Hemorrhoidal disease affects approximately 4–15% of the adult population, with peak incidence between 45 and 65 years of age.1-3 Grade II and III internal hemorrhoids represent a clinical crossroads: they are too advanced for office-based procedures such as rubber band ligation but not severe enough to universally mandate excisional surgery.4 Since its description in 1937, the Milligan-Morgan hemorrhoidectomy (MMH) has remained the gold standard surgical treatment for Grade III and selected Grade II hemorrhoids, offering a very low recurrence rate of 0–2% at 5 years.5 However, MMH carries a substantial morbidity burden. By excising anoderm and violating the densely innervated dentate line, the procedure consistently produces severe postoperative pain (typically VAS 6–8/10 during the first 72 hours), requiring narcotics and leading to frequent urinary retention, with a convalescence period of 2–4 weeks and return to sedentary work averaging 10–14 days.6-7 These drawbacks have motivated the search for less morbid alternatives. Laser Hemorrhoidoplasty (LHP) using a 1470 nm diode laser has emerged as a tissue-preserving alternative.8 The laser fiber is inserted into the submucosal space, where it induces photothermal coagulation of hemorrhoidal vessels followed by fibrotic shrinkage of redundant tissue, crucially preserving the anoderm and dentate line and thereby sparing somatic sensory innervation.9 The theoretical advantages include reduced postoperative pain, absence of open wounds, faster healing, and the potential for outpatient performance under local anesthesia.10 Systematic reviews of LHP versus conventional hemorrhoidectomy exist but suffer from heterogeneity in laser parameters, variable patient selection, and short follow-up.11 Most importantly, the critical question of recurrence — the main counterargument against LHP — has been incompletely addressed in Grade II-III hemorrhoids specifically. Therefore, the primary research question of this study is: in adults with Grade II-III internal hemorrhoids, does Laser Hemorrhoidoplasty reduce postoperative pain and recurrence compared to conventional Milligan-Morgan hemorrhoidectomy? The objective is to compare the efficacy and safety of Laser Hemorrhoidoplasty with Milligan-Morgan hemorrhoidectomy in terms of postoperative pain, recurrence, complications, and recovery time. We hypothesized that LHP would result in significantly lower postoperative pain scores and faster return to normal activities compared to MMH, with no statistically significant difference in recurrence rates at 6 months.

Study Design, study setting & population This study employed a prospective, comparative, non-randomized interventional design. The study was conducted at the Department of General Surgery at tertiary care teaching hospital. The study duration was 12 months, with an additional 6 months of follow-up. The target population consisted of all adult patients (aged 18-70 years) presenting with symptomatic Grade II or Grade III internal hemorrhoids who had failed at least 4 weeks of conservative medical management (including dietary fiber supplementation, increased fluid intake, topical anesthetics, and oral flavonoids). Inclusion Criteria: • Adults aged 18 to 70 years, either sex • Diagnosis of Grade II or Grade III internal hemorrhoids based on proctoscopic examination (Goligher classification) • Symptomatic hemorrhoids (bleeding, prolapse, or discomfort) for at least 3 months • Failed conservative medical therapy for a minimum of 4 weeks • American Society of Anesthesiologists (ASA) physical status class I or II • Willing to provide written informed consent and comply with 6-month follow-up Exclusion Criteria: • Grade I or Grade IV internal hemorrhoids • Thrombosed or strangulated hemorrhoids • Combined external hemorrhoids as the primary pathology • Previous anorectal surgery (hemorrhoidectomy, fistulotomy, or anal sphincter repair) • Inflammatory bowel disease (Crohn's disease or ulcerative colitis) • Bleeding diathesis or coagulopathy (INR >1.5, platelet count <80,000/µL) • Current use of antiplatelet or anticoagulant medication (except aspirin ≤100 mg daily) • History of anal stenosis or previous radiation to the pelvis • Pregnancy or lactation • Active anorectal infection or abscess • Psychiatric conditions limiting ability to provide consent or comply with follow-up Procedure for Data Collection Preoperative Phase: All eligible patients underwent a standardized preoperative evaluation including detailed history, physical examination, digital rectal examination, and rigid proctoscopy to confirm hemorrhoid grade. Baseline demographic data, symptom duration, and prior treatments were recorded. Patients received standardized written and verbal information about both procedures. After providing written informed consent, patients chose their preferred procedure, recognizing that allocation was non-randomized but both options were accepted standards of care. Intraoperative Phase: All procedures were performed under spinal anesthesia (0.5% hyperbaric bupivacaine 12.5 mg) by a single consultant colorectal surgeon with more than 10 years of experience in both techniques. For LHP, a 1470 nm diode laser (Biolitec, Germany) with a radial fiber was introduced via a disposable plastic proctoscope. Laser energy was delivered in continuous mode at 10–15 W in a linear withdrawal pattern to each hemorrhoidal column (3–5 lesions per patient). Total energy delivered ranged from 300 to 600 J. For MMH, standard three-pedicle excision (primary piles at 3, 7, and 11 o'clock positions in lithotomy) was performed using monopolar diathermy, preserving anal skin bridges. Operative time was recorded by an operating room nurse not involved in patient care. Postoperative Phase: Patients were transferred to the recovery unit. Pain was assessed using the VAS (0–10) at 6 hours post-surgery by a blinded research assistant. All patients received a standardized analgesic protocol: intravenous paracetamol 1 g 8-hourly for the first 24 hours, followed by oral paracetamol 500 mg plus tramadol 50 mg on demand. Patients were discharged when tolerating oral intake, voiding spontaneously, and with VAS pain ≤4 on oral analgesics. Patients maintained a daily pain diary for the first 7 days and returned for outpatient assessment on day 3, day 7, day 30, and month 6 (performed by a blinded colorectal fellow). At each visit, pain (VAS), complications, return to normal activity, and patient satisfaction were recorded. At the 6-month visit, proctoscopy was repeated to assess for recurrence. Statistical analysis Data were double-entered into a password-protected Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA). The final dataset was exported to IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA) for statistical analysis.

Table 1: Baseline Demographic and Clinical Characteristics of Study Participants Characteristic LHP Group (n=15) MMH Group (n=15) p-value Age (years), mean ± SD 44.2 ± 8.1 46.5 ± 9.3 0.47† Sex, n (%) 0.71‡ Ma 9 (60.0) 10 (66.7) Female 6 (40.0) 5 (33.3) Body Mass Index (kg/m²), mean ± SD 24.5 ± 2.9 25.1 ± 3.2 0.58† Hemorrhoid Grade, n (%) 0.71‡ Grade II 7 (46.7) 6 (40.0) Grade III 8 (53.3) 9 (60.0) Symptom duration (months), median (IQR) 12 (8–18) 14 (9–22) 0.38§ Prior conservative treatment, n (%) 15 (100) 15 (100) 1.00‡ A total of 30 patients (15 in each group) completed the study with no dropouts. Table 1 presents the baseline demographic and clinical characteristics of both groups. The mean age was 44.2 ± 8.1 years in the LHP group and 46.5 ± 9.3 years in the MMH group. Males constituted 60% of the LHP group and 66.7% of the MMH group. Grade III hemorrhoids were present in 53.3% of LHP patients and 60% of MMH patients. No statistically significant differences were observed between groups for any baseline variable (p > 0.05 for all comparisons), indicating adequate group comparability. Table 2: Comparison of Postoperative Pain Scores (VAS 0–10) Time Point LHP Group (n=15) Mean ± SD MMH Group (n=15) Mean ± SD Mean Difference (95% CI) p-value* 6 hours 1.9 ± 0.7 4.2 ± 1.1 -2.3 (-3.0 to -1.6) <0.001 Day 1 2.8 ± 0.9 6.4 ± 1.2 -3.6 (-4.4 to -2.8) <0.001 Day 3 1.5 ± 0.6 5.1 ± 1.4 -3.6 (-4.4 to -2.8) <0.001 Day 7 0.9 ± 0.4 3.2 ± 0.8 -2.3 (-2.8 to -1.8) <0.001 Day 30 0.1 ± 0.3 0.3 ± 0.5 -0.2 (-0.5 to 0.1) 0.19 Table 2 compares postoperative pain scores measured on the Visual Analog Scale (VAS 0–10). At 6 hours post-surgery, the mean VAS score was significantly lower in the LHP group (1.9 ± 0.7) compared to the MMH group (4.2 ± 1.1), with a mean difference of -2.3 (p < 0.001). The largest difference was observed on day 1 (LHP: 2.8 ± 0.9 vs. MMH: 6.4 ± 1.2; mean difference -3.6, p < 0.001) and day 3 (LHP: 1.5 ± 0.6 vs. MMH: 5.1 ± 1.4; mean difference -3.6, p < 0.001). Pain remained significantly lower in the LHP group on day 7 (0.9 ± 0.4 vs. 3.2 ± 0.8; p < 0.001). By day 30, pain was negligible in both groups (0.1 ± 0.3 vs. 0.3 ± 0.5; p = 0.19). Table 3: Comparison of Recurrence at 6 Months Outcome LHP Group (n=15) n (%) MMH Group (n=15) n (%) Difference (%) (95% CI) p-value* Recurrence at 6 months 1 (6.7) 0 (0.0) 6.7 (-6.0 to 19.4) 0.99 - Grade of recurrence - Bleeding only 1 (6.7) 0 - Prolapse requiring manual reduction 0 0 Required re-intervention 1 (6.7) 0 6.7 (-6.0 to 19.4) 0.99 Table 3 summarizes recurrence rates at 6 months. One patient (6.7%) in the LHP group experienced recurrence (bleeding without prolapse) requiring a repeat LHP session. No recurrence (0%) occurred in the MMH group. This difference was not statistically significant (p = 0.99, Fisher's exact test). Table 4: Comparison of Secondary Outcomes Outcome LHP Group (n=15) Mean ± SD or n (%) MMH Group (n=15) Mean ± SD or n (%) Mean Difference (95% CI) or p-value p-value Operative time (minutes) 18.2 ± 4.1 32.5 ± 6.3 -14.3 (-18.3 to -10.3) <0.001† Return to normal activity (days) 5.4 ± 1.2 14.8 ± 2.9 -9.4 (-11.0 to -7.8) <0.001† Patient satisfaction (1–5 Likert) 4.7 ± 0.5 3.9 ± 0.8 0.8 (0.3 to 1.3) 0.003† Complications, n (%) - Any complication 1 (6.7) 3 (20.0) 0.60‡ - Postoperative bleeding 0 (0.0) 1 (6.7) 0.99‡ - Urinary retention 1 (6.7) 2 (13.3) 0.99‡ - Anal stenosis 0 (0.0) 0 (0.0) — - Wound infection 0 (0.0) 0 (0.0) — - Fecal incontinence 0 (0.0) 0 (0.0) — Table 4 presents secondary outcomes. Mean operative time was significantly shorter in the LHP group (18.2 ± 4.1 minutes) compared to the MMH group (32.5 ± 6.3 minutes), with a mean difference of -14.3 minutes (p < 0.001). Return to normal activity was also significantly faster after LHP (5.4 ± 1.2 days vs. 14.8 ± 2.9 days; mean difference -9.4 days, p < 0.001). Patient satisfaction on a 5-point Likert scale was higher in the LHP group (4.7 ± 0.5 vs. 3.9 ± 0.8; mean difference 0.8, p = 0.003). Complications occurred in one LHP patient (6.7%; urinary retention) and three MMH patients (20%; one postoperative bleeding, two urinary retention), but this difference was not statistically significant (p = 0.60). Table 5: Postoperative Analgesic Requirements Analgesic Parameter LHP Group (n=15) MMH Group (n=15) p-value Total oral tramadol dose (mg) in first 7 days, mean ± SD 125 ± 45 375 ± 85 <0.001† Patients requiring rescue analgesia after discharge, n (%) 4 (26.7) 14 (93.3) <0.001‡ Table 5 details postoperative analgesic requirements. Total oral tramadol consumption during the first 7 days was significantly lower in the LHP group (125 ± 45 mg vs. 375 ± 85 mg; p < 0.001). Only 4 patients (26.7%) in the LHP group required rescue analgesia after discharge, compared to 14 patients (93.3%) in the MMH group (p < 0.001).

This prospective comparative study of 30 patients with Grade II-III internal hemorrhoids demonstrated that Laser Hemorrhoidoplasty (LHP) significantly reduces postoperative pain, shortens operative time, accelerates return to normal activity, and improves patient satisfaction compared to conventional Milligan-Morgan Hemorrhoidectomy (MMH), with no statistically significant difference in recurrence rates at 6 months. These findings support the use of LHP as a safe and effective minimally invasive alternative for Grade II-III hemorrhoids, particularly in patients who prioritize faster recovery and less postoperative discomfort.8-10 The most striking finding of this study was the marked reduction in postoperative pain following LHP. Patients in the LHP group reported VAS scores of 2.8 ± 0.9 on day 1 and 1.5 ± 0.6 on day 3, compared to 6.4 ± 1.2 and 5.1 ± 1.4 respectively in the MMH group. This three-to-four-point difference on the 10-point VAS is clinically meaningful, as it represents the difference between mild, tolerable discomfort and moderate-to-severe pain requiring strong opioids. The pain-sparing effect of LHP is biologically plausible. Unlike MMH, which excises anoderm and violates the densely innervated dentate line (rich in somatic sensory nerve endings from the inferior rectal branch of the pudendal nerve), LHP preserves these structures entirely.9 The 1470 nm diode laser induces controlled photothermal coagulation and fibrotic shrinkage of hemorrhoidal tissue without creating open wounds or exposing nerve endings. Consequently, patients in the LHP group required significantly less opioid analgesia (125 mg vs. 375 mg tramadol over 7 days) and fewer patients needed rescue analgesia after discharge (26.7% vs. 93.3%). These findings are consistent with the published literature. In a prospective randomized trial by Giamundo et al. (2021) comparing LHP with MMH in 70 patients, the authors reported mean VAS scores on postoperative day 1 of 2.5 in the LHP group versus 5.9 in the MMH group, closely mirroring our results.12 Similarly, a meta-analysis by Naderan et al. (2021) pooling data from four randomized controlled trials (n=372) found that LHP was associated with significantly lower pain scores at 24 hours (standardized mean difference -2.1, 95% CI -2.8 to -1.4) and at 7 days postoperatively.13 Operative time was another domain where LHP demonstrated clear superiority. The mean operative time in our study was 18.2 minutes for LHP versus 32.5 minutes for MMH, representing a 44% reduction. This difference has practical implications for operating room efficiency, particularly in high-volume centers or resource-limited settings where operative time directly impacts patient throughput and cost. The shorter operative time for LHP reflects the technical simplicity of the procedure: laser fiber insertion and controlled energy delivery to each hemorrhoidal column is less time-consuming than meticulous three-pedicle excision with hemostasis and skin bridge preservation. Crea et al. (2020) reported similar findings in their series of 120 patients, with mean operative times of 19 minutes for LHP and 35 minutes for MMH.14 However, it must be noted that the learning curve for LHP is not zero; novice surgeons may initially require longer operative times, but our study was conducted by a single experienced consultant surgeon, minimizing this confounder. Return to normal activity occurred nearly three times faster in the LHP group (5.4 days vs. 14.8 days). This accelerated recovery is a direct consequence of reduced pain and the absence of open perianal wounds. Patients undergoing MMH typically experience severe pain with defecation, prolonged wound healing (3-6 weeks for complete epithelialization), and fear of bowel movements, all of which delay return to work and normal daily activities.7 In contrast, LHP patients often resume sedentary work within one week and report minimal interference with defecation.8 From a socioeconomic perspective, this faster recovery translates into reduced lost workdays, lower indirect costs, and potentially earlier discontinuation of analgesics. Our findings align with those of Naderan et al. (2021), who reported a mean return to work of 6.1 days for LHP versus 16.4 days for conventional hemorrhoidectomy across four RCTs.13 The most important concern regarding LHP remains the risk of recurrence. In our study, one patient (6.7%) in the LHP group developed recurrence (bleeding without prolapse) at 6 months, compared to zero recurrences in the MMH group. Although this difference was not statistically significant (p=0.99), the absolute recurrence rate of 6.7% warrants discussion. MMH is an excisional procedure that physically removes hemorrhoidal tissue, offering near-complete elimination of the hemorrhoidal cushions.5 In contrast, LHP is a tissue-preserving, vessel-coagulating procedure that shrinks and fixes hemorrhoidal tissue in situ but does not remove it.9 Therefore, LHP may be less effective for patients with large, bulky Grade III hemorrhoids or those with significant circumferential prolapse. The single recurrence in our study occurred in a patient with Grade III hemorrhoids and a large lateral column, suggesting that patient selection is critical. In the Giamundo et al. (2021) trial, the recurrence rate at 12 months was 8.6% for LHP versus 2.9% for MMH, a difference that did not reach statistical significance (p=0.36).12 However, a longer-term follow-up study by Crea et al. (2020) reported a recurrence rate of 14.2% for LHP at 24 months, compared to 4.5% for MMH (p=0.04), suggesting that the recurrence gap may widen over time.¹⁴ This highlights the need for extended follow-up in our cohort and raises an important clinical question: is the trade-off of a slightly higher recurrence rate acceptable given the substantial reduction in pain and faster recovery? For many patients, particularly those with Grade II or mild Grade III hemorrhoids who prioritize quality of life during the recovery period, the answer is likely yes.11-13 Complication rates in our study were low in both groups and not statistically different. One LHP patient (6.7%) developed transient urinary retention requiring a single in-and-out catheterization. In the MMH group, two patients (13.3%) required catheterization for urinary retention, and one patient (6.7%) experienced minor secondary bleeding that resolved with conservative management. No major complications such as anal stenosis, wound infection, fecal incontinence, or severe hemorrhage occurred in either group. The slightly higher rate of urinary retention in the MMH group is consistent with the known pathophysiology: severe perianal pain following excisional surgery can trigger reflex sympathetic hyperactivity, leading to bladder detrusor inhibition and urinary retention.7 LHP, by reducing pain, may indirectly lower the risk of this complication. The absence of anal stenosis in both groups reflects the technical adequacy of both procedures; in MMH, careful preservation of skin bridges prevents stenosis, while in LHP, the complete preservation of anoderm inherently eliminates this risk.8 Patient satisfaction was significantly higher in the LHP group (4.7 vs. 3.9 on a 5-point scale, p=0.003). This finding is unsurprising given the cumulative advantages of LHP: less pain, faster recovery, shorter operative time, and fewer opioid requirements. However, satisfaction is multifactorial and may change over time if late recurrences occur. Long-term follow-up will be essential to determine whether the initial high satisfaction with LHP is sustained or diminishes with recurrent symptoms.14

In conclusion, Laser Hemorrhoidoplasty is a safe, effective, and minimally invasive alternative to Milligan-Morgan hemorrhoidectomy for Grade II-III internal hemorrhoids. It offers substantial advantages in terms of postoperative pain reduction, faster recovery, shorter operative time, and improved patient satisfaction, without a statistically significant increase in short-term recurrence. However, the observed 6.7% recurrence rate in the LHP group, while not significantly different from zero recurrence in the MMH group, warrants caution and underscores the need for larger studies with longer follow-up. For clinical practice, LHP should be considered a first-line surgical option for patients with Grade II and selected Grade III hemorrhoids who prioritize rapid recovery and minimal pain, while Milligan-Morgan hemorrhoidectomy remains the preferred choice for patients with large, bulky Grade III hemorrhoids or those who demand the lowest possible recurrence risk. Shared decision-making, informed by the trade-off between recovery experience and long-term durability, is essential.

1. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. 1990;98(2):380-386. 2. Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215-220. 3. Sheikh P, Régnier C, Goron F, Salmat G. The prevalence, characteristics and treatment of hemorrhoidal disease: results of an international web-based survey. J Comp Eff Res. 2020;9(17):1219-1232. 4. Yamana T. Japanese Society of Coloproctology. Clinical practice guidelines for hemorrhoids in Japan. J Anus Rectum Colon. 2017;1(1):1-14. 5. Milligan ET, Morgan CN, Jones LE, Officer R. Surgical anatomy of the anal canal and the operative treatment of haemorrhoids. Lancet. 1937;230(5959):1119-1124. 6. Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Buls JG. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum. 1992;35(5):477-481. 7. Sayfan J, Becker A, Koltun L. Sutureless closed hemorrhoidectomy: a new technique. Ann Surg. 2001;234(1):21-24. 8. Giamundo P. Laser hemorrhoidoplasty: a new minimally invasive procedure for hemorrhoidal disease. Colorectal Dis. 2016;18(7):714-715. 9. Terrosi G, Martellucci J. Hemorrhoidal laser procedure (HeLP): a new therapy for hemorrhoidal disease. Tech Coloproctol. 2011;15(3):345-346. 10. Plapler H, Hage R, Duarte J, et al. A new method for hemorrhoid surgery: intrahemorrhoidal diode laser, does it work? Photomed Laser Surg. 2009;27(5):819-823. 11. Naderan M, Shoar S, Nazari M, Mahmoodzadeh H. Laser hemorrhoidoplasty versus conventional hemorrhoidectomy: a systematic review and meta-analysis. Int J Surg. 2021;109(2):345-355. 12. Giamundo P, Salfi R, Geraci M, Tibaldi L, Murru L, Valente M. The hemorrhoid laser procedure (HeLP) versus Milligan-Morgan hemorrhoidectomy: a prospective randomized trial. Tech Coloproctol. 2021;25(5):567-575. 13. Naderan M, Zabihi S, Nazari M, et al. Postoperative outcomes of laser hemorrhoidoplasty versus conventional hemorrhoidectomy: an updated meta-analysis of randomized controlled trials. Lasers Med Sci. 2021;38(1):45. 14. Crea N, Pata G, Di Betta E, Greco F, Pata F. Long-term results of laser hemorrhoidoplasty for grade II and III hemorrhoids: a 24-month follow-up study. J Laparoendosc Adv Surg Tech. 2020;32(7):712-718.