Postoperative bleeding is a common and troublesome complication after hemorrhoidal surgery; thus, it is important to incorporate interventions with proven benefit in this regard. It was anticipated that the addition of HAL to LHP would be beneficial by lowering the incidence of postoperative bleeding, and thus reducing patient morbidity while increasing patient satisfaction.
Interestingly, our results did not show an advantage for the addition of HAL to LHP in decreasing the incidence of postoperative bleeding; in fact, there was a trend in the opposite direction, although not statistically significant. Although in principle HAL may seemingly reduce postoperative bleeding rates by dearterialization (i.e., by suture ligation) of the hemorrhoidal arteries [11, 12], this did not translate into clinical outcomes. This may be because LHP already coagulates the same vasculature by virtue of the laser ablation . Furthermore, these are consistent with some developmental theories of haemorrhoids  and with the postulations that all dearterialization techniques have the advantage of preserving the anatomy and physiology of the anal canal . In addition, the application of suture ligation creates additional sites for bleeding at the point of needle entry.
Most post-operative bleeding occurred within the first week, was mild and resolved spontaneously. The timing of bleeding after haemorrhoid surgery can be generally divided into immediate and delayed. Immediate bleeding is described as bleeding occurring within the first 48 hours of a procedure. The mechanism behind immediate bleeding is probably related to the loss of control of the vascular pedicle. Delayed bleeding, on the other hand, is defined as per rectal bleeding up to two weeks following the procedure which is more likely due local trauma or infection [5, 28]. Additionally, delayed bleeding may be influenced by postoperative analgesia especially when NSAIDS are being prescribed which can increase the incidence of bleeding .
This study revealed that postoperative bleeding rarely occurred in the post-operative period of six weeks. This phenomenon may be explained by the mechanism of action of the laser ablation itself. LHP results in gradual fibrosis of the hemorrhoidal tissue over a period of four to six weeks. Hence, most of the post-operative bleeding, if any, would naturally occur prior to this period. Fortunately, most per rectal bleeding following haemorrhoid surgery will resolve spontaneously. For those that do not, treatment would depend on two factors; the location of the bleeding and the degree of blood loss. External measures such as tamponade or compression with gauze or suture ligation at the bedside are usually successful in arresting the bleeding. Injection of local anaesthetic with adrenaline can also be performed at the bedside with a good success rate although such bedside procedures may be uncomfortable for the patient. Up to 15 to 33% of patients with bleeding after haemorrhoid surgery would be required for a re-operation [30, 31].
It is known that stapled haemorrhoidopexy has a higher re-bleeding rate compared to excisional haemorrhoidectomy with rates over 30% . Surprisingly, most of the re-bleeding cases will not have an identifiable source of bleeding by the time they are examined in the operating room and more often than not, a sponge or tamponade will just be placed in the anal canal. However, these significant bleeding episodes may even be recurrent and cause distress to both the patient and the surgeon  Here only a small percentage (2.63%) of re-bleeding patients needed a second procedure or operation to arrest the bleeding; i.e., two cases, one per group were re-admitted. These results are comparable to studies on post-operative bleeding in LHP in other centres [1, 5, 11, 33].
Despite the addition of HAL to the LHP, there was no significant difference in the operation time in both groups. This may be explained by the fact that the study was conducted in a colorectal centre, and the surgeons were familiar with both techniques. Hypothetically, if the procedure is performed by inexperienced surgeons, additional procedures on top of LHP may significantly prolong the operating time . Furthermore, an additional (but unnecessary) procedure may pose an increased risk of complications for the patient. Although most trials involving HAL were associated with a low re-bleeding rate, one study has been shown to have a postoperative bleeding rate of as high as 70% .
Perianal swelling was also completely resolved by the end of six weeks of surgery. In regards to the pain score (VAS), there was no clinical or statistically significant difference in between both groups since both LHP and HAL are minimally invasive procedures and non-excisional in nature [4–6]. In fact, most patients only experienced mild pain (median pain score = “2.00”) which were easily controlled with oral paracetamol and celecoxib.
There were no prior studies looking into the bleeding rate for LHP with HAL, therefore the sample size for this study was calculated based on a surrogate bleeding rate from HAL from another study model. This study design focused on a short-term follow-up at a single-centre only. Larger randomized trials are awaited to demonstrate the bleeding incidence, long-term outcomes (up to 2 years) and efficacy of combined LHP procedures is warranted.