Modified HAL-RAR proced ure for treatment of high -grade hemorrhoids and red uction of mucosal rectal prolapse

Abstract

The essential of the Doppler-guided hemorrhoid arterial ligation (HAL) operation is the high, exact and selective ligation of the arteries supplying blood to the hemorrhoids guided by disappearance of the Doppler signal. Recto Anal Repair technique (RAR) is an anorectal mucopexy performed for cases with expressed anorectal prolapse. This allows making one-session hemorrhoid arterial ligation and reduction of mucosa prolapse. If there is anal fissure or perianal this method should be combined with fissurectomy, fistulotomy or fistulectomy and excision of hypertrophic anal papillae. We review the existing knowledge published on various problems and aspects of HAL and RAR procedures for treating hemorrhoids with mucosa prolapse as well as regarding and comparing the other methods for treating hemorrhoids and reduction of mucosa prolapse. We assess the designed concept for this operation, anesthesia, postoperative care, results, complications, need of second HAL-RAR procedure. For 2005-2012 period, we performed 717 HAL-RAR operations. Our patients were mostly in III and IV stage (90%) (n=501). Some patients had history for hemorrhoid operation: Whitehead hemorrhoidectomy - 6; cryosurgery - 9; rubber band ligation - 38; Longo operation - 9. Our concept: For hemorrhoids stages I and II without prolapse we performed HAL procedures - 6 to 12 sutures. For stages III and IV - HAL-RAR procedures - with 6 to 12 HAL sutures and 4 to 6 RAR sutures. We modified the RAR suture, starting placing it from below to above; and usually using the simple HAL anoscope. For the prolabing fibrous mucosa-cutaneous doublicatures or hypertrophic anal papillae now we prefer always to perform simultaneous excision. Until the end of 2006, we made simultaneous excision in 35% of cases but 1 to 6 months later we had to perform excision under local anesthesia in 30% of the rest ones. Regress of the symptoms of hemorrhoids is achieved in 4-6 weeks after operation. In the first 7-14 postoperative days, patients feel tension, tenesmus, call for defecation, slight bleeding. Out of all 717 patients we had serious complications in: 1) Significant bleeding with blood transfusions in 3 patients and operative hemostasis in 1 of them. No pelvic sepsis; 2) Thrombosis of the hemorrhoids occurred in 3 patients. When we operate on thrombosed hemorrhoids and to avoid thrombosis in the end of procedure we make slight incisions on some of the piles and extract the thrombus. Unsatisfying results after the procedure - 5% of all patients continue to have complaints such as pain and discomfort. To 5% of stage IV patients we offer a second HAL-RAR procedure to achieve maximal prolapse reduction. In 15 patients we made excision of the mucosa-cutaneous doublicatures 1-5 months after the HAL-RAR procedure. HAL-RAR procedure is adequate technique for treating hemorrhoids of all stages and mucosa prolapse reduction. It is versatile and may be combined with other methods. As a minimally invasive operation, it is less painful, less analgetics are used postoperatively and is cost-effective. It allows shorter postoperative hospital stay and early return to the everyday activities.