Invest Clin 62(3): 230 - 235, 2021 https://doi.org/10.22209/IC.v62n3a04

Corresponding author: Mahmut Said Degerli. Department of General Surgery, University of Health Sciences, Ha-

seki Training and Research Hospital, Istanbul, Turkey. Phone number: +90536 957 86 88. E-mail: drmsdegerli@

gmail.com

Hemorrhoidal artery ligation without using

a doppler guide: Is it a feasible and safe

technique?

Mahmut Said Degerli, Dogan Yildirim, Mikail Cakir, Okan Murat Akturk, Orcun Alpay,

Alp Omer Canturk, Omer Faruk Kandaz and Muzaffer Akinci

Department of General Surgery, University of Health Sciences, Haseki Training and

Research Hospital, Istanbul, Turkey.

Key words: hemorrhoidal disease; hemorrhoidal artery ligation; doppler-guided

hemorrhoidal artery ligation.

Abstract. The objective of this work was to analyze the results of the hem-

orrhoidal artery ligation technique without using a doppler guide, in patients

with grade 3 hemorrhoidal disease; by evaluating cost-effectiveness, operation

time, recurrence rate, postoperative pain, and secondary outcomes. A hemor-

rhoidal artery ligation procedure, without using a doppler guide, was performed

on 43 patients (15 females, 28 males) with grade 3 symptomatic hemorrhoidal

disease, from June 2015 to June 2019, in the Haseki Training and Research

Hospital, Istanbul, Turkey. Patients were followed up clinically for one month.

They completed a questionnaire within one year after their procedure. The me-

dian age was 46 years (range: 24 to 82 years). The main complaints were bleed-

ing in 27 patients, pain in 22 patients, and skin tag in 14 patients. The mean

preoperative VAS score was 3.4. The mean operating time was 18 mins (range:

13 to 25 min). All patients remained hospitalized for 24 h. Reoperation was

necessary for only one patient because of bleeding. One year after the surgery,

the pain was resolved in 21 (95.4%) out of 22 patients with preoperative pain,

and bleeding resolved in 25 (92.5%) out of 27 patients with preoperative bleed-

ing. The hemorrhoidal artery ligation is a simple method with a shorter learn-

ing curve producing similar postoperative results to other surgical procedures.

The surgical technique is cost-effective as it does not require any particular

device (anoscope with Doppler ultrasound) to apply.

Hemorrhoidal artery ligation without Doppler 231

Vol. 62(3): 230 - 235, 2021

Ligadura de la arteria hemorroidal sin utilizar guía doppler:

¿Es una técnica factible y segura?

Invest Clin 2021; 62 (3): 230-235

Palabras clave: enfermedad hemorroidal; ligadura de la arteria hemorroidal; ligadura de

la arteria hemorroidal guiada por doppler.

Resumen. El objetivo del trabajo fue analizar los resultados de la técnica de

la ligadura hemorroidal sin usar una guía doppler en pacientes con enfermedad

hemorroidal de grado 3, evaluando el costo-efectividad, el tiempo de operación,

la tasa recurrente, el dolor posoperatorio y los resultados secundarios. Se reali-

zó el procedimiento de la ligadura de la arteria hemorroidal, sin usar una guía

doppler, en 43 pacientes (15 mujeres, 28 hombres) con enfermedad hemorroidal

sintomática de grado 3, desde junio del 2015 hasta junio del 2019, en el “Ha-

seki Training and Research Hospital, Istanbul, Turkey”. Los pacientes tuvieron

un seguimiento clínico por un mes. Ellos completaron un cuestionario dentro

de un año después de su procedimiento. La edad media fue 46 años (rango, 24

a 82 años). Las principales quejas fueron sangrado en 27 pacientes, dolor en 22

pacientes y acrocordón de la piel en 14 pacientes. La puntuación media preope-

ratoria VAS fue 3.4. El tiempo medio de la operaciún fue 18 mins (rango: 13 a 25

min). Todos los pacientes quedaron hospitalizados por 24 h. La re-operación fue

necesaria para un solo paciente, debido al sangrado. Un año después de la ciru-

gía, el dolor se resolvió en 21 de 22 pacientes (95,4%) con dolor preoperatorio; y

el sangrado se resolvió en 25 de 27 pacientes (92,5%) con sangrado preoperato-

rio. La ligadura de la arteria hemorroidal es un método simple con una curva de

aprendizaje más corta produciendo resultados postoperatorios similares a otros

métodos. La técnica quirúrgica es rentable ya que no requiere utilizar ningún

dispositivo en particular (anoscopio con ecografía doppler).

Received: 14-02-2021 Accepted: 15-05-2021

INTRODUCTION

Hemorrhoidal disease (HD) is one of

the most frequent reasons for consultation

in proctology. Between 4.4 and 39% of the

general population is estimated to be affect-

ed by HD (1-3). There are three treatment

options available in the literature to cure

this disease: medical treatments, instrumen-

tal treatments (elastic ligation, sclerosis),

and surgical treatments. Where conservative

treatments have failed, surgical intervention

needs to be performed to treat hemorrhoids.

There is no consensus on a gold standard

treatment. Since excisional hemorrhoidec-

tomy (EH) is associated with severe pain and

a high rate of chronic complications, less in-

vasive techniques have been developed with

lower pain and complication rates. EH is still

the preferred technique most widely used.

Newer techniques, such as doppler-guided

transanal hemorrhoidal artery ligation (DG

HAL), are considered alternatives to EH

(Milligan-Morgan or Ferguson).

DG HAL was first described by Morina-

ga (4). DG HAL is a technique that uses an

232 Said Degerli et al.

Investigación Clínica 62(3): 2021

ultrasound probe to detect hemorrhoidal ar-

teries for ligation. Studies that compare DG

HAL and EH show that postoperative pain

was lower and symptom resolution was sig-

nificantly higher in the DG HAL procedure.

No differences have been found in morbidity

and recurrence rate (5,6).

The purpose of the paper is to provide

an overview of the hemorrhoidal artery li-

gation (HAL) technique. We analyze the

results of the hemorrhoidal artery ligation

technique without using a doppler guide in

patients with grade 3 HD by evaluating cost-

effectiveness, operation time, recurrence

rate, postoperative pain, and secondary out-

comes.

METHODOLOGY

Study design

A retrospective observational study was

conducted in patients with grade 3 hemor-

rhoidal disease treated with hemorrhoidal

artery ligation without using a doppler

guide (HAL) at our general surgery unit

from June 2015 to June 2019. All patients

were operated on by the same surgeon who

has extensive experience in performing the

procedure. The study was conducted with

approval from the Ethics Committee of the

University of Health Sciences, Haseki Train-

ing and Research Hospital (Ref No. 2020/79

Date: 27.05.2020).

Inclusion criteria: patients over 18

years old with grade 3 symptomatic hemor-

rhoidal disease who did not respond to con-

servative treatment.

Exclusion criteria were the following;

previous anorectal surgery, HD other than

grade 3, associated recto-anal disease (peri-

anal fistulas, anal fissures, rectal prolapse,

perianal abscess, fecal incontinence, anal

stenosis).

Hemorrhoidal artery ligation without

using a doppler guide was performed in 43

patients with grade 3 HD (15 females, 28

males). All patients were diagnosed with

grade 3 hemorrhoidal disease via proctos-

copy at our institution. The grade of HD was

assessed based on Goligher’s classification

(7). Patients were followed up clinically for

one month. They completed a questionnaire

within one year after their procedure.

Surgical Technique

Preoperative preparation consisted of a

cleaning enema administered the morning

of surgery. No prophylactic antibiotics were

administered. Operations were performed

in the modified lithotomy position with legs

spread apart on supports under spinal anes-

thesia.

The proctoscope was introduced into

the anal canal. Distal branches of the supe-

rior rectal artery were conventionally posi-

tioned at 1, 3, 5, 7, 9, and 11 h. After the

exploration and identification of the hemor-

rhoids, hemorrhoidal packs were held with a

clamp. Ligations were made with a Z-shape

suture using 2-0 absorbable polyglycolic acid

at 3 cm above the dentate line to the pro-

jection of the hemorrhoidal packs. No tissue

was excised. No further procedures were per-

formed.

Postoperative care and complications

All patients were hospitalized for 24 h

after the procedure. The patients were dis-

charged when adequate pain control and

spontaneous micturition were achieved after

examination by the surgeon to discard im-

mediate complications. Postoperative con-

sultations were scheduled to be held one

week and one month after the procedure.

The ambulatory treatment consisted of an

osmotic laxative, and paracetamol (1 g) for

7 days was prescribed to all the patients. No

diet was suggested before or after the sur-

gery.

During the scheduled appointments,

none of the patients had anal stenosis or

incontinence. Only one patient visited the

hospital for bleeding. The patient was hospi-

talized for 48 h for blood transfusion, moni-

toring, blood pressure control, and re-oper-

ated (Milligan-Morgan). Complications were

Hemorrhoidal artery ligation without Doppler 233

Vol. 62(3): 230 - 235, 2021

classified by Clavien-Dindo classification (8).

No other complication or death had been re-

corded.

Data Collection

Pain was measured by using the Vi-

sual Analogic Scale (VAS), ranging from no

pain (VAS:0) to the worst imaginable pain

(VAS:10).

All patients were hospitalized for 24 h

following the procedure. After the physical

examination was performed and postopera-

tive pain was recorded using the VAS, pa-

tients were discharged.

Documented postoperative symp-

toms, such as pain, bleeding, urinary re-

tention, and rectal discomfort during

scheduled appointments, were analyzed

retrospectively.

RESULTS

The HAL procedure was performed on

43 patients with grade 3 symptomatic hem-

orrhoids (15 females and 28 males), from

June 2015 to June 2019. The median age

was 46 years (range: 24 to 82 years). All

patients had a history of persistent hem-

orrhoidal symptoms despite receiving con-

servative treatments. All patients were di-

agnosed with grade 3 hemorrhoidal disease

via proctoscopy in our institution. The main

complaints were bleeding in 27 patients,

pain in 22 patients, and skin tags in 14 pa-

tients. The mean preoperative VAS score

was 3.4.

Spinal anesthesia was used for all pa-

tients. The mean operating time was 18 min

(range: 13 and 25 min). The number of hem-

orrhoidal artery ligations performed was two

in six patients and three in 37 patients. All

patients remained hospitalized for 24 h.

When the complications were evalu-

ated, reoperation in one patient because of

bleeding was the only complication within

24 h. However, no significant complications

were observed in any patient up to the 30th

postoperative day.

In the first postoperative week, tenes-

mus was reported by two patients, headache

by seven, urinary retention was present in

three, and superficial infection in one pa-

tient. However, all of these disappeared dur-

ing the 13th-day controls.

In conclusion, one year after the sur-

gery, the pain was resolved in 21 (95.4%) of

22 patients with preoperative pain; bleeding

resolved in 25 (92.5%) out of 27 patients

with preoperative bleeding. The mean VAS

score was 1.1.

DISCUSSION

Hemorrhoidal disease is seen with a

prevalence of up to even 39% in the general

population (1,9). According to our clinical

experience, the presence of such a high rate

of hemorrhoidal disease is not an acceptable

rate. Among the reasons for the high rates

mentioned in the publications, we can count

the patients’ referring to every problem in

the anus region as hemorrhoids, biases in

survey studies, and problems in consulting

a doctor about feelings of embarrassment.

When reaching out to clinicians who can

make the correct diagnosis, we believe that

the 4.4% rate reported by Johanson et al.

better reflects the reality (10).

While the widely accepted approach in

its treatment is conservative, such as diet,

lifestyle changes, and topical treatments in

grade 1 and grade 2 diseases, more invasive

treatments are necessary for grade 3 and

grade 4 diseases (11–13).

The optimal procedure for the surgical

treatment of hemorrhoidal disease is still

controversial. New minimally invasive tech-

niques have developed as an alternative to

traditional and invasive procedures, such as

excisional hemorrhoidectomy.

One of these techniques, DG-HAL, has

become one of the leading surgical applica-

tions in treating symptomatic hemorrhoidal

diseases (14). The technique has many ad-

vantages, such as being minimally invasive

and easy to apply (15-17).

234 Said Degerli et al.

Investigación Clínica 62(3): 2021

In previous prospective randomized tri-

als comparing DG HAL and EH, DG HAL pro-

duce less operative pain and morbidity with a

similar long-term recurrence rate and report

similar chronic complications after hemor-

rhoidectomy alone (5,6). Carvajal-López et

al. compared DG-HAL-RAR (doppler guided

transanal hemorrhoidal artery ligation with

recto-anal repair) with EH and found that

the early postoperative pain was less in the

group that underwent hemorrhoidal artery

ligation (5). Trenti et al., in their study, com-

pared DG-THD (doppler-guided transanal

hemorrhoidal dearterialization with muco-

pexy) with conventional hemorrhoidectomy.

These authors emphasized that DG-THD was

not a more inferior technique than conven-

tional surgery (18).

The disadvantages of the DG-HAL tech-

nique include requiring a special procto-

scope with a doppler transducer, being cost-

ly; and the necessity for a learning process.

On the other hand, HAL is a simple

method with a shorter learning curve that

produces similar postoperative results. The

surgical technique is cost-effective, as it

does not require any particular device (dop-

pler ultrasound anoscope) for its implemen-

tation. The HAL procedure offers shorter

surgical time and similar postoperative out-

comes using only sutures.

According to our HAL experience, the

controls on the first and 13th days after sur-

gery yielded follow-up results that were least

dependent on the person and were least af-

fected by subjective personal characteristics.

In the first postoperative week, subjective

complaints due to the surgical wound in the

outpatient clinic were quite different from

person to person, even increasing VAS score

beyond levels of preoperative days. These

complaints were temporary. Tenesmus was

reported by two patients, headache by seven,

urinary retention was present in three, and

superficial infection in one patient. However,

all of these disappeared during the 13th-day

controls. Thus, more analytical results were

obtained after one month. Therefore, the

findings on the first and 30th days were em-

phasized more in the foreground in our study.

When we compare the results of our

study with the literature, Hoyuela et al.

found tenesmus was present in nine of their

30 patients (30%), postoperatively, in their

prospective study regarding DG-HAL-RAR.

In our series, tenesmus was reported only

by two patients (4.65%). In the same study,

the VAS score was 0.7 after one month (15).

However, our VAS result was 1.1. In their

DG-THD study, Trenti et al. found urinary

retention in 9.6% of patients. In the study

at hand, our rate of urinary retention was

6.9% (18). Regarding headache, Bansal et al.

reported 24% in their study, which was 16%

in the present study (19). When superficial

infections were evaluated, our results were

similar compared to the literature; Trenti et

al. reported a rate of 2.4%, which was almost

identical to our rate of 2.3% (18).

The design of this study has limitations.

There were no DG HAL and EH groups to be

compared. Further prospective studies that

compare HAL and DG HAL techniques with a

larger group of patients should be conducted.

REFERENCES

1. Loder PB, Kamm MA, Nicholls RJ, Phi-

llips RK. Haemorrhoids: pathology, patho-

physiology and aetiology. Br J Surg 1994;

81(7):946-954.

2. Mott T, Latimer K, Edwards C. Hemorr-

hoids: diagnosis and treatment options. Am

Fam Physician 2018;97(3):172-179.

3. Hollingshead JR, Phillips RK. Haemorr-

hoids: modern diagnosis and treatment.

Postgrad Med J 2016;92(1083):4-8.

4. Morinaga K, Hasuda K, Ikeda T. A novel

therapy for internal hemorrhoids: ligation

of the hemorrhoidal artery with a newly de-

vised instrument (Moricorn) in conjunction

with a Doppler flowmeter. Am J Gastroente-

rol 1995;90(4):610-613.

5. Carvajal López F, Hoyuela Alonso C, Ju-

vany Gómez M, Troyano Escribano D,

Trias Bisbal MA, Martrat Macià A, Ardid

Brito J. Prospective randomized trial com-

Hemorrhoidal artery ligation without Doppler 235

Vol. 62(3): 230 - 235, 2021

paring HAL-RAR versus excisional hemo-

rrhoidectomy: postoperative pain, clinical

outcomes, and quality of life. Surg Innov

2019;26(3):328-336.

6. Ferrandis C, De Faucal D, Fabreguette JM,

Borie F. Efficacy of Doppler-guided hemo-

rrhoidal artery ligation with mucopexy, in

the short and long terms for patients with

hemorrhoidal disease. Tech Coloproctol

2020;24(2):165-171.

7. Elmér SE, Nygren JO, Lenander CE. A

randomized trial of transanal hemorrhoi-

dal dearterialization with anopexy compa-

red with open hemorrhoidectomy in the

treatment of hemorrhoids. Dis Colon Rec-

tum 2013;56(4):484-490.

8. Clavien PA, Barkun J, de Oliveira ML,

Vauthey JN, Dindo D, Schulick RD, de

Santibañes E, Pekolj J, Slankamenac K,

Bassi C, Graf R, Vonlanthen R, Padbury

R, Cameron JL, Makuuchi M. The Cla-

vien-Dindo classification of surgical com-

plications: five-year experience. Ann Surg

2009;250(2):187-196.

9. Riss S, Weiser FA, Schwameis K, Riss T,

Mittlböck M, Steiner G, Stift A. The preva-

lence of hemorrhoids in adults. Int J Colo-

rectal Dis 2012;27(2):215-220.

10. Johanson JF, Sonnenberg A. The prevalen-

ce of hemorrhoids and chronic constipa-

tion. An epidemiologic study. Gastroente-

rology 1990;98(2):380-386.

11. Alonso-Coello P, Guyatt G, Heels-Ansdell

D, Johanson JF, Lopez-Yarto M, Mills E,

Zhou Q. Laxatives for the treatment of he-

morrhoids. Cochrane Database Syst Rev.

2005;(4):CD004649. Published 2005 Oct 19.

12. Alonso-Coello P, Zhou Q, Martinez-Zapata

MJ, Mills E, Heels-Ansdell D, Johanson JF,

Guyatt G. Meta-analysis of flavonoids for

the treatment of haemorrhoids. Br J Surg

2006;93(8):909-920.

13. Perera N, Liolitsa D, Iype S, Croxford A,

Yassin M, Lang P, Ukaegbu O, van Issum

C. Phlebotonics for haemorrhoids. Cochra-

ne Database Syst Rev 2012;(8):CD004322.

14. van Tol RR, Bruijnen MPA, Melenhorst J,

van Kuijk SMJ, Stassen LPS, Breukink

SO. A national evaluation of the manage-

ment practices of hemorrhoidal disease

in the Netherlands. Int J Colorectal Dis

2018;33(5):577-588.

15. Hoyuela C, Carvajal F, Juvany M, Troyano

D, Trias M, Martrat A, Ardid J, Obiols J.

HAL-RAR (Doppler guided haemorrhoid ar-

tery ligation with recto-anal repair) is a safe

and effective procedure for haemorrhoids.

Results of a prospective study after two-

years follow-up. Int J Surg 2016;28:39-44.

16. Banai Z, Harkai Z, Király L, Szekeres P,

Ottlecz I. HAL-RAR-műtét – egy új, non-

invasiv lehetőség az aranyerek kezelésére

[HAL-RAR for the treatment of hemorrhoi-

ds - a new, non invasive method]. Magy Seb

2019;72(4):161-166.

17. Rodoman GV, Kornev LV, Shalae-

va TI, Malushenko RN. Éffektivnost›

kombinirovannoĭ metodiki lecheniia gemo-

rroia s ispol’zovaniem HAL-RAR i lazernoĭ

destruktsii uzlov [Efficiency of combined

methods of hemorroid treatment using

hal-rar and laser destruction]. Khirurgiia

(Mosk). 2017;(5):47-51.

18. Trenti L, Biondo S, Galvez A, Bravo A,

Cabrera J, Kreisler E. Correction to: Dis-

tal Doppler-guided transanal hemorrhoi-

dal dearterialization with mucopexy versus

conventional hemorrhoidectomy for grade

III and IV hemorrhoids: postoperative mor-

bidity and long-term outcomes. Tech Colo-

proctol 2018;22(6):479.

19. Bansal H, Jenaw RK, Mandia R, Yadav

R. How to do open hemorrhoidectomy

under local anesthesia and its compari-

son with spinal anesthesia. Indian J Surg

2012;74(4):330-333.