Comparative Study of Postoperative Outcomes and Morbidity Among Laser, Open, and Stapled Hemorrhoidectomy for the Treatment of Grade III and Grade IV Hemorrhoids.

Background Hemorrhoidal disease is a highly prevalent anorectal condition that impairs quality of life. Grade III and Grade IV disease may be treated by open hemorrhoidectomy (Milligan-Morgan technique), stapled hemorrhoidopexy, or laser hemorrhoidoplasty (LHP), which differ in postoperative pain, recovery, morbidity, and satisfaction. The primary outcome was pain on the Visual Analogue Scale (VAS) at postoperative day 1 (POD1). Secondary outcomes were VAS at day 7 (postoperative day 7), operative time, hospital stay, recovery time, complications graded by the Clavien-Dindo classification, bleeding, continence (Cleveland Clinic Florida Fecal Incontinence Score (Wexner Score)), three-month recurrence, and satisfaction. Methods In this prospective observational study at a tertiary care center, 180 patients aged 18-60 years with Grade III-IV hemorrhoids were enrolled over six months by consecutive sampling into three groups of 60: open hemorrhoidectomy, LHP, and stapled hemorrhoidopexy, each followed for three months. Allocation was non-random, determined by clinical suitability, device availability, affordability, and patient preference. Anesthesia, analgesia, and pain-assessment timing were standardized. Longitudinal VAS data were analyzed with a linear mixed-effects model with Bonferroni-adjusted pairwise contrasts, reported as mean differences with 95% CIs. Categorical outcomes used the chi-square or Fisher's exact test. Multivariable regression adjusted for age, sex, BMI, hemorrhoid grade, and socioeconomic status, with a propensity-score sensitivity analysis. Fifty-six patients per group gave 80% power to detect a mean VAS difference of 1.5 (SD 2.5) at alpha 0.05; 60 were enrolled per group. A two-sided p < 0.05 was significant. Results Measured baseline characteristics were similar (mean age 39.1 ± 7.2, 38.2 ± 6.8, and 38.5 ± 7.0 years for laser, open, and stapled; p = 0.890). LHP showed lower VAS at POD1 (4.04 ± 1.36) than open (7.53 ± 1.28; mean difference -3.49, 95% CI -3.97 to -3.01) and stapled (5.12 ± 1.10; -1.08, 95% CI -1.53 to -0.63) procedures (p < 0.001). Operative time (22.4 ± 4.5 vs. 29.1 ± 5.2 and 39.6 ± 6.8 minutes) and hospital stay (1.2 ± 0.4 vs. 1.8 ± 0.6 and 2.7 ± 0.8 days) were shortest after laser surgery (both p < 0.001). Recovery was fastest after laser surgery (10.72 ± 3.10 days) vs. stapled (13.85 ± 3.50) and open (20.40 ± 4.20) (p < 0.001). Urinary retention was least frequent after laser treatment (3.3% vs. 15.0% and 13.3%; p = 0.080), reaching significance after adjustment (adjusted OR 0.22, 95% CI 0.04-0.86). Good or excellent satisfaction at three months was highest after laser surgery (88.3%) vs. stapled (80.0%) and open (60.0%) (p < 0.001). All complications were Clavien-Dindo grade I-II, and three-month recurrence did not differ between groups (p = 0.548). Conclusions All three modalities were safe and effective in the short term, with no complication exceeding Clavien-Dindo grade II and no mortality. LHP produced the shortest operative time, shortest hospital stay, least early pain, fastest return to activity, and highest three-month satisfaction, with stapled hemorrhoidopexy consistently intermediate and converging with laser by the end of the first postoperative week. These findings support individualized technique selection according to disease morphology, patient priorities, and available resources.