Study intervention

LHP access for all patients was through stab incisions at the ano-cutaneous junction, followed by submucosal tunneling to the pedicle of the haemorrhoids with artery forceps. The laser catheter was introduced submucosally towards the pedicle guided by a visible beam to ascertain the exact location of the laser fiber. Ceralas D 50 Evolve Laser (Biolitec AG, Jena, Germany), a 980 nm diode laser, was used. Pulsed laser energy, each lasting 3 s, was subsequently delivered at 5 mm intervals, while gradually withdrawing the laser catheter. Patients in the HAL supplementation group underwent suture-ligation (especially for dearterialization) of each identified pedicle without Doppler guidance. Here, 2–0 coated Vicryl Plus Violet 70 cm CT-2 (needle used) sutures (Ethicon) were employed. In all cases no more than one suture was required even if more than one hemorrhoidal column needed suture ligation. Post-operative analgesia was standardized to oral paracetamol 1gm six hourly, and oral celecoxib 200 mg 12-hourly, for 5 days. Syrup Lactulose 15 mL 12-hourly for 1 week to prevent constipation. Subjects were discharged at the discretion of the surgeon based on discharge criteria for post-operative bleeding (VRS) and its severity (Clavien-Dindo Classification), presence of perianal swelling and pain score (VAS).

Patients had general anaesthesia (n = 16) or regional anaesthesia (n = 60) and were blinded to the type of operative procedure. Of the patients on general anaesthesia, 10 were in the LHP group while 6 were LHP with HAL group. It was anticipated that method of anaethesia would not affect the pain score at 24 h post-operation, as the half-lives of either method would have been exceeded. Prophylactic antibiotics, comprising intravenous cefoperazone 2gm and intravenous metronidazole 500 mg, were given at induction. Intravenous Ciprofloxacin 400 mg was used if patients were allergic to the aforementioned antibiotics. Once the patients were anaesthetised, they were positioned in lithotomy. Randomization of the procedures was performed using sealed envelopes. Procedures were performed through an anoscope inserted into the anus. Two drugs used for Clavien-Dindo Grade II/III type complications were tranexamic acid, and Daflon, which is a micronized flavonoid; operative interventions for Grade III complications could include hemostatic suturing or topical hemostats.