Conventional Hemorrhoidectomy Versus Recent Advances in Energy-Based Devices: A Comparative Narrative Review

Abstract

Excisional hemorrhoidectomy by the open Milligan–Morgan or closed Ferguson technique remains the most durable treatment for advanced hemorrhoidal disease, but the wide wounds it creates in the sensitive anoderm are associated with substantial postoperative pain, bleeding, urinary retention and prolonged convalescence. Over the past two decades several energy-based devices have been introduced to reduce this morbidity while preserving efficacy. This narrative review compares conventional hemorrhoidectomy with three contemporary modalities — laser hemorrhoidoplasty, radiofrequency excision and the LigaSure bipolar vessel-sealing system — and additionally compares LigaSure with the ultrasonic Harmonic device. Across randomised trials and a recent meta-analysis, laser hemorrhoidoplasty offered shorter operative times, lower intraoperative blood loss, less early postoperative pain and a lower risk of postoperative haemorrhage, at the cost of higher equipment expense, operator dependence and a theoretical risk of recurrence when redundant mucosa is preserved rather than excised. Radiofrequency excision reduced severe postoperative pain and improved wound healing with complication rates comparable to conventional diathermy, although an earlier return to daily activity was not consistently demonstrated. LigaSure has the most robust evidence base, with multiple randomised trials showing reduced operative time, blood loss and pain, faster healing and earlier return to activity, while complication and recurrence rates remained broadly similar to conventional surgery. Head-to-head, LigaSure and Harmonic produced comparable outcomes. Energy devices reduce perioperative morbidity without clearly increasing complications; device selection should be guided by hemorrhoid grade, available expertise, cost and patient priorities.