The term “radiosurgery” has been used to indicate utilization of high frequencies, allowing a considerable improvement of several surgical techniques, including proctologic ones.

The LigaSure vessel sealing system ™ is a bipolar electrothermal device that seals blood vessels through an optimized combination of pressure and radiofrequency.

After providing pressure on the tissues by the LigaSure™ forceps application, the Force Triad energy platform™ generates energy tailored to the tissue impedance, reducing fusion cycle time and tissue desiccation with consistently controlled tissue effect. The completion of coagulation is signalled by the feedback sensors and the tissue can be excised along the line of coagulum.

LigaSure™ is different from conventional bipolar systems by using low voltage and high current and works at lower temperatures (50–80°C) than the electric scalpel (600°C).

LigaSure™ preserves the patient’s own collagen and uses it to form a permanent autologous seal that is strong enough to withstand up to three times the normal systolic (normal systolic: 120 mm/hg) on vessels or tissue bundles. This result makes LigaSure™ comparable to the mechanical methods of vessel occlusion; it ensures complete coagulation of arteries and veins up to 7 mm in diameter with minimal surrounding thermal spread up to 2 mm in diameter and limited tissue charring. Thus, a decrease in thermal injury at the surgical site may reduce anal spasm and pain. In addition, healing time is considerably shorter than that in the traditional techniques (14.8 days with LigaSure™ vs. 25.6 days with conventional diathermy in our experience (2)) and tissue damage is limited to the dissection line. The risk of cicatrization-linked stricture may also be reduced.

The area of thermal spread after monopolar electrocoagulation depends on many factors: time of application, power of electrocoagulation, and number of applications. Thermal injury after monopolar electrocoagulation, LigaSure™, bipolar electrocoagulation, and ultracision has been evaluated in many experimental studies (3). Monopolar electrocoagulation results in poorer hemostasis and more side-thermal injury of the adjacent tissue.

Open hemorrhoidectomy can be performed either in the lithotomy or prone position. In the lithotomy position, the buttocks are raised by a firm pad to project over the
edge of the table. In the prone position, the patient lies face down, hips on a 6-inch gel ridge, with the buttocks projecting upward. Although the prone position may help reduce venous circulation from the anorectal area, extra care should be taken to prevent restriction of breathing and ensure proper lung inflation during surgery. In both the positions, the buttocks are strapped back with an adhesive tape to facilitate access, especially for obese patients. Most surgeons perform LigaSure™ hemorrhoidectomy using an Eisenhammer retractor with the patient in the lithotomy position (Fig. 2.1).

A small V-shaped anodermal seal is formed by applying the precise LigaSure™ forceps close to the outer edge of the internal hemorrhoid (Fig. 2.2). The seal is then transected with scissors along the line of coagulum. Care should be taken in order to limit the
amount of tissue removed to minimize the risk of stricture (Fig. 2.3). Repeated applications of the device are performed and the excision is continued into the anal canal, lifting the pile from the internal anal sphincter (Fig. 2.4). The vascular pedicle is finally sealed by LigaSure™ and divided (Fig. 2.5).

The area is inspected with the Eisenhammer retractor to ensure hemostasis. The operation is terminated by placing a hemostatic absorbable gelatin sponge in the anal canal (Fig. 2.6). At the end of the operation, a single layer of nonadhesive gauze is used to dress the wounds. Finally, a large surgical dressing is applied to the buttocks and held in place with a bandage.

In the LigaSure™ hemorrhoidectomy, pedicles are not transfixed, but sealed by LigaSure™ to avoid incorporation of the underlying sphincter in the ligatures.