A Novel Combined Surgical Technique for Mixed Hemorrhoidal Disease Using Carbon Dioxide Laser and Botulinum Toxin: Analysis of the First 100 Cases

Abstract

Introduction

Traditional surgical approaches for mixed hemorrhoidal disease are often associated with significant postoperative pain and prolonged recovery periods. The present study describes the findings in the first 100 patients undergoing a novel minimally invasive hybrid technique combining staged internal ligations, mucosal transection, and external resection using carbon dioxide (CO₂) laser, followed by layered anatomical closure and intersphincteric injection of type-A botulinum toxin.

Materials and Methods

A prospective study of 100 patients undergoing a hybrid procedure. Collected variables included demographic, surgical, and clinical data: age, sex, number of cutaneous papillae, operative time, time to first defecation, postoperative pain scores, return-to-work interval, and complication rates.

Results

The mean patient age was 46.1 years. Median operative time was 60.5 minutes. Pain during first defecation had a median score of 5, decreasing to 1 by day 7. Median time of return to work was on postoperative day 15. The overall complication rate was 10%. The number of cutaneous papillae had a positive correlation with pain during defecation (ρ = 0.501; p < 0.001), pain on day 1 (ρ = 0.228; p = 0.023), and operative time (ρ = 0.848; p < 0.001). Persistent pain on day 7 was also associated with complications (ρ = 0.391; p = 0.0001).

Conclusion

The combined technique using staged ligation and CO₂ laser appears to be a safe, effective, and innovative approach to mixed hemorrhoidal disease, with the potential to reduce postoperative pain, accelerate functional recovery, and minimize complications.

Keywords

hemorrhoids - laser therapy - carbon dioxide - botulinum toxins - colorectal surgery - minimally invasive surgical procedures

Introduction

Hemorrhoidal disease is a common condition that significantly impacts the quality of life of millions of individuals worldwide. The presence of both internal and external prolapsing components, characterizing mixed hemorrhoidal disease, poses additional challenges for surgeons, particularly in achieving effective management of different anatomical planes while minimizing tissue trauma.[1]

Traditional surgical techniques, such as those described by Milligan-Morgan, Ferguson, Parks, and Whitehead, while effective, are still associated with considerable postoperative pain, risk of anal stenosis, and prolonged recovery time.[1] [2] [3] In response, less invasive alternatives have been explored, including diode laser-assisted hemorrhoidoplasty and hybrid techniques. However, no previously published technique in the international literature specifically addresses the comprehensive treatment of mixed hemorrhoidal disease using carbon dioxide (CO₂) laser technology.

In this context, we present an original hybrid approach that incorporates multiple modern surgical principles: staggered ligation of the internal hemorrhoidal component, CO₂ laser-assisted mucosal transection, external hemorrhoidectomy with CO₂ laser, layered closure in two anatomical planes, and sphincter modulation through intersphincteric injection of botulinum toxin type A. Their goal is to reduce postoperative pain, minimize complications, and expedite return to normal activities. This novel approach aims to deliver effective treatment with reduced morbidity and has not yet been described in scientific publications.

Materials and Methods

The present was a prospective study conducted between December 2023 and May 2025, including patients diagnosed with mixed hemorrhoidal disease characterized by a prominent internal component associated with prolapse and hypertrophy of the external component. All patients underwent a hybrid surgical technique that combines staged ligation, excision, and carbon dioxide (CO₂) laser application in a specialized surgical center.

The inclusion criteria consisted of patients with clinically classified grade-III and -IV hemorrhoids, presenting symptoms refractory to conservative treatment and associated external hemorrhoidal disease. The exclusion criteria included individuals with coagulopathies, active inflammatory bowel disease, or history of pelvic radiotherapy.

Following intravenous sedation and supplemental oxygenation, patients were placed in the lithotomy position, and regional anesthesia was administered using 0.5% bupivacaine with vasoconstrictor. Anal canal exposure was achieved with a Hill-Ferguson anoscope (Acheron Instruments Ltd.), and the operative field was magnified using a ZEISS TTL analog surgical loupe (Carl Zeiss AG, 2.5 × 350 mm, 70 mm field).

With the internal hemorrhoidal mucosa adequately exposed, staged ligations were performed using absorbable Vycril 2-0 sutures (Ethicon Inc.) in simple X-shaped stitches. An average spacing of 2 to 3 cm was maintained between sutures, starting just above the dentate line and progressing cranially ([Fig. 1A]).

Fig. 1 (A) Staggered ligatures using simple X-shaped stitches with spacing of approximately 2 to 3 cm between each point. (B) Fusiform marking of the area to be resected from the external hemorrhoids. (C) First suture layer with continuous chuleio stitch involving the muscular and subcutaneous planes. (D) Second layer with continuous subdermal suture, promoting aesthetic coaptation and functional recovery.

Immediately following the ligations, mucosal transection was performed by connecting the previously placed sutures using a continuous-mode carbon dioxide laser platform (MedicalSan), set at 8 watts. The procedure was conducted with strict respect for anatomical safety zones, avoiding exposure of underlying muscle fibers.

The external hemorrhoid component was marked using a sterile dermographic pen in a fusiform shape. Resection was performed using the same CO₂ laser system in continuous mode, with power set to 5 watts, ensuring clean incision and simultaneous hemostasis ([Fig. 1B]).

Surgical wound closure was performed in two layers: the first with continuous running suture with Vycril Rapid 3-0 (Ethicon Inc.), encompassing muscular and subcutaneous planes ([Fig. 1C]), and the second with continuous subdermal running suture using Monocryl 4-0 (Ethicon Inc.), as shown in [Fig. 1D].

At the end of the procedure, type-A botulinum toxin was injected into the posterior intersphincteric plane, targeting the lateral quadrants (5 and 7 o'clock). A total dose of 40 or 50 units was administered (20–25 U per quadrant), aiming to reduce sphincteric hypertonia and mitigate postoperative anal pain. We used the following criteria to choose the dose type-A botulinum toxin: 40 units for female and 50 units for males.

The clinical, intraoperative, and postoperative variables were systematically collected from all 100 patients, according to predefined inclusion criteria. Demographic data included age, sex, and the number of hemorrhoids components on physical examination.

Intraoperative data included total surgical time (minutes) and the total dose of type-A botulinum toxin administered (international units), which was injected into the posterior intersphincteric plane following layered closure.

Postoperative pain was assessed using the Visual Analog Scale (VAS),[4] ranging from 0 (no pain) to 10 (worst imaginable pain). Patients were asked to self-report their pain intensity on postoperative days 1, 3, and 7, as well as during the first bowel movement after surgery. Additionally, the interval between surgery and the first spontaneous defecation (days) and the number of days until full return to work were recorded. Postoperative complications were noted as a dichotomous variable (yes/no), with specification of the type of adverse event when present.

Statistical analysis was performed using Python (Python Software Foundation) version 3.11 with the aid of specialized libraries including pandas, scipy.stats, and matplotlib. Continuous variables were described using measures of central tendency and dispersion: mean, median, standard deviation (SD), and interquartile range (IQR), as appropriate.

To evaluate associations between continuous and/or ordinal variables (e.g., pain scores, operative time, age, and number of hemorrhoids components), Spearman's rank correlation coefficient (ρ) was applied, as it is suitable for nonparametric data and ordinal scales. Associations between continuous variables and dichotomous outcomes (operative time vs. presence of complications) were tested using the point-biserial correlation coefficient, a variant of Pearson's correlation adapted for this purpose.

To compare the distribution of continuous variables between two independent groups (e.g., pain scores by sex), the Mann-Whitney U test was employed due to the absence of normal distribution assumptions.

The level of statistical significance was set at p < 0.05 for all tests. Graphical analyses included boxplots and scatterplots to enhance visualization of variable distributions and interrelations.

Results

A total of 100 patients underwent the proposed hybrid surgical technique for mixed hemorrhoidal disease, which combines staged internal ligation, mucosal transection, and external hemorrhoidectomy using CO₂ laser CO2, two-layered anatomical wound closure, and intersphincteric injection of botulinum toxin type A.

The mean patient age was 46.1 ± 12.6 years, ranging from 24 to 73 years, with a relatively balanced gender distribution: 56% male and 44% female. The number of hemorrhoids components on physical examination had a median value of three.

The median operative time was 60.5 minutes (IQR: 48–70), reflecting the standardized execution of the full procedure. The botulinum toxin dose ranged from 40 to 50 units, according to intraoperative criteria. The median time from surgery to the first spontaneous bowel movement was 3 days. Return to work occurred at a median of 15 days postoperatively (IQR: 10–21), as shown in [Fig. 2].

Fig. 2 Time to return to work activities (days).

Pain was assessed using the VAS, showing a downward trajectory throughout the postoperative course. Pain during the first bowel movement had a median score of five. On postoperative day one (POD1), the VAS result was 3, remaining the same on day 3 (POD3), and decreasing to 1 by day 7 (POD7).

The overall complication rate was 10%, including 5 cases of wound dehiscence, 3 cases of localized abscess, and 2 episodes of self-limited postoperative bleeding. No cases of stenosis, fecal incontinence, or reoperation were reported.

Several statistical analyses were performed to explore associations between clinical, anatomical, and technical characteristics and the main outcomes: pain, complications, and return to work. The number of hemorrhoids components showed a statistically significant positive correlation with pain during the first bowel movement (ρ = 0.501; p < 0.001) and with pain on POD1 (ρ = 0.228; p = 0.0226), as shown in [Fig. 3A and B]). A strong positive correlation was also observed between the number of hemorrhoids components and surgical time (ρ = 0.848; p < 0.001), as shown in [Fig. 3C], suggesting that multiple external structures may increase procedural complexity and peripheral sensitivity.

Fig. 3 Number of hemorrhoids components (A) versus pain during first bowel movement, (B) versus pain on postoperative day 1, (C) versus surgical time. (D) Surgical time versus pain during first bowel movement.

Surgical time also correlated significantly with pain during the first bowel movement (ρ = 0.419; p < 0.001), as shown in [Fig. 3D], but not with the occurrence of complications. No significant correlation was found between the dose of botulinum toxin and pain levels on POD1 or POD3, suggesting that dose standardization may have reduced variability. Likewise, no correlation was found between the interval to the first bowel movement and evacuation-related pain, contradicting the hypothesis that delayed defecation increases discomfort.

No significant associations were identified between return to work and pain levels on POD1, POD3, or POD7, nor with patient age. This suggests that return-to-work timing may be multifactorial and more dependent on occupational demands and individual context. Age also showed no correlation with pain scores at any assessed time point.

An important finding was that persistent pain on POD7 was positively correlated with the presence of complications (ρ = 0.391; p = 0.0001), as shown in [Fig. 4], reinforcing the clinical relevance of late pain as a potential indicator of postoperative morbidity. However, pain on POD3 did not correlate with complications.

Fig. 4 Pain on postoperative day 7 versus presence of complications (NO or YES).

Lastly, patient sex was not associated with postoperative pain levels, as determined by Mann-Whitney U tests on POD1 and POD7. This suggests that, under the standardized surgical and anesthetic protocol applied, pain perception and inflammatory response are similar between sexes.

Discussion

The present study is the first in medical literature to describe and analyze the clinical outcomes of a hybrid and minimally invasive surgical technique for the treatment of mixed hemorrhoidal disease. The technique combines staged ligation, CO₂ laser-assisted mucosal transection, fusiform external resection with laser, layered wound closure, and intersphincteric modulation using type-A botulinum toxin.

While conventional techniques such as Milligan-Morgan, Ferguson, or transanal hemorrhoidal dearterialization (THD) remain standard for advanced grades of the disease, they share significant limitations, most notably intense postoperative pain, risk of anal stenosis, and symptomatic recurrence, particularly in mixed forms with prominent external components.[1] [2] [3] The proposed approach aims to overcome these drawbacks by tailoring treatment to the anatomical compartments involved. It incorporates modern technologies for precise resection under magnification, photothermal hemostasis, and controlled anatomical closure, thereby reducing exposure of nociceptive terminals and dampening the acute inflammatory response.[5]

Layered closure, which has been validated in other surgical contexts,[5] [6] [7] facilitates tissue coaptation and healing, also reducing dehiscence risk. The addition of botulinum toxin at the end of the procedure acts on the internal sphincter to decrease anal tone, potentially reducing evacuation-related pain and lowering the risk of secondary fissures.

Type-A botulinum toxin was administered in the lateral quadrants of the intersphincteric plane to temporarily relax the internal sphincter. This intervention targets the common baseline hypertonia observed after anal surgical trauma and is hypothesized to reduce immediate postoperative evacuation pain.[8] [9]

In this initial cohort, clinical outcomes were encouraging. Median pain score on postoperative day seven was only 1 on a 0 to 10 numerical scale. The median time to return to work was 15 days, shorter than the 20 to 30 days typically reported following conventional hemorrhoidectomy.[1] The overall complication rate was 10%, composed solely of minor and self-limited events, with no need for reintervention or evidence of stenosis or fecal incontinence.

Statistical analysis revealed that the number of cutaneous papillae was significantly associated with greater pain during the first bowel movement (ρ = 0.501; p < 0.001) and higher pain levels on postoperative day one (ρ = 0.228; p = 0.0226). Additionally, a strong correlation was identified between the number of papillae and operative time (ρ = 0.848; p < 0.001), suggesting that seemingly trivial external anatomical traits may have a meaningful impact on operative complexity and peripheral inflammatory response. While the physiological explanations remain unclear, this novel observation opens avenues for future research into peripheral morphological markers and their association with pain sensitivity.[10]

Operative time also correlated positively with pain during the first defecation (ρ = 0.419; p < 0.001), which is expected given the greater extent of dissection and tissue manipulation. However, longer operative time was not associated with increased complication rates, supporting the technical safety of the approach even in prolonged procedures.

Pain levels on days 1, 3, and 7 postoperatively did not correlate with time to return to work, indicating that this outcome is likely influenced by broader contextual, personal, and occupational variables rather than postoperative pain alone.

It is important to point out that persistent pain on postoperative day 7 was significantly associated with complications (ρ = 0.391; p = 0.0001), highlighting the clinical relevance of delayed pain as an indirect marker of adverse events. This is particularly notable because patients with complications did not necessarily report higher pain early on, but sustained pain beyond the expected inflammatory peak (POD3–5) may indicate local infection or scar-related tension. This insight, unprecedented in the context of minimally invasive anal surgery, may aid outpatient follow-up and facilitate early identification of patients at higher risk for complications.

Variables such as age, biological sex, and botulinum toxin dose did not show significant associations with pain levels or other outcomes, reinforcing the reproducibility of the technique and its uniform clinical impact across diverse patient profiles. The absence of correlation between botulinum toxin dose and pain may reflect the uniform dosing strategy (40–50 IU), which has already been validated in studies involving chronic anal fissure.[11]

Conclusion

This new technique represents an innovative, safe, and functionally effective alternative to treat mixed hemorrhoidal disease. It shows promise in reducing postoperative pain, accelerating functional recovery, and minimizing complications. Its reproducibility and alignment with the principles of minimally invasive surgery suggest a strong potential for widespread adoption, enhanced postoperative outcomes, and greater patient satisfaction. However, its broader application and validation through multicenter and comparative studies are still warranted.

Conflict of Interests

The author has no conflict of interests to declare.

Contribution of the Author

• References

• 1 Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol 2012; 18 (17) 2009-2017
• 2 Altomare DF, Rinaldi M, Sallustio PL, Martino P, Rubino M. Long-term outcome of stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy. Dis Colon Rectum 2004; 47 (08) 1207-1212
• 3 Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele RJC, Loudon MA. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev 2005; 2005 (03) CD005034
• 4 Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011; 63 (Suppl. 11) S240-S252
• 5 Ho YH, Tan M. Innovations in surgical technique for hemorrhoids: beyond Milligan-Morgan and Ferguson. Tech Coloproctol 2020; 24 (02) 93-95
• 6 Ellis CN, Lin EH. Surgical management of hemorrhoids. Clin Colon Rectal Surg 2007; 20 (01) 60-67
• 7 Campos F. et al. Hemorroidectomia estética com fechamento em dois planos: descrição de técnica cirúrgica. J Coloproctol (Rio J) 2024
• 8 Patti R, Aiello P, Di Vita G, Montalto G, Angelo GL. Role of botulinum toxin in anal fissure treatment: a review. World J Gastroenterol 2010; 16 (06) 669-672
• 9 Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. Botulinum toxin injection in the internal anal sphincter for the treatment of chronic anal fissure: long-term results after two different dosage regimens. Ann Surg 2002; 236 (02) 121-127
• 10 Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A. et al; Pelvic Floor Disorders Network. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 2009; 137 (02) 512-517 , 517.e1–517.e2
• 11 Mentes BB, Ege B, Leventoglu S. Botulinum toxin injection for the treatment of chronic anal fissure: long-term results and patient satisfaction. Colorectal Dis 2003; 5 (06) 442-445

Publication History

Received: 26 June 2025

Accepted: 11 August 2025

Article published online:
31 December 2025