Postoperative edema results from inflamma­tion caused by cellular injury from thermal energy. Furthermore, there is the latent heat of vaporization despite a low thermal relaxation time.

Although rare, damage to the blood vessels can lead to the formation of a blood clot. It typically resolves itself.

I must admit that I have never performed LHP without HAL.Many authors recommend that LHP as a stand-alone procedure is sufcient, which I nd difcult to agree with. While elu­cidating the anatomy and etiopathogenesis of hemorrhoids, it has been explained that the hybrid procedure gives better results.

• Where is the entry point for the laser ber? I came across a procedure protocol in a publi­cation recommending inserting the laser ber through an incision in the perianal area. I am not in favor of this approach. As we know, the anal cushions are disruptions of submucosa at 3, 7, and 11 o’clock. In addition, there is anas­tomosis present between the superior and inferior hemorrhoidal arteries below the den­tate line, extending beyond the mucocutane­ous junction. So, the mucocutaneous junction is considered an entry point for the laser ber. Entering the hemorrhoidal masses through the intersphincteric or perianal spaces is inappro-

Usually, collagen sheets are used for wound contraction. Some authors have recommended the use of collagen sheets with bupivacaine. Nevertheless, I see no benet of using them in LHP.

In a cohort study [27] of 497 patients, the postoperative VAS score is reported as 2. In my practice, it is usually 3–4 in the initial 24h. Many surgeons have promoted the LHP procedure as painless. I disagree, as LHP is in no way a painless procedure.

0.1, respectively [7, 8].

• Which wavelength is the best—1470nm or

Blood and water are among the components of our body that absorb laser energy. 1470nm is absorbed by water 40 times more than 980nm, resulting in minimal thermal damage. Moreover, water is the target for the 1470nm laser, while 980 nm works on hemoglobin. The penetration is 1–2 mm in 1470 versus 5–7mm in 980nm. Many vascular surgeons have shifted from 980 to 1470nm for endo­vascular varicose vein laser removal (EVLA).

with laser hemorrhoidoplasty. The dearterializa­tion is achieved with hemorrhoidal artery liga­tion by taking a suture 2–4cm above the dentate line. The stitch includes the feeding vessels and a few bers of the internal anal sphincter. This occludes the branches of SHA. As discussed earlier, this technique cannot achieve complete dearterialization due to the course of the ves­sels. Hence, the energy delivered by lasers takes care of CCR formed by other branches, leading to complete dearterialization. In addition, the prolapsed pile masses reduce by brosis. In the studies by Halit Maloku in 2014 on laser hemor­rhoidoplasty and open surgical hemorrhoidec­tomy, the laser procedure had a VAS score of 5 on the rst day, which reduced gradually. There were no signicant side effects associated with the procedure, concluding that laser hemor­rhoidoplasty was a safe and effective technique to be carried out for hemorrhoids [23]. In a study by Asmz Rahman, 88% of patients had complete resolution of symptoms following laser hemorrhoidoplasty [28]. Paolo Giamundo etal. published a randomized control trial on a hemorrhoid laser procedure that indicated a 90% success rate and a better quality of life fol­lowing the surgery [29].

A 45-year-old male patient presented to the OPD with a complaint of mass coming out of the anal orice during defecation that reduced on its own. It was associated with bleeding, blood being bright red, and in the form of a spurt. The patient had a history of straining and constipation, for which he was taking laxatives. He spent approxi­mately half an hour on the commode to clear his bowels. On local and digital rectal examination, there was no signicant nding. The proctoscopy revealed grade 2 hemorrhoids. On sigmoidos­copy, except for hemorrhoids, there was no other pathology. FGHAL with LHP was planned. All the palpable branches of SHA were ligated, fol­lowed by laser hemorrhoidoplasty.

As it was a simple case of grade 2 hemor­rhoids, FGHAL with LHP was done. After a week, the patient came for a follow-up. He was cheerful as there was no bleeding or prolapse. He resumed work on the eighth postoperative day. The recovery was fast as no excision was done, nor any raw areas were created. The VAS score was signicantly low.

4. Hylase was injected. A reduction in edema was seen in a few seconds, and all the reduced pile masses were pushed back into the anal canal. A half-cut proctoscope was inserted, and FGHAL was done at all the palpable branches of SHA. Clot evacuation of thrombosed internal hemorrhoids was done, followed by LHP.In the

As discussed earlier, Injection Hylase reduces edema by increasing tissue permeability. Once the hemorrhoidal tissue reduces, FGHAL with LHP can be easily done. Over the years, I have realized that in grade 4 hemorrhoids, where a small prolapsing element is still present after LHP, mucopexy or rectoanal repair is effective. For external hemorrhoids, giving an elliptical incision is a good option if the thrombus is small. In large thrombosed external hemorrhoids, clot evacuation with laser at the site of corrugator cutis ani can also be done.

One of my friends, a family physician, referred a young male patient around 35 years. He had one episode of bleeding per rectum, constipation, and fullness in the rectum. He was diagnosed to have second-degree hemorrhoids. Ten days after being diagnosed, he went to a local hospital and was taken for sclerotherapy. After 2 days of sclerotherapy, his symptoms worsened. He had severe pain in the anal region during defecation, further exacerbated on sitting. On local examina­tion, nothing signicant was seen. However, there was a mild spasm on digital rectal examina­tion. The proctoscopy showed strangulated inter­nal hemorrhoids. Sigmoidoscopy revealed strangulated hemorrhoids at 3 and 7 o’clock posi­tions and second-degree hemorrhoids at 11 o’clock. In this case, excisional hemorrhoidec­tomy was done for strangulated hemorrhoids, and for second-degree hemorrhoids, FGHAL at the apex of pile masses was followed by LHP.

The excruciating pain associated with throm­bosed external hemorrhoids is due to the swelling and bleeding within the inferior hemorrhoidal venous plexus. The venous plexus is present in the corrugator cutis ani muscle in the perianal space, a tightly packed area due to dense fatty tis­sue. The fascia covering the tissues within the muscle does not stretch or expand and hence acts as a compartmental syndrome. Once the swelling is formed, the nerves, capillaries, and muscles in the perianal area come under pressure. The blood ow to the nerves and muscles is decreased. Lack of blood supply and oxygenation results in isch­emia leading to intense pain [8].

Thrombosed external hemorrhoids present with intense pain in the anal region and difculty in sitting. On examination, a small swelling can be seen in the perianal area. Sometimes, the throm­bosed external hemorrhoids may become ulcer­ated or rupture (Figs.9.2 and 9.3).