform and surgeon. The principles matter more than a fixed recipe.

Assessment under anaesthesia
The surgeon performs examination and anoscopy to identify the main cushions, commonly left lateral, right anterior, and right posterior. Any external component and degree of mucosal prolapse are assessed.
Access above the sensitive anoderm
A small puncture or incision is made at the base of the internal haemorrhoidal cushion, maintaining a safe position relative to the dentate line.
Submucosal fibre placement
A laser fibre, usually with a radial-emitting tip, is advanced within the submucosal plane of the haemorrhoidal cushion. It should not be in the sphincter muscle and should not be perforating mucosa.
Controlled intrahaemorrhoidal energy delivery
The fibre is activated in a controlled, staged manner while being withdrawn. The intended endpoint is tissue contraction and blanching, not charring or a deep crater. The laser energy seals small vessels and denatures collagen, initiating later fibrosis and volume reduction.
Address prolapse if needed
Where prolapse is a major component, some surgeons add a mucopexy, using sutures to lift and fix the prolapsing mucosa. Laser alone shrinks the cushion but may not provide enough mechanical lift for substantial prolapse.
Haemostasis and recovery
Because there is little or no open wound, bleeding is usually limited. The procedure is commonly ambulatory, under local anaesthesia with sedation, regional, or general anaesthesia depending on patient, extent of disease, and local practice.

The operation is conceptually different from laser-assisted excision. In a true LHP, the haemorrhoidal cushion is ablated from within and preserved, not dissected off the internal sphincter.

Why patients often recover more comfortably

Conventional excisional haemorrhoidectomy creates wounds in or near highly sensitive anoderm. That is why it remains very effective but can hurt substantially. LHP seeks to avoid that wound burden.

A 2024 meta-analysis of 17 trials involving 1,196 patients found that, compared with Milligan-Morgan or Ferguson haemorrhoidectomy, LHP was associated with:

Less operative blood loss
Less postoperative bleeding
Shorter operating time
Lower pain on postoperative day 1
Lower anal-stenosis rates

It did not show a statistically significant difference in recurrence, urinary retention, or continence outcomes overall. See the 2024 meta-analysis.

That is the appealing trade-off: less early pain and quicker recovery, but not necessarily a more durable answer for every pattern of disease.

Limitations and the recurrence question

LHP is not a magic substitute for excision.

The fundamental limitation is that it shrinks vascular cushions but does not remove redundant tissue to the same degree as an excisional operation. If the dominant pathology is severe mechanical prolapse, large external disease, or scarred high-grade haemorrhoids, a conventional excisional haemorrhoidectomy can be the more definitive operation.

The evidence base also has limitations:

Techniques, laser wavelengths, energy protocols, and patient selection differ between studies.
Follow-up is often shorter than is ideal for judging long-term recurrence.
The 2024 wavelength review found lower pain and complications with LHP compared with open surgery, but reported a signal of higher recurrence with 1470-nm LHP versus conventional haemorrhoidectomy. Systematic review

Practical surgical message: choose LHP for the right anatomy, not simply because it is called “laser” or “painless.”

Risks and complications

Even a minimally invasive anorectal operation has real risks:

Postoperative bleeding, including delayed bleeding
Pain, tenesmus, spasm, or transient difficulty passing stool
Urinary retention
Thrombosis of residual external haemorrhoids
Infection, ulceration, or tissue necrosis if energy is excessive or misplaced
Persistent prolapse, recurrent bleeding, or need for subsequent banding, mucopexy, or excisional surgery
Rarely, mucosal injury, fistulation, anal stenosis, or continence disturbance

Avoiding deep thermal injury to the internal sphincter and avoiding excessive energy near the mucosa are technical safety priorities.

How it compares

Procedure	Main strength	Main limitation
Rubber-band ligation	Office procedure, inexpensive, effective for many grade I-II and selected III internal haemorrhoids	May need repeat treatment; not for external disease
LHP	Less wound-related pain, minimal tissue removal, faster early recovery	Cost, variable technique, may be less definitive for major prolapse/external disease
Doppler-guided artery ligation with mucopexy	Treats arterial inflow and adds lift for prolapse	Requires equipment and suturing; recurrence can occur
Excisional haemorrhoidectomy	Most definitive for large mixed grade III-IV disease, external component, and major prolapse	More painful recovery and wound morbidity

Surgical texts emphasize that no single operation fits every patient, and that mixed internal-external disease or advanced grade III-IV disease often warrants definitive surgical assessment. Sleisenger and Fordtran's Gastrointestinal and Liver Disease, pp. 2670-2673.

Bottom line

LHP is a minimally invasive, submucosal shrinkage operation, not a laser “removal” of piles. For bleeding grade II or selected grade III internal haemorrhoids, it can offer materially less early pain and less wound morbidity than conventional excision. For bulky external disease, fixed grade IV prolapse, or a need for the most durable anatomical correction, conventional excisional haemorrhoidectomy may be the better operation.

For any rectal bleeding, diagnosis should be established before choosing a haemorrhoid procedure, particularly with anaemia, weight loss, bowel-habit change, family history of colorectal cancer, or bleeding that does not fit a typical haemorrhoid pattern.

You didn’t tell about types and different instruments used

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laser hemorrhoidoplasty equipment radial fiber 980 1470 nm proctoscope technique review

You are right. “Laser piles surgery” is an umbrella term. From a colorectal surgeon’s standpoint, you must distinguish the laser technique from the laser machine and fibre being used.

1. Types of laser treatment for haemorrhoids

A. Laser haemorrhoidoplasty (LHP)

This is the modern, tissue-preserving technique most clinics mean when they advertise “laser piles surgery.”

A fine laser fibre is introduced into the submucosa of each internal haemorrhoidal cushion.
Energy causes intrahaemorrhoidal coagulation, vessel sealing, collagen contraction, and gradual fibrosis.
The pile shrinks over weeks. Nothing substantial is cut away.
Often used for grade II and selected grade III internal haemorrhoids.
A mucopexy may be added when prolapse is significant.

Best feature: little external wound and lower early postoperative pain.
Weak point: it may not adequately correct a bulky external component, extensive skin tags, or fixed grade IV prolapse.

This is also called:

Intra-haemorrhoidal laser coagulation
Laser coagulation of haemorrhoids
Sometimes, imprecisely, “laser ablation”

B. Laser haemorrhoidoplasty plus mucopexy

This is LHP combined with a lift.

The laser treats vascular bulk.
A running or interrupted absorbable suture lifts prolapsing mucosa back upward and fixes it in place.

This combination makes anatomical sense for a patient with a prominent prolapse component, because laser shrinkage alone does not always give enough upward fixation.

C. Laser-assisted excisional haemorrhoidectomy

This is a very different operation.

The surgeon actually excises the haemorrhoid, similar in principle to Milligan-Morgan or Ferguson haemorrhoidectomy.
Laser is used as the cutting and coagulating instrument instead of a scalpel, diathermy, or LigaSure device.

It may reduce bleeding, but because tissue is removed from the anal canal, postoperative pain and wound-related issues can still occur. Do not confuse this with LHP.

A surgical text describes laser haemorrhoidectomy as dissection of haemorrhoidal tissue off the internal sphincter with laser-assisted haemostasis. It is not the same as intrahaemorrhoidal shrinkage. Fischer's Mastery of Surgery, 8th ed., p. 4272.

D. Laser photocoagulation or superficial laser coagulation

This is an older, more superficial thermal approach.

Laser energy is applied to coagulate tissue or vessels externally rather than delivered within the cushion.
It is mainly relevant to small bleeding internal haemorrhoids and is less commonly what is meant today by LHP.

E. Hybrid surgery

For a mixed haemorrhoidal problem, a surgeon may combine techniques:

LHP for internal cushions
Limited excision of a symptomatic external pile or tag
LHP plus mucopexy for prolapse
LHP plus Doppler-guided artery ligation in selected practices

The important point is that external disease requires a different solution from internal vascular cushions.

2. Laser wavelengths used in LHP

The principal diode-laser wavelengths in published LHP studies are:

Wavelength	Usual role	Practical interpretation
980 nm diode laser	Common LHP platform	Absorbed by haemoglobin and water; widely used with bare-tip or radial fibres
1470 nm diode laser	Common modern LHP platform	More strongly water-absorbed, giving localized thermal contraction and coagulation
CO₂ laser	Primarily cutting/vaporisation, not standard modern intrahaemorrhoidal LHP	May be used in laser-assisted excision or superficial work
Nd:YAG laser	Historical/less common in current LHP practice	Deep penetration means careful tissue control is required

A 2024 systematic review found that 980 nm and 1470 nm are the two wavelengths used in modern LHP literature, but direct head-to-head comparative evidence is limited. Outcomes depend heavily on technique, total energy delivery, fibre placement, and patient selection rather than wavelength alone. See the systematic review (PMID: 39048788).

3. Instruments used in laser haemorrhoidoplasty

Core laser system

Diode laser generator
- The console producing the chosen wavelength, commonly 980 or 1470 nm.
- It has adjustable power, pulse duration, and energy-delivery controls.
- The unit must be appropriate for medical laser use and maintained according to manufacturer standards.
Foot pedal
- Lets the surgeon trigger the laser precisely while maintaining control of the fibre and anoscope.
- It reduces inadvertent firing compared with uncontrolled activation.
Laser delivery cable
- Connects the generator to the disposable or reusable fibre.
Laser safety equipment
- Wavelength-specific protective eyewear for everyone in theatre.
- Laser warning sign, smoke evacuation if plume can be generated, and fire precautions.
- This is not optional. Laser safety is part of the procedure, not an accessory.

4. Laser fibres: the instrument that determines the pattern of energy delivery

A. Bare-tip fibre

A standard optical fibre with energy emitted from its end.

Produces a more forward-directed energy effect.
Can be used for intrahaemorrhoidal coagulation.
Requires very controlled positioning and withdrawal.
If fired too superficially, deeply, or while stationary, it can lead to mucosal injury, tissue charring, or unwanted deeper thermal damage.

B. Radial-emitting fibre

This has a modified distal tip that distributes energy circumferentially.

Produces a more even radial thermal effect within the haemorrhoidal cushion.
Often preferred for LHP because it is designed to create controlled, circumferential submucosal coagulation rather than a focal forward burn.
May have a single radial-emission zone or, depending on manufacturer design, multiple emission rings.

C. Ball-tip or conical-tip fibre

Some systems use modified tips intended to diffuse energy and avoid the sharp forward effect of a bare fibre.

Their availability and naming are manufacturer-specific.
The key issue is not the marketing name. It is whether the fibre gives a controlled, predictable tissue effect without excessive surface or sphincter heating.

Surgical principle: the fibre should remain in the haemorrhoidal submucosa. It must not be in the sphincter complex, through the mucosa, or inadvertently in the external anoderm.

5. Non-laser surgical instruments required

Even in “laser surgery,” the laser is only one part of the set.

Instrument	Role
Anoscope or operating proctoscope	Exposes the anal canal, dentate line, and individual cushions
Lubricant and local anaesthetic infiltration set	Analgesia and tissue handling where local/regional technique is used
Fine artery forceps / mosquito forceps	Gentle traction, haemostasis, and handling small tissues
Fine scissors	Tiny access incision, limited tag excision, or mucosal trimming if required
Needle holder and absorbable sutures	Mucopexy, closure, or control of focal bleeding
Suction-irrigation	Keeps the view clear if there is blood, mucus, or char
Gauze swabs and sponge forceps	Compression haemostasis after fibre withdrawal
Electrocautery or bipolar device	Backup haemostasis, not necessarily the main treatment
Doppler proctoscope	Used only if combined with Doppler-guided haemorrhoidal artery ligation

A normal operating anoscope is essential because correct treatment depends on visualizing the dentate line and internal cushions. Sleisenger and Fordtran's Gastrointestinal and Liver Disease, p. 2670.

6. The technical distinction that matters most

A surgeon should be able to answer this question clearly:

“Are you doing true intrahaemorrhoidal laser shrinkage, laser plus mucopexy, or a laser-assisted excisional haemorrhoidectomy?”

These are not interchangeable operations.

True LHP: fibre within the pile, tissue preserved, no major wound.
LHP + mucopexy: fibre shrinkage plus sutured lift for prolapse.
Laser excision: pile removed, laser used as a cutting/coagulating tool.
Hybrid: laser for internal disease plus tailored excision of external disease.

7. Evidence-based choice of technology

LHP generally produces less early pain, less operative blood loss, and less postoperative bleeding than conventional excisional haemorrhoidectomy. A 2024 meta-analysis of 17 trials and 1,196 patients found those early recovery advantages, while recurrence was not significantly different overall. Meta-analysis (PMID: 38762410).

However, the equipment alone does not make the result. Outcomes are influenced by:

Correct diagnosis and exclusion of other causes of rectal bleeding
Haemorrhoid grade and dominant symptom, bleeding versus prolapse
Presence of an external component
Fibre placement
Energy delivery protocol
Whether a mucopexy is added
Surgeon experience and readiness to choose excision when it is the more appropriate operation

For grade IV disease, bulky mixed internal-external haemorrhoids, or major fixed prolapse, a colorectal surgeon should be cautious about promising that laser alone is definitive.

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