TO THE EDITOR
Circumferential prolapsed hemorrhoids (CPHs) represent a severe form of grade III and IV hemorrhoids that often requires surgical treatment[1]. The Milligan-Morgan hemorrhoidectomy (MMH), a classic and widely adopted procedure, remains the standard choice for hemorrhoids[2,3]. However, MMH is frequently associated with considerable postoperative pain, delayed wound healing, and notable impairment of anal function[4]. Thus, colorectal surgeons face the critical challenge of striking a balance between resecting sufficient pathological tissue to minimize recurrence and preserving enough healthy tissue to avoid stenosis. The innovation of transverse incision with longitudinal ligation (TILL) lies in its ability to address this dilemma effectively. By modulating anal tension and tightness during surgery, TILL enables the complete removal of hemorrhoids while simultaneously reducing the incidence of postoperative anal pain, stenosis, edema, and recurrence. Its distinctive combination of incision design and ligation technique optimizes anal canal tension while preserving adequate blood supply. As illustrated in Figure 1B (original text)[5], the transverse incisions at the anterior and posterior midline of the anal canal redirect wound contraction forces through a “breaking the circle” effect, providing a controlled release mechanism [original step (3)] that effectively lowers the risk of anal stenosis caused by circumferential scar contraction[6]. At the same time, the longitudinal ligation [original step (2)] follows the course of axial vessels in the anal canal, with staggered ligation points preserving the microcirculatory network within the mucosal bridges. This approach maximizes blood supply and lymphatic drainage, thereby markedly reducing postoperative edema. Another noteworthy feature of TILL is its attention to anal aesthetics, accomplished mainly through the transverse “I-shaped” incision design and meticulous trimming and adjustment of wound edges[5]. TILL procedure offers a distinct clinical advantage by achieving a balance between radical resection and functional preservation when compared with two traditional surgical techniques: (1) The MMH; and (2) The Whitehead hemorrhoidectomy. The MMH technique often fails to adequately preserve anal function during the removal of circumferential hemorrhoids, while the Whitehead procedure, although effective in completely excising hemorrhoidal tissue, has been largely abandoned in current surgical practice due to its high rate of postoperative anal deformity. A major technical feature of the TILL procedure is the division of large hemorrhoidal masses using transverse incisions followed by longitudinal ligation, which effectively reduces tension at individual ligation sites. This method enables simultaneous modulation of tension between the ligated vascular pedicles and the resting pressure of the anal canal during surgery. The concept of "tension modulation" forms the theoretical foundation of the TILL technique. Further investigation is needed to clarify how this modulation influences local microcirculation, lymphatic drainage, and neural pathways, which may contribute to reduced postoperative edema and pain. Experimental studies using techniques such as direct tissue pressure measurement and blood flow perfusion imaging could provide valuable quantitative evidence and strengthen the scientific understanding of this mechanism.
OUR OBSERVATIONS AND REFLECTIONS
Nonetheless, both the procedure itself and the clinical trial by Song et al[5] are not without limitations. The following are our observations and reflections. First, it should be acknowledged that patients were enrolled during the clinical observation period. Although the retrospective study design incorporated block randomization, this approach may still introduce unmeasured confounding and potential bias. For example, surgeon-related variability can directly influence surgical outcomes[7] and should therefore be considered as a covariate. Second, the six-month follow-up period is inadequate for evaluating long-term recurrence rates and the stability of anal function, particularly with respect to changes in continence over time[8]. Extending the follow-up duration with periodic assessments would provide more clinically meaningful data on the long-term efficacy and safety of TILL. The study applied relatively strict and uniform protocols for the technical execution of both TILL and MMH, with all procedures performed according to standardized schemes, which helps to mitigate, at least in part, the influence of technical variability on outcomes. Nonetheless, the absence of patient-reported outcomes (PROs) – including postoperative quality of life assessments and overall patient satisfaction – limits the comprehensiveness of the therapeutic evaluation[9]. Incorporating validated PRO instruments, such as Hemorrhoidal Symptom Score[10], Short Form Health Survey (SF-36 or SF-12) and EuroQol-5 Dimension, would provide a more holistic assessment of treatment benefits and patient-centered outcomes[11].
From another perspective, the field of hemorrhoidal surgery has been evolving rapidly toward minimally invasive approaches. The procedure for prolapse and hemorrhoids (PPH) and energy device-assisted hemorrhoidectomy, utilizing tools such as ultrasonic scalpels and LigaSure, have emerged as important alternatives for the management of hemorrhoids[12,13]. Compared with traditional MMH, PPH provides notable advantages in terms of postoperative pain control and faster wound healing[14]. Similarly, energy-based devices such as ultrasonic scalpels and LigaSure enable precise dissection and effective vessel sealing, permitting MMH-style resection while reducing intraoperative bleeding and limiting thermal injury to surrounding tissues[14,15]. Minimally invasive procedures, such as laser hemorrhoidoplasty and radiofrequency ablation, cause minimal tissue damage[15,16], whereas tissue-selecting therapy is appreciated for its precision and reduced postoperative pain[17]. However, these techniques often face limitations in achieving complete correction of severe CPHs. In comparison, TILL procedures provide a balanced approach that offers distinct advantages in managing such complex cases. Therefore, TILL represents a valuable complementary technique within the range of evolving surgical options, contributing to greater therapeutic flexibility and allowing for more individualized treatment of patients with different forms of hemorrhoidal disease.
Based on our clinical experience, the TILL technique is a promising approach with significant clinical potential. Our team has substantial expertise in the diagnosis and management of anorectal disorders, particularly in performing surgical treatments for mixed hemorrhoids. For patients with grade III or IV CPH, conventional hemorrhoidectomy has long been our standard procedure, providing high cure rates and low recurrence. However, postoperative complications continue to present challenges for both clinicians and patients. Postoperative pain is almost inevitable; despite careful patient selection and the routine use of patient-controlled analgesia, many patients still experience severe discomfort. This expected pain often discourages patients with severe symptoms from opting for surgery. In addition, postoperative wound edema commonly causes anxiety regarding the healing process. In contrast, the TILL technique offers comparable therapeutic outcomes while substantially reducing postoperative pain and anal edema and promoting faster wound healing. As colorectal surgeons, we find these advantages to be highly significant and supportive of the wider application of the TILL procedure in suitable clinical scenarios.
CONCLUSION
In conclusion, despite the methodological limitations inherent in the existing evidence presented by Song et al, the TILL technique exhibits considerable advantages over the conventional MMH method for the treatment of CPHs. It is anticipated that future large-scale, multicenter clinical trials with prolonged follow-up periods will further substantiate its clinical efficacy and safety, thereby establishing it as a significant advancement in contemporary hemorrhoid treatment procedures.
ACKNOWLEDGEMENTS
The authors are grateful to the investigators of the original study for their valuable contribution, which served as the basis for this commentary.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B, Grade B
Novelty: Grade C, Grade C
Creativity or Innovation: Grade C, Grade C
Scientific Significance: Grade B, Grade B
P-Reviewer: Kayılıoğlu I, MD, Associate Professor, Türkiye; Xiang F, MD, Professor, China S-Editor: Luo ML L-Editor: A P-Editor: Lei YY
