Other Haemorrhoidal Treatments

M Saeed

Powerpoint File

Doppler Guided Haemorrhoidal Artery Ligation (DG-HAL)

The Haemorrhoidal Artery Ligation Operation is designed to treat haemorrhoids without the need for any external wounds

The operation uses a modified proctoscope housing a miniature Doppler transducer to locate the terminal branches of the superior rectal artery supplying the haemorrhoids as they come down from the rectum under the mucosa.

The device also has a small window which allows a suture to be placed around the artery thus cutting off the blood supply to the haemorrhoid. During the course of the procedure all the arteries supplying the haemorrhoids are located (up to 6) and tied off. Over the next few days and weeks the haemorrhoids regress in size and symptoms start to improve. This technique was introduced by a Japanese surgeon Morinaga in 1995.

The DG-HAL technique aims specifically at interrupting the arterial flow to the haemorrhoid which is thought to be the main factor in the aetiology. The design of the instrument ensures a maximum needle insertion of 5mm whereby only small pieces of mucosa & submucosa are taken thus providing safety. The insertion of a ring of sutures which bunches up mucosa results in pulling up the prolapse while interrupting its blood supply. The venous outflow is not affected but the inflow/outflow ratio drops significantly. The sutures are placed well above the dentate line and therefore the procedure is relatively painless and can be carried out under mild sedation. A new modification of the proctoscope now has a bigger window which allows an anopexy to be carried out.

This technique has been used for grade 2 & 3 haemorrhoids but now with an anopexy window in the newer proctoscope it can be applied to grade 4 haemorrhoids. Follow up periods of upto a year have shown significant improvement in symptoms but randomised studies with longer follow up are required.

1. Morinaga K et al A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am J Gastroenterology 1995; 90:610-613
2. Felice G et al Doppler guided hemorrhoidal artery ligation: an alternative to hemoohoidectomy Diseases of Colon & Rectum 2005; 48:2090-2093
3. Greenberg R et al First 100 cases with Doppler guided hemorrhoidal artery ligation Diseases of Colon & Rectum 2006; 49: 485-489

Ligasure Haemorrhoidectomy

Conventional haemohhoidectomy is associate with considerable pain and prolonged hospital stay. The standard techniques include the Milligan Morgan (open) or the Ferguson (closed) techniques. Other techniques include the stapled anopexy but this is associated with certain complications and therefore no single procedure is superior. Haemorrhoidectomy using Ligasure diathermy has been described. The underlying principle of haemorrhoidectomy with ligasure is the same as for standard Ferguson method with only difference being the choice of diathermy. Several studies have shown Ligasure haemorrhoidectomy to be associated with less postoperative pain and reduced operative time when compared with conventional techniques.

1. Palazzo FF et al Randomised clinical trial of Ligasure versus open haemorrhoidectomy, Br J Surg 2002; 89:154-7
2. Jayne DG et al Randomised clinical trial of ligasure versus conventional diathermy for day case haemorrhoidectomy. Br J Surg 2002;89:428-32
3. Franklin EJ et al Randomised clinical trial of Ligasure vs conventional diathermy in hemorrhoidectomy Dis Colon Rectum 2003; 46:138-1383