**6.11 Laser hemorrhoidoplasty**

Laser energy can coagulate the venous plexus tissue. The patient is set in the lithotomy position. Local anesthetic infiltration is performed with xylocaine 20 mL 1% around the anal and perianal skin. A C-shape anoscope is used. A small cut is made in the skin of the anal canal close to hemorrhoid to be targeted for the laser shot. Then a small tube is inserted through which the laser probe will pass, followed by laser shots in several places, generally 5-6 shots, but it can be more, depending on the size of hemorrhoid. The direction of the probe and laser beam can be seen in **Figure 7**. After finishing one point, you can move to another point. The results and the complications were not significantly different from Milligan-Morgan hemorrhoidectomy, or stapler, but less painful [22].

Are there any different indications between sclerotherapy and RBL? There is no difference in terms of indication, but RBL can be done for small IIIrd-degree internal hemorrhoids. If there are no different indications, which one is the best? Research comparing sclerotherapy and RBL concluded that RBL is superior in the resolution of anal protrusion but with higher pain [23]. A survey in the Netherlands reported that most surgeons who treat hemorrhoids choose RBL for the first treatment of Grade II or III internal hemorrhoids [24]. A combination of sclerotherapy and RBL can be done and may improve the result. Research by Kanellos et al. (2003) reported that for the treatment of IInd degree hemorrhoids, the combination of sclerotherapy and RBL is significantly more efficient than sclerotherapy or RBL alone, and RBL is better than sclerotherapy [25]. The results of laser hemorrhoidoplasty are promising [22]. But we are still waiting for long-term results in many cases, and the other problem is that the cost is very expensive.

**Figure 7.** *Laser hemorrhoidoplasty. a. Dentate line, b. Schematic direction of laser shot. (Illustrated by Kanaya).*

#### **6.12 Surgical management**

Surgical treatment is indicated when nonsurgical treatment is unsuccessful or in hemorrhoids with complications. The presence of strangulation, bleeding that does not stop nonsurgically, and thrombosis indicates emergency surgery. If the presence of other anal canal diseases associated with hemorrhoids, such as fissures and fistulas that require surgery, can be considered for hemorrhoid surgery at once if hemorrhoids are also a complaint [3]. However, surgery is indicated for hemorrhoids in grades III and IV. In general, there are two kinds of surgery—the first is excision of the enlarged and prolapsed anal cushion, and the second is surgery to spare and fix the anal cushion ("anal cushion preserving surgery").

Based on the understanding of the pathogenesis of hemorrhoids as varicose veins, an excision is an option, but based on the theory of sliding or prolapsing of the anal cushion, surgery by fixing the anal cushion toward the cranially is the superior choice. The discovery of increasing caliber and flow of the rectal artery in hemorrhoids and the presence of a sphincter-like structure, in the form of thickening of the tunica media, at the arteriovenous connection, that is thinning or missing in hemorrhoids, [5, 6] superior rectal artery ligation is more rational.

#### **6.13 Excisional hemorrhoidectomy (EH)**

EH is a hemorrhoid surgery by removing the hemorrhoids, where nowadays the gold standard is radially removing the three largest lumps (11, 3, and 7 o'clock). Tissues are removed, including the mucosa and the venous plexus below it, without damaging the internal anal sphincter, and maintaining a normal mucosal bridge in between them. After excision, the lump can be left unstitched (Morgan Milligan technique **Figure 8a**) or sutured (Fergusson technique, **Figure 8b**) [1].

It is still debatable which one is better, left open or sewn, because, from various studies, the results are inconsistent. Rationally, in sutured cases, it is very often that the wound will also open in the next couple of days, either because the thread is broken or the tissue is cut. For those reasons, many surgeons choose the open technique. However, a meta-analysis done by Batti et al. (2016) showed the superiority of closed hemorrhoidectomy (Ferguson) over open hemorrhoidectomy (Morgan Milligan) in reducing postoperative pain, risk of postoperative bleeding, and faster wound healing. The only advantage of Morgan Milligan is shorter operative time, while the other

**Figure 8.**

*a. After removing three piles and leaving no suture (Milligan-Morgan) (Personal collection). b. After removing 3 piles and suturing is performed (Ferguson technique) (Illustrated by Kanaya).*

aspects, such as length of hospital stay, postoperative complications, recurrence, and risk of surgical site infection, were similar in both groups [26].

There is a circular hemorrhoid excision technique that involves removing the entire lump, including the skin, mucosa, and the underlying venous plexus while maintaining the internal anal sphincter, followed by circular suturing of the skin with the mucosa as well. This technique, known as the Whitehead technique, has been abandoned because of the severe postoperative pain and complications that often arise, namely the risk of injury to the internal anal sphincter, which will cause incontinence, strictures that will cause difficulty passing stools, and exposing the mucosa, which will cause frequent anal canals to be wet (wet anal syndrome/whipping anus) [27]. Because the anal mucosa is rich in nerves and is able to feel and distinguish the desire to defecate solid, liquid, or fart, there are two cases, which I noticed from my personal cases, of patients complaining of the urge to fart but passing stool after Whitehead hemorrhoid surgery. The other method of hemorrhoidectomy technique is submucosal hemorrhoidectomy, which involves removing the venous plexus only (Park's technique). It is currently being discontinued because the technique is more difficult and the risk of bleeding is high [2].

As excisional hemorrhoidectomy is done by removing the anal cushion, the possibility of reducing anal resting pressure after surgery is possible. According to the findings of a study conducted by Li et al. (2012), patients with preoperative compromised continence may have further deterioration of their continence, and thus Milligan-Morgan hemorrhoidectomy should be avoided in such patients [28].

Although the long-term recurrence rate is significantly lower than other methods, the main problem with excisional hemorrhoidectomy is the excruciating postoperative pain. The pain is thought to be caused by a side-burning wound caused by the use of electrocautery. Research shows that the use of lower-temperature cutting energies, such as ligasures or ultrasonic blades (Harmonic scalpel) provides significantly less pain than electrocautery [29].

#### **6.14 Repositioning the anal cushions**

The pathology of grade III and IV internal hemorrhoids shows damage to the structure of the supporting tissue of the anal cushions, namely the Treitz muscle and the muscularis mucosae so that if it prolapses, it cannot be repositioned spontaneously but must be repositioned with fingers or cannot be reposed manually. In the beginning, the first effort to treat prolapse is made by performing sutures to fix anal

cushions to the base of the hemorrhoids. However, this method still causes problems, namely bleeding and annoying pain, so this method is less attractive [2].
