Stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and the symptom of prolapse. It is also associated with a higher likelihood of long-term symptom recurrence and the need for additional operations compared to conventional excisional hemorrhoid surgeries. Patients should be informed of these risks when being offered the stapled hemorrhoidopexy as surgical therapy. If hemorrhoid recurrence and prolapse are the most important clinical outcomes, then conventional excisional surgery remains the "gold standard" in the surgical treatment of internal hemorrhoids.
Randomized clinical trial of stapled hemorrhoidectomy vs open with Ligasure for prolapsed piles.
The aim of the study was to compare the results in 95 patients randomly allocated to undergo either stapled or open hemorrhoidectomy using Ligasure.
                Ninety-five patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open using Ligasure (45 patients). Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique by using Ligasure. Postoperative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and an 18 (12-24) month median telephone follow-up were obtained in all patients.
                Operation time for open hemorrhoidectomy using Ligasure was shorter [median 13 (range 9.2-16.1) min vs 15 (range 8-17) minutes, p < 0.05]. Median range of VAS score in the stapled group were significantly lower [VAS score after 8 h: 3 (2-6) vs 5 (3-8), p < 0.01; VAS score after first defecation: 5 (3-8) vs 7 (3-9), p < 0.001. The stapled hemorrhoidectomy was associated with an increased incidence of intraoperative bleeding in 18 cases (36%) vs four cases (8.8%) of the Ligasure group. There were three cases (6%) from the stapled group with recurrence of the hemorrhoids and none from the open technique.
                Hemorrhoidectomy with a circular stapler device is easy to perform, but one more line of clips must be added to the device to avoid intraoperative bleeding from the cut line. Hemorrhoidectomy performed using Ligasure is more painful postoperatively but is a more radical operation.