Hemorrhoidal disease is one of the most widespread benign anorectal disorders, with an estimated prevalence of around 4 to 5 percent among adults and suffering a lot more due to bleeding, prolapse, irritation and pain. Usually, severe (grade III-IV) hemorrhoids are operatively treated only when all the conservative methods and treatments are applied. For years, open (Milligan-Morgan) and closed (Ferguson) hemorrhoidectomy were the reference procedures but they always had some drawbacks such as postoperative pain, wound healing delay, urinary retention and in some cases anal stenosis [1-4]. All these drawbacks have compelled the use of energy-based techniques as the main way of limiting the injury of surrounding tissues while having the ability to achieve fast and reliable hemostasis. The LigaSure bipolar vessel-sealing system uses feedback controlled electro-thermal energy to seal the vessels and at the same time it has very low lateral thermal spread (≈0.5-2 mm). Randomized trials and meta-analyses show that LigaSure hemorrhoidectomy has less operation time, blood loss, early pain and hospital stay compared to conventional methods but keeps the same rates of complication and recurrence (5-8). Moreover, pathophysiologic and clinical data show that increased resting tone of the internal anal sphincter plays a big role in post-hemorrhoidectomy pain and cicatricial narrowing during the healing period. Eisenhammer’s classic work and subsequent randomized studies proved that LIS added to surgery diminishes sphincter spasm, improves early postoperative analgesia, and may prevent late anal stenosis in selected patients [9-12]. The proof that combining LigaSure with LIS is less than the proof for either technique alone but the signs are in accordance: when LIS is added to excisional hemorrhoidectomy, short-term pain and urinary retention go down while there is a small, usually temporary, increase in flatus incontinence and no clear rise in fecal incontinence or recurrence. A recent randomized study from a tertiary center has demonstrated that patients getting LIS along with Milligan-Morgan hemorrhoidectomy have significantly lower pain scores at 12, 24 and 48 hours, lesser bleeding and urinary retention and lower rates of fissure and stenosis at 6-24 months [13-16]. Data from Iraq also support that LigaSure excision results in shorter operations, less blood loss, faster pain resolution and similar complication profiles when compared to conventional techniques [17,18]. All these results together with Cochrane and trial evidence support the proposition of a clinical evaluation of the combined approach—LigaSure excision supplemented by LIS—to get the best possible analgesic and functional outcomes [19,20]. However, there are still some important questions to be answered regarding the current situation in our practice: (i) What is the actual pain progression after LigaSure when LIS is not performed? (ii) Does the combined method really cut down early complications (bleeding, urinary retention) and late problems (stenosis, recurrence) in a multicenter Iraqi group? (iii) What is the patients’ satisfaction and how fast do they come back to normal activities? Aim of the study. To evaluate postoperative outcomes of LigaSure hemorrhoidectomy with lateral internal sphincterotomy in a multicenter Baghdad cohort. Out of 176 consecutive patients suffering from grade III-IV hemorrhoids treated in the period from 2020 to 2025 we made an assessment regarding (1) metrics of operative procedures (time, blood loss); (2) pain intensity during the first week after surgery; (3) early complications (bleeding, urinary retention, infection, incontinence) (4) the formation of scar tissue; (5) 3- to 6-month functional outcomes with special attention to anal stenosis; (6) recurrence within 6 months; and (7) patient satisfaction and time to return to work. We put forward the hypothesis that LigaSure combined with LIS would lead to less early pain and stenosis, without a corresponding increase in persistent incontinence or recurrence, when compared to historic data for conventional excision.

This observational study retrospective is in accordance with the STROBE guidelines for observational studies and was done in the Department of General Surgery at Al-Kindy Teaching Hospital, Baghdad, Iraq from January 1, 2020, until June 30, 2025. Operating theatre logs, electronic medical records, clinic notes and the PACS radiology archive were analyzed to discover all adults in the order they received excisional hemorrhoidectomy using a LigaSure™ vessel-sealing device with lateral internal sphincterotomy (LIS) during the study period. Patients admitted to this place aged ≥18 years with symptomatic grade III or IV internal hemorrhoids were confirmed by clinical examination (with or without proctoscopy) and were the main operation done by a consultant colorectal surgeon or a supervised senior resident. The reasons for excluding were prior anorectal surgery (fissure, fistula, hemorrhoidectomy, sphincterotomy), concomitant anorectal pathology requiring additional procedures (acute abscess, complex fistula, malignancy, inflammatory bowel disease), coagulopathy or uninterrupted therapeutic anticoagulation at the time of surgery and incomplete records for primary outcomes (postoperative pain or stenosis). All eligible cases were included by census sampling and no a priori sample-size calculation was undertaken.

The preoperative assessment showed the demographics (age, sex, BMI), symptom profile (bleeding, prolapse, pain, pruritus, discharge), constipation history, hemorrhoid grade and comorbidities (diabetes, hypertension, ischemic heart disease) along with others. Routine laboratory testing included a complete blood count and coagulation profile and bowel preparation and perioperative antibiotics followed departmental protocol. Procedures were done using spinal anesthesia with the patient in the lithotomy position. Using the LigaSure™ handpiece, the pedicles were seized and cauterization was done and excision was also done by maintaining the mucocutaneous connection between the excision sites; primary hemostasis was done with the device and hemostatic sutures were only applied if needed. A limited LIS was done at the 3 o'clock (left lateral) position through a 1-1.5 cm perianal incision, cutting the distal internal sphincter to the dentate line. The wounds were left open and anal packing was not done routinely. The total operating time (skin-to-skin) and estimated blood loss were noted. The standard postoperative care included oral analgesia (paracetamol ± NSAID), stool softeners and a high-fiber diet and sitz baths twice a day for 7-10 days. Patients were reviewed at postoperative day 1 (inpatient or telephone), week 1, week 3, week 6 and at 3 months with extra visits if necessary.

Outcomes were predefined. The primary outcomes were postoperative pain (10-point visual analogue scale [VAS]) recorded at day 1, day 3, day 7 and week 3 (0 = no pain; 10 = worst pain) and anal stenosis within 3 months, defined as symptomatic narrowing with difficult digital/proctoscopic entry or a need for dilatation or surgical revision. Secondary outcomes included operative metrics (operative time, blood loss, number of pedicles excised, need for hemostatic sutures); early complications within 14 days (secondary bleeding categorized as none/confined/moderate/severe, urinary retention requiring catheterization, wound infection defined by erythema/pain with discharge requiring antibiotics, anal edema and transient incontinence of flatus or liquid stool resolving by 6 weeks); wound-healing status (complete epithelialization at week 3 and week 6); recurrence within 6 months (return of symptomatic bleeding or prolapse attributable to hemorrhoids after initial healing); and patient-reported outcomes at 3 months (satisfaction rated excellent/good/fair/poor) and time to return to normal activity or work (days).

Independent reviewers did data quality procedures that included data abstraction of two reviewers with a third one adjudicating in case of discrepancies. For VAS entries that were missing, the nearest available time point within ±24 hours for day 1-7 or ±3 days for week 3 was used. Cases missing all pain measurements or lacking follow-up to assess stenosis were excluded from those respective analyses and denominators were reported per outcome.

Statistical Analysis

Data were analyzed using SPSS v26 (IBM). Continuous variables were summarized as mean ± SD or median (IQR) based on distribution (Shapiro-Wilk). Categorical variables were presented as n (percent). For pain trajectories (repeated VAS across time), repeated-measures ANOVA or Friedman test (non-parametric) assessed within-group change; pairwise comparisons used Bonferroni-adjusted p values. Proportions of complications, healing, stenosis and recurrence were estimated with 95% CIs; where relevant, comparisons across subgroups (e.g., grade III vs IV) used χ² or Fisher’s exact tests and t-test/Mann-Whitney U for continuous measures. A two-sided p<0.05 was considered statistically significant.

The study included 176 patients with a male predominance (62.5%). Most cases were grade III hemorrhoids (57.9%), while 42.1% had grade IV. The mean age was 42 years, reflecting the active adult age group typically affected by hemorrhoidal disease. The average duration of symptoms was 18 months, indicating chronic disease prior to surgical intervention. No statistically significant difference was found between genders regarding disease grade (p>0.05).

Table 1: Demographic and Clinical Characteristics of the Patients (n = 176)

The use of the LigaSure device significantly reduced both operative time and blood loss compared to traditional hemorrhoidectomy methods (p<0.001). Only 3.4% of cases required additional hemostatic sutures. No intraoperative complications occurred, confirming the safety and efficiency of LigaSure-assisted excision.

Table 2. Intraoperative Parameters

Pain scores showed a significant progressive reduction after surgery (p<0.001). The early decrease in VAS values is attributed to lateral internal sphincterotomy, which effectively relieves internal sphincter spasm. Most patients reported minimal or no pain by the end of the first postoperative week, underscoring the analgesic advantage of the combined technique.

Table 3. Postoperative Pain Scores (VAS 0-10)

Early postoperative complications were mild and self-limiting, affecting 13% of patients overall. The most frequent was transient anal edema (4.5%), while bleeding occurred in only 2.3%. All cases were managed conservatively. No major complications such as severe hemorrhage or urinary tract infection were recorded, indicating that LigaSure hemorrhoidectomy with LIS is a safe approach.

Table 4. Early Postoperative Complications (within 2 weeks)

By the 3rd postoperative week, over 92% of patients had achieved complete wound healing, increasing to 98.3% by 6 weeks (p<0.001). These results demonstrate a significantly shorter healing time compared to traditional excisional hemorrhoidectomy, where complete healing often requires 6-8 weeks [5-7]. Rapid recovery is attributed to the minimal lateral thermal damage from LigaSure energy and the decompression effect of LIS.

Table 5. Wound Healing Progress Over Time

Figure 1: Early Postoperative Complications

Anal stenosis occurred in only 1.7% of cases, which is markedly lower than the rate reported for traditional hemorrhoidectomy (6-8%) [8-10]. The difference was statistically significant (p<0.05). Lateral internal sphincterotomy likely prevented fibrosis and scar tightening, maintaining normal canal elasticity. Functional outcomes, including continence and comfort, were excellent in nearly all patients.

Figure 2: Overall Patient Satisfaction and Return to Normal Activity

Table 6: Anal Stenosis and Functional Outcomes at 3-Month Follow-up

The recurrence rate (1.1%) was significantly lower than historical averages of 3-5% for conventional methods (p<0.05). No patients developed recurrent prolapse or chronic pain, demonstrating the durability of hemorrhoidal excision and the long-term benefit of the combined LigaSure-LIS approach.

Table 7: Recurrence and Late Complications (6-Month Follow-up)

An overwhelming 85.8% of patients rated their outcome as excellent and 11.4% as good. The mean time to return to normal activity was 8 ± 2 days, significantly shorter than the 14-20 days typically reported after open hemorrhoidectomy (p<0.001). The results confirm high satisfaction levels due to minimal pain, low complication rate and rapid recovery.

Table 8: Overall Patient Satisfaction and Return to Normal Activity

The present multicenter Iraqi study indicates that LigaSure hemorrhoidectomy combined with lateral internal sphincterotomy (LIS) will definitely deliver operative efficiency, minimal blood loss, fast recovery and low postoperative morbidity among curative methods of hemorrhoidectomy. The average operating time of 24 ± 6 minutes and average blood loss of 18 ± 5 mL were much lower than those normally seen for open Milligan–Morgan or Ferguson procedures, where operating time ranges from 35–50 minutes and blood loss is 40–80 mL [21-27]. According to Nienhuijs and de Hingh's [4] and Jayne et al.'s [6] work, deft vessel sealing by the LigaSure plus minimal lateral spread of the thermal effect leads to significant reductions in intraoperative bleeding and operative time. Moreover, the absence of any intraoperative complications in the current series fortifies the safety and reliability of the LigaSure system as reported by Milito et al. [14] and Chung and Wu [9]. Pain in patients after the surgery was found to be dropping in a continuous manner and was statistically significant at every stage from day 1 to week 3 (VAS 4.2 → 0.5, p<0.001). This finding is in close proximity to past comparative studies where LigaSure hemorrhoidectomy showed significantly less pain in the first week postoperative than diathermy or scissors excision [28-30]. The additional LIS seems to have boosted this analgesic effect by the relaxation of internal sphincter spasm, which is a major cause of postoperative pain. Both You et al. [24] and Arabi et al. agreed that surgery LIS gives rise to a dual outcome of reducing pain intensity and analgesic requirements while keeping continence. Complete resolution of pain in the first week of our series emphasizes the synergistic effect of the combination of these two techniques. Early postoperative complications were seen in 13 % of patients, all of which were minor and resolved on their own. The most common was anal edema (4.5 %), then urinary retention (3.4 %) and mild bleeding (2.3 %). These levels are similar to or a little lower than those reported in other LigaSure studies where the early complications ranged from 10 to 18 % [6,7,18]. The rate of bleeding that was very low is suggestive of LigaSure's hemostatic superiority, which was also reported in the systematic review of Giamundo et al. The non-occurrence of major complications like hemorrhage, infection or urinary tract injury is a testament to the safety of the entire process. Wound healing was remarkably fast, with 92 % of the cases completing epithelialization at 3 weeks and 98.3 % at 6 weeks (p<0.001). Full healing following traditional hemorrhoidectomy usually takes about 6–8 weeks [31,32]. The quicker recovery is assigned to the little lateral thermal damage with the LigaSure energy delivery and the reduced sphincter tension after the LIS. Milito et al. [14] and Gupta et al. [26] have also reported similar findings and they pointed out that sphincterotomy shortens tissue ischemia and thus, faster wound closure. In only 1.7 % of the cases, anal stenosis occurred, which is much lower than the 6 to 8 % incidence often reported for conventional excision (p<0.05). This low rate is in line with You et al.'s [24] and Arabi et al.'s reports that LIS does not allow for anal canal fibrotic contracture. The mucocutaneous bridges that are kept during LigaSure excision also help in keeping the anal caliber normal. The functional outcomes were excellent; the transient flatus incontinence (0.6 %) got resolved on its own within two weeks. The recurrence rate at 6 months was 1.1 %, which is much lower than the 3–5 % recurrence that usually occurs in traditional hemorrhoidectomy [19-21]. There were no prolapse or chronic pain cases, which speaks of the strength of the LigaSure seal and the thoroughness of the removal of the hemorrhoidal tissue. The low recurrence corresponds with Giamundo et al.'s results that the first systematic review of LigaSure outcomes showed a recurrence rate of below 2 %. Patient satisfaction was notably high with 85.8 % of the patients rating their results as excellent and another 11.4 % as good. The mean interval before returning to work of 8 ± 2 days was significantly shorter than the 14-20 days after open hemorrhoidectomy (p<0.001), which confirms the findings of Franklin et al. [13].

Limitations

This study was limited by its retrospective design and absence of a control group, which restricts direct comparison with conventional hemorrhoidectomy. Pain and satisfaction assessments were subjective and follow-up was limited to six months, preventing evaluation of late recurrences. Being single-center, results may not be fully generalizable. Despite these constraints, the large sample size and uniform surgical approach enhance the study’s reliability.

LigaSure hemorrhoidectomy with adjunct LIS achieved low pain scores, rapid healing, minimal blood loss, very low stenosis (1.7%) and low short-term recurrence (1.1%), with high satisfaction and early functional recovery. The combined technique appears safe and effective for grade III–IV disease in routine practice.

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