1. Hemorrhoidal Artery Ligation without Doppler Guidance vs Rubber Band Ligation: A Pilot Study
Dr Arbin Joshi
Dr Santosh Mishra
Dr Shantabir Maharjan
Prof Rajesh Gongal
Patan Academy of Health Sciences (PAHS)

2. Haemorrhoid………… Options Patient friendly procedure????
Rubber Band Ligation
Stapled Haemorrhoidectomy
Open Haemorrhoidectomy
Patient friendly procedure????

3. Haemorrhoidal Artery Ligation (HAL)
Ligating the terminal branches of superior rectal artery.
Developed in 1995 (Morinaga 1995, AmJGastro)
Decreasing the arterial blood flow decrease the bleeding.
Vascular anatomy of the anal canal – constant location of six terminal branches of SRA.

4. Objective
To assess feasibility and safety of HAL procedure without doppler guidance.
To determine immediate postoperative complications of HAL as compared to traditional Rubber band ligation (RuBL).

5. Methodology
Design
Prospective randomized controlled trial.
Randomization done by opaque envelope method by a single person.
Single surgeon.
Statistical analysis done by SPSS 16.0.

6. Inclusion Criteria Exclusion criteria Age above 18.
Symptomatic second and third degree hemorrhoids.
Not associated with malignancy, tuberculosis or IBD.
Exclusion criteria
Patients with co-morbidities.
Receiveing aspirin or warfarin.
Recurrent hemorrhoids.
Non-willing patients.

7. Procedure Lithotomy position Perianal block
Hemorrhoidal artery ligation done with 3:0 polyglycolic acid suture in ‘Z’ fashion at 1,3,5,7,9 and 11 o clock position.
5 days supply of paracetamol.
High residue diet, stool softeners and sitz bath advised.

9. Follow up Telephone follow up on day one. Follow up SOS.
Proctoscopic evaluation is planned only if
Patients come for follow up with complications.
Routinely after 6 weeks of the procedure.

10. Results HAL (n=10) RuBL (n=9) P value 43.6 (23-67) 43.8 (29-56) 0.957
Mean Age in years (range)
43.6
(23-67)
43.8
(29-56)
0.957
Gender (M:F ratio)
10:0
7:2
0.211
Third degree
1/10
1/9
0.737
History of bleeding
9/10
9/9
0.526

11. Results HAL (n=10) RuBL (n=9) P value 5 2 0.001 2/10 1/10 0.542 0/10 -
VAS on day one (median) 5 2
0.001
Came for follow up with complications
2/10
1/10
0.542
Persistent bleeding
0/10 -

12. Conclusion
HAL without Doppler guidance is a safe procedure with no serious postoperative complications.
Larger study can be carried based on this pilot study to assess the effectiveness of this procedure.

13. Significant hemorrhage in 3 patients. Overall recurrence
Seventeen articles.
1996 patients.
Postoperative pain 18.5%.
Significant hemorrhage in 3 patients.
Overall recurrence
9.0% for prolapse,
7.8% for bleeding, and
4.7% for pain at defecation

14. N=135
If doppler was not used, ligation in odd numbered position would have ligated all 6 terminal branches in 71% of patients.

15. Frequency of arteries at
Odd numbered positions %
3 97%
5 88%
7 98%
9 88%
11 100%
Even numbered positions
2 8.8%
4 6.6%
6 8.1%
8 5.1% %
12 5.9%
Avital et al 2012

16. Ann Surg 2012;255:840–845
N=82. Follow up upto 6 months.
Doppler transducer does not contribute to the beneficial effect of HAL.

17. Double blind RCT
N=48, Follow up 1 year.
Recurrence 4 vs 3 (p<0.93)
Doppler assistance offer no advantage and is time consuming.

18. Bronstein (2008), Pakravan (2010) and Tagariello (2010) – switched over to manual hemorrhoidopexy without doppler.

19. ………………………….. Medical Technology for surgical advancement.

20. Sometimes…….we don’t need Medical Technology for surgical advancement.
Thank you