7.3.6 Results

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7.3 Stapled Hemorrhoidopexy (Procedure forProlapsed Hemorrhoids: PPH)

circular anal dilator (CAD) with an obturator is introduced into the anal canal. This causes a reduction of hemorrhoidal prolapse into the rectum. After removing the obturator, an anoscope is introduced through this dilator, pushing back the prolapsing mucosa against the rectal wall along a circumference of 270°. The mucous membrane that protrudes through an anoscope window is held with the help of a stitch. The anoscope is gradually rotated through the entire rectal circumference, 4 cm higher than the dentate line

Fig. 7.3 Stapler equipment

and proximal to the hemorrhoidal apex for com-

Fig. 7.4 (a–d) Stapler technique for hemorrhoids. (a) Insertion and xation of circular anal dilator. This is followed by insertion of anoscope. (b) Purse-string suture

being taken. (c) Insertion of stapler device after taking a purse-string suture. (d) Donut as seen after releasing the staplers. (Images courtesy Dr. Niranjan Agarwal)

7 Minimal Invasive Procedures forHemorrhoids

pleting a “purse-string” suture. The purse-string suture includes mucosa and submucosa. One should ensure that the purse string is complete and there are no gaps. A PPH 01/03 stapler is then unfolded to its extreme limit and inserted with the opened stapler head. This purse-string is then tied with one throw knot. Both suture ends are externally tied or are clamped with forceps.

Along the anal canal axis, the stapler is aligned and closed, keeping a normal amount of tension on the string. The stapler is closed at the end and kept in place for a minute to reduce the interstitial edema. A nger is passed into the vagina in a female patient to check the posterior vaginal wall and ensure this is not incorporated into the purse string. The stapler is red, releasing a row of double staggered titanium staples through the tissue. The tissue is excised using a circular stapler knife, and the mucosa is removed circumferentially. The stapler device is removed by opening the head. One should be very careful and inspect the stapler line to check if there is any bleeding. In the presence of bleeding, the bleeding area is reinforced with a gure of eight stitch using an absorbable suture. Some surgeons use spongostan to maintain hemostasis.

The donut is checked to ensure that it contains a 2-cm wide rectal mucosa strip [9, 11, 13].

7.3.6 Results

The procedure has a recurrence rate of 25.6–

53.3% [14] (Table7.2).

7.3.7 Complications

Many severe complications have been reported following stapled hemorrhoidopexy, including perforation peritonitis, rectal obstruction, fecal urgency, postoperative pain, rectovaginal stula, urinary retention, and pelvic sepsis [16]. The incidence of complications reported by various authors has been mentioned in Tables 7.3, 7.4, and 7.5. The pain was severe in a few studies, with persistent anal pain and a visual analog score higher than 7 [23]. This procedure should be painless, as the donut is removed above the dentate line.

Table 7.3 Incidence of urinary retention

Journal Year Urinary retention (%) Tech Coloproctol

B.Ravo [16] Dis Colon Rectum

Chung etal. [17] Heptogastroenterology

Araujo etal. [18] Dis Colon Rectum

Sultan [19]

Table 7.4 Incidence of bleeding after stapled hemorrhoidopexy

Journal Year Bleeding rate (%) Dis colon rectum

Ho etal. [20] Dis Colon Rectum

Cheetham etal. [21] Colorectal Dis

S.Sultan [19] J Gastrointest Surg

Kim S.J. [22]

2002 1.5

2005 6.9

2007 14

2010 9.3

2000 1.70

2003 13

2010 3–5

2013 4.2–7.5

Table 7.2 Recurrence rate after PPH

Journal Year Recurrence rate (%) Int J Colorectal Dis

K.Laughlan [15] Dis Colon Rectum

H.Otriz [14]

2009 8

2005 50

Table 7.5 Incidence of urgency after stapled hemorrhoidopexy

Journal Year Incidence of urgency (%) Hepatogastroenter-

ology Arajuo etal. [18]

J Gastrointest Surg Kim S.J. [22]

2007 3.60

2013 12

7.4 Comparison ofExcisional Hemorrhoidectomy withDGHAL andPPH

7.4 Comparison ofExcisional

Hemorrhoidectomy

Table 7.6 Comparative study of DGHAL and stapled

hemorrhoidopexy

withDGHAL andPPH

A comparison amongst excisional hemorrhoidectomy, DGHAL, and stapled hemorrhoidopexy for complications and recurrence has been mentioned in Tables 7.6, 7.7, 7.8, and 7.9.

Table 7.7 Comparative study of stapled hemorrhoidopexy with Milligan Morgan

Pain VAS

Journal Procedure Annals of

surgery Gravie J.F. [25]

Annals of surgery Gravie J.F. [25]

Milligan Morgan 4.20 3.1 0 3 1.8

Stapled hemorrhoidopexy

score

2.66 2.2 1 1 7.5

Journal Procedure Tech

Coloproctol S.Avital etal. [24]

Tech Coloproctol S.Avital etal. [24]

Hospital stay

Postoperative bleeding (%)

DGHAL 18 2.1

Stapled hemorrhoidopexy

Urinary retention (%)

Persistent bleeding (%)

3 5.5

Prolapse recurrence (%)

Pain VAS score

Table 7.8 Comparative study of DGHAL versus Milligan Morgan

Procedure Iranian Red Crescent

Medical Journal DGHAL [26]

Iranian Red Crescent Medical Journal Milligan Morgan [26]

Pain VAS score

1.2 92 2 0 2

4.6 67 2 6 10

No complication (%)

Bleeding (%)

Urinary retention (%)

Painful defecation (%)

Table 7.9 Recurrence rate of DGHAL, PPH, and Milligan Morgan

Journal Procedure Recurrence Journal of the Korean Society of Coloproctology

Wan Jo Jeong [27] Tech Coloproctol

C.Ferrandis [28] Gastroenterology Research and Practice

Min Zhai [9] Videosurgery and other Mininvasive Techniques

Maciej Michalik [29]

Dis Colon Rectum Ortiz etal. [14]

Trauma Monthly Seyed Mohsen [30]

The Egyptian Journal of Surgery Eskandaros [31]

European Surgery Andrea Cariati [32]

DGHAL 14.4%

DGHAL 35.6%

DGHAL 8%

Stapled hemorrhoidopexy 36% (relating to the degree

Stapled hemorrhoidopexy 53.3%

Stapled hemorrhoidopexy 7.5%

Milligan Morgan 5%

Milligan Morgan 2.5%

Milligan Morgan 0.5%

7 Minimal Invasive Procedures forHemorrhoids

of the hemorrhoidal prolapse)

specially designed, self-illuminated sliding

7.5 Transanal Suture

Rectopexy

valve proctoscope with a slit is inserted. The engorged mucosa and dentate line are then

visualized. For xation of the laxed submucosa In 2012, Dr. Chivate from India introduced this procedure [33].

and mucosa, the sutures are passed through the

mucosa, submucosa, and the internal sphincter

muscle, starting at the 3 o’clock position, 4cm

proximal to the dentate line [33]. A 30-mm

7.5.1 Principle

atraumatic 1/2 circle needle with 2-0 polyglac-

tin (Vicryl) is used for the stitch. After tying the The principle is based on dearterialization by blocking the vessels at two sites, 2 and 4cm above the dentate line, thus preventing the collateral formation and subsequent recurrence [33].

rst stitch, the next stitch is taken 1–2 mm

away, overlapping the rst stitch’s ending. Each

suture is taken 0.5–1 cm apart and is double

locked to prevent the purse-string effect. The

suture is carried out around the complete cir-

cumference of the rectal wall at the same level.

The second line of circumferential sutures is

7.5.2 Indications

taken 2 cm proximal to the dentate line. The

procedure is painless as all the sutures are Second to fourth degree hemorrhoids.

above the dentate line.

7.5.3 Technique

The patient is placed in a lithotomy position. A Sim’s speculum is introduced in the anal canal to compress and push the pile mass upwards. A

7.5.4 Results

A study was conducted on 166 patients with

hemorrhoids, who underwent transanal suture

rectopexy, to evaluate recurrence, hospital

7.6 Superior Hemorrhoidal Artery Embolization

stay, bleeding, complications, and pain. No continence impairment and recurrence were reported. However, long-term results are still awaited [33].

7.6 Superior Hemorrhoidal

Artery Embolization

Described rst in 2014 by Vidal etal., this procedure aims at occluding the blood ow in the hemorrhoidal arteries [34].

7.6.1 Principle

The principle is occlusion of the blood ow to the hemorrhoidal tissue following the “emborrhoid” method (embolization of hemorrhoidal arteries) by placing coils in the terminal branches of superior hemorrhoidal arteries [34, 35].

7.6.2 Indications

Grade 1 and 2 hemorrhoids.

7.6.3 Technique

The embolization is carried out via the right femoral route. A 5F introducer sheath is inserted using a Simmon catheter, and the inferior mesenteric artery is catheterized. By using a rapid transit microcatheter, the superior rectal arteries are catheterized. The coils used for the embolization are pushable microcoils (0.018) [34].

In 2020, the “Spaghetti technique” was proposed by Giurazza using oversized coils, which were released in a stretched manner in patients showing signs of hemorrhoidal bleeding and portal hypertension. This method helps avoid sudden blocking of the vessels and uses only a small amount of coils [36].

7.6.4 Results

The success rate is between 90% to 100%. In grade 3 and 4 hemorrhoids, there is no role for embolization. The long-term results are awaited [36].

7.7 Discussion

The basic principle in all minimally invasive procedures is “Dearterialization.” However, the recurrence rate is greater after PPH and DGHAL.Several technical factors may be accountable for the recurrence.

By ligating the distal branches of a superior hemorrhoidal artery and xing prolapsed hemorrhoids, the DGHAL procedure blocks blood ow in the distal branches of the superior rectal artery. A doppler allows for accurate localization of artery branches in the rectal wall [3].

The terminal branches of the superior rectal arteries become thin (0.6–2mm) and supercial (2mm deep), roughly 2–3cm above the dentate line [37, 38]. Because there are no interpositions of capillaries between the hemorrhoidal plexus and the arterial system, these terminal branches may be responsible for blood overow into hemorrhoidal tissue [38].

Suture ligations are carried out about 1 cm above a point where an arterial pulse is found using a doppler [37–39]. The creation of collaterals in a short period may be linked to the high recurrence rate [33].

The branching pattern of the superior hemorrhoidal artery is not constant in every patient. One-third of the individuals surveyed had one artery in an even-numbered clock position [37]. As a result, localization with a doppler is used to pinpoint the arteries appropriately [37]. DGHAL has a higher recurrence rate of roughly 12% for follow-ups of more than 12months and 5.3–6.7% for follow-ups of less than 12months [24, 40].

Finger-Guided hemorrhoidal artery ligation (FGHAL) is gaining popularity because it has

7 Minimal Invasive Procedures forHemorrhoids

similar results to DGHAL [41]. Although DGHAL is a simple procedure, the cost can be substantial. Identication of vessels with a nger is comparable to doppler detection in studies, casting doubt on the utility of Doppler for vascular localization.

Stapled hemorrhoidectomy is a well-known procedure devised as an alternative to traditional hemorrhoidectomy. It interrupts the branches of SHA, and the hemorrhoidal masses are restored to their anatomic position [42]. The PPH procedure reduces prolapsed tissue but not hemorrhoids since the hemorrhoidal tissue is not removed; instead, it is left to regress over time. The procedure does not entirely dearterialize the cushions. According to Aigner [37], reaching the postero-lateral “branches of the superior hemorrhoidal artery,” which are too high and too deep, is difcult. Furthermore, except for the submucosal branches, the other branches, such as the transmural and intramural branches, cannot be ligated. Only mucosectomy and auto suturing are performed in stapled hemorrhoidopexy [33].

Following PPH, studies have suggested chronic discomfort of unknown etiology. According to research, 15.1% of surgeons have seen patients in severe pain for months, and 2.4% have had patients in agonizing pain for years [43]. Chronic pain has been associated with brosis surrounding staples and direct trauma to the pudendal and sacral spindles of the nerve by staples [42, 43]. According to Ielpo et al. [44], over 1.59% of patients experienced chronic pain up to 7 months after PPH, which could only be eased by removing the staples.

In transanal suture rectopexy, “the transxation of the mucosa and submucosa is done with the internal sphincter, which prevents prolapse of the anal cushion” [33]. The vessels are blocked at 2 and 4cm, decreasing the risk of collaterals and recurrences [33].

The goal of superior hemorrhoidal artery embolization is to “occlude the superior rectal arteries” by an endovascular procedure. Selective embolization, the absence of direct damage to the anorectal region, and the preservation of anal cushions are all potential benets of the endo-

vascular technique [34, 35]. As a result, optimal outcomes could be obtained with minimal morbidity. The long-term benets are still unknown [34, 35].

DGHAL itself is ineffective at controlling hemorrhoid prolapse and may require additional surgical procedures like mucopexy in some cases [45].

Despite the benets of minimally invasive procedures, such as reduced postoperative discomfort and a quicker return to everyday life, the only factor restricting their acceptability is the high cost. Transanal suture rectopexy is the only technique that is cost-effective.

Take-Home Message

• As discussed, each approach has its limita-

tions. Minimally invasive procedures are less

painful and allow patients an early return to

work. They are associated with less morbid-

ity. However, it can be extrapolated from the

data that, regardless of the surgery, immedi-

ate postoperative pain and discomfort vary

from a VAS score of 3–4, which improves in

48–72h.

• Based on the principle of DGHAL to treat

hemorrhoids, I prefer a hybrid procedure,

nger- guided hemorrhoidal artery ligation

(FGHAL) with laser hemorrhoidoplasty

(LHP). DGHAL laid the basis for FGHAL

and transanal suture rectopexy. The effective-

ness of FGHAL is similar to that of

DGHAL.Although PPH is a minimally inva-

sive procedure, I do not practice it.

References

1. Blaisdell PC.Ofce ligation of internal hemorrhoids. Am J Surg. 1958;96:401–4.

2. Pata F, Gallo G, Pellino G, Vigorita V, Podda M, Di Saverio S, D’Ambrosio G, Sammarco G.Evolution of surgical management of hemorrhoidal disease: an historical overview. Front Surg. 2021;8:727059. https://

doi.org/10.3389/fsurg.2021.727059.

3. Morinaga K, Hasuda K, Ikeda T.A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn)

References

in conjunction with a Doppler owmeter. Am J Gastroenterol. 1995;90(4):610–3.

4. Scheyer M, Antonietti E, Rollinger G, Mall H, Arnold S.Doppler-guided hemorrhoidal artery ligation. Am J Surg. 2006;191(1):89–93. https://doi.org/10.1016/j.

amjsurg.2005.10.007.

5. Lienert M. Literature review on dearterialization of hemorrhoids and mucopexy. In: Ratto C, Parello A, Litta F, editors. Hemorrhoids, Coloproctology, vol. 2. Cham: Springer; 2018. https://doi.

org/10.1007/978- 3- 319- 53357- 5_41.

6. Yilmaz İ, Sücüllü İ, Karakaş DÖ, Özdemir Y, Yücel E, Akin ML.Doppler-guided hemorrhoidal artery ligation: experience with 2 years follow-up. Am Surg. 2012;78(3):344–8.

7. Wilkerson PM, Strbac M, Reece-Smith H, Middleton SB. Doppler-guided haemorrhoidal artery ligation: long-term outcome and patient satisfaction. Color Dis. 2009;11(4):394–400. https://doi.

org/10.1111/j.1463- 1318.2008.01602.x.

8. Wałega P, Scheyer M, Kenig J, Herman RM, Arnold S, Nowak M, etal. Two-center experience in the treatment of hemorrhoidal disease using Doppler-guided hemorrhoidal artery ligation: functional results after 1-year follow-up. Surg Endosc. 2008;22(11):2379–83.

9. Zhai M, Zhang YA, Wang ZY, Sun JH, Wen J, Zhang Q, Li JD, Wu YZ, Zhou F, Xu HL. A randomized controlled trial comparing suture-xation mucopexy and Doppler-guided hemorrhoidal artery ligation in patients with grade III hemorrhoids. Gastroenterol Res Pract. 2016;2016:8143703.

https://doi.org/10.1155/2016/8143703.

10. Figueiredo MN, Campos FG.Doppler-guided hemorrhoidal dearterialization/transanal hemorrhoidal dearterialization: technical evolution and outcomes after 20 years. World J Gastrointest Surg. 2016;8(3):232–7.

https://doi.org/10.4240/wjgs.v8.i3.232.

11. Longo A. Treatment of hemorrhoids disease by reduction of mucosa and hemorrhoidal prolapse with a circular- suturing device: a new procedure. Proceedings of the Sixth World Congress of Endoscopic Surgery, Rome, Italy; 1998. p.777.

12. Practice parameters for the treatment of hemorrhoids. The Standards Task Force American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 1993;36(12):1118–20.

13. Hardy A, Chan CL, Cohen CR.The surgical management of haemorrhoids—a review. Dig Surg. 2005; 22(1–2):26–33. https://doi.org/10.1159/000085343.

14. Ortiz H, Marzo J, Armendáriz P, De Miguel M. Stapled hemorrhoidopexy vs. diathermy excision for fourth-degree hemorrhoids: a randomized, clinical trial and review of the literature. Dis Colon Rectum. 2005;48(4):809–15. https://doi.org/10.1007/

s10350- 004- 0861- z.

15. Laughlan K, Jayne DG, Jackson D, Rupprecht F, Ribaric G. Stapled haemorrhoidopexy compared to Milligan-Morgan and Ferguson haemorrhoidectomy:

a systematic review. Int J Color Dis. 2009;24(3):335–

44. https://doi.org/10.1007/s00384- 008- 0611- 0.

16. Ravo B, Amato A, Bianco V, Boccasanta P, Bottini C, Carriero A, Milito G, Dodi G, Mascagni D, Orsini S, Pietroletti R, Ripetti V, Tagariello GB.Complications after stapled hemorrhoidectomy: can they be prevented? Tech Coloproctol. 2002;6(2):83–8. https://

doi.org/10.1007/s101510200018.

17. Chung CC, Cheung HY, Chan ES, Kwok SY, Li MK.Stapled hemorrhoidopexy vs. harmonic scalpel hemorrhoidectomy: a randomized trial. Dis Colon Rectum. 2005;48(6):1213–9.

18. Se A, de Caravatto PP, Dumarco RB, Sousa M.Stapled hemorrhoidectomy vs. closed diathermyexcision hemorrhoidectomy without suture ligation: a case-controlled trial. Hepatogastroenterology. 2007;54(80):2243–8.

19. Sultan S, Rabahi N, Etienney I, Atienza P. Stapled haemorrhoidopexy: 6 years experience of a referral centre. Color Dis. 2010;12(9):921–6. https://doi.

org/10.1111/j.1463- 1318.2009.01893.x.

20. Ho YH, Cheong WK, Tsang C, Ho J, Eu KW, Tang CL, etal. Stapled hemorrhoidectomy—cost and effectiveness: randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum. 2000;43(12):1666–75.

21. Cheetham MJ, Cohen CR, Kamm MA, Phillips RK. A randomized, controlled trial of diathermy hemorrhoidectomy vs. stapled hemorrhoidectomy in an intended day-care setting with longer-term follow up. Dis Colon Rectum. 2003;46(4):491–7.

22. Kim JS, Vashist YK, Thieltges S, Zehler O, Gawad KA, Yekebas EF, Izbicki JR, Kutup AJ.Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy in circumferential third-degree hemorrhoids: long-term results of a randomized controlled trial. Gastrointest Surg. 2013;17(7):1292–8.

23. Palimento D, Picchio M, Attanasio U, Lombardi A, Bambini C, Renda A.Stapled and open hemorrhoidectomy: a randomized controlled trial of regular results. World J Surg. 2003;27(2):203–7. https://doi.

org/10.1007/s00268- 002- 6459- 5.

24. Avital S, Inbar R, Karin E, Greenberg R. Fiveyear follow-up of Doppler-guided hemorrhoidal artery ligation. Tech Coloproctol. 2012;16(1): 61–5.

25. Gravié JF, Lehur PA, Huten N, Papillon M, Fantoli M, Descottes B, Pessaux P, Arnaud JP. Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy: a prospective, randomized, multicenter trial with 2-year postoperative follow-up. Ann Surg. 2005;242(1):29–35. https://doi.org/10.1097/01.

sla.0000169570.64579.31.

26. Shabahang H, Maddah G, Sadat Fattahi A.Comparison of Doppler guided hemorrhoid artery ligation and Milligan Morgan hemorrhoidectomy in management of hemorrhoid disease. Iran Red Cres Med J. 2013;15(5).

7 Minimal Invasive Procedures forHemorrhoids

27. Jeong WJ, Cho SW, Noh KT, Chung SS. One year follow-up result of Doppler-guided hemorrhoidal artery ligation and recto-anal repair in 97 consecutive patients. J Korean Soc Coloproctol. 2011;27(6):298–

302. https://doi.org/10.3393/jksc.2011.27.6.298.

28. Ferrandis C, De Faucal D, Fabreguette JM, Borie F. Efcacy of Doppler-guided hemorrhoidal artery ligation with mucopexy, in the short- and longterms for patients with the hemorrhoidal disease. Tech Coloproctol. 2020;24(2):165–71. https://doi.

org/10.1007/s10151- 019- 02136- 1.

29. Michalik M, Pawlak M, Bobowicz M, Witzling M.Long-term outcomes of stapled hemorrhoidopexy. Wideochirur Inne Tech Maloinwazyjne. 2014;9(1):18–

23. https://doi.org/10.5114/wiitm.2011.35784.

30. Towliat Kashani SM, Mehrvarz S, Mousavi Naeini SM, Erfanian R. Milligan-Morgan hemorrhoidectomy vs. stapled hemorrhoidopexy. Trauma Mon. 2012;16(4):175–7. https://doi.org/10.5812/

kowsar.22517464.3363.

31. Eskandaros MS, Darwish AA.Comparative study between Milligan-Morgan hemorrhoidectomy, stapled hemorrhoidopexy, and laser hemorrhoidoplasty in patients with thirddegree hemorrhoids. Egypt J Surg. 2020;39(2):352–63.

https://doi.org/10.4103/ejs.ejs_214_19.

32. Cariati A.Stapled hemorrhoidopexy versus Milligan– Morgan hemorrhoidectomy: a short-term follow-up on 640 consecutive patients. Eur Surg. 2015;47:112–

6. https://doi.org/10.1007/s10353- 015- 0316- x.

33. Chivate SD, Ladukar L, Ayyar M, Mahajan V, Kavathe S. Transanal suture rectopexy for haemorrhoids: Chivate’s painless cure for piles. Indian J Surg. 2012;74(5):412–7. https://doi.org/10.1007/

s12262- 012- 0461- 4.

34. Vidal V, Louis G, Bartoli JM, Sielezneff I. Embolization of the hemorrhoidal arteries (the emborrhoid technique): a new concept and challenge for interventional radiology. Diagn Interv Imaging. 2014;95(3):307–15.

35. Talaie R, Torkian P, Moghadam AD, Tradi F, Vidal V, Sapoval M, Golzarian J. Hemorrhoid embolization: a review of current evidence. Diagn Interv Imaging. 2022;103(1):3–11.

36. Giurazza F, Corvino F, Cavaglià E, Silvestre M, Cangiano G, Amodio F, etal. Emborrhoid in patients

with portal hypertension and chronic hemorrhoidal bleeding: preliminary results in ve cases with a new coiling release fashion “Spaghetti technique”. Radiol Med. 2020;125(10):1008–11.

37. Aigner F, Bodner G, Conrad F, Mbaka G, Kreczy A, Fritsch H.The superior rectal artery and its branching pattern with regard to its clinical inuence on ligation techniques for internal hemorrhoids. Am J Surg. 2004;187:102–8. https://doi.org/10.1016/j.

amjsurg.2002.11.003.

38. Schuurman JP, Go PM, Bleys RL. Anatomical branches of the superior rectal artery in the distal rectum. Color Dis. 2009;11(9):967–71. https://doi.

org/10.1111/j.1463- 1318.2008.01729.x.

39. Giamundo P. Advantages and limits of hemorrhoidal dearterialization in the treatment of symptomatic hemorrhoids. World J Gastrointest Surg. 2016;8(1):1–4.

40. Yeo D, Tan KY. Hemorrhoidectomy- making sense of the surgical options. World J Gastroenterol. 2014;20(45):16976–83. https://doi.org/10.3748/wjg.

v20.i45.16976.

41. Gupta K, Agarwal N, Mita K.Clinical outcomes in patients with hemorrhoids treated by nger-guided hemorrhoidal artery ligation with laser hemorrhoidoplasty: a retrospective cohort study. J Adv Med Med Res. 2021;2021:143–52.

42. Khubchandani I, Fealk MH, Reed JF.Is there a postPPH syndrome? Tech Coloproctol. 2009;13:141–144; discussion 144.

43. De Nardi P, Corsetti M, Passaretti S, Squillante S, Castellaneta AG, Staudacher C, Testoni PA.Evaluation of rectal sensory and motor function by means of the electronic barostat after stapled hemorrhoidopexy. Dis Colon Rectum. 2008;51:1255–60.

44. Ielpo B, Venditti D, Balassone V, Favetta U, Buonomo O, Petrella G.Proctalgia as a late complication of stapled hemorrhoidectomy. Report of our case series. Int J Surg. 2010;8:648–52.

45. Gupta PJ. Radioablation and suture xation of advanced grades of hemorrhoids. An effective alternative to staplers and Doppler-guided ligation of hemorrhoids. Rev Esp Enferm Dig. 2006;98(10):

740.

Laser Hemorrhoidoplasty

“I am a big laser believer-I really think they are the waves of future.”

Courteney Cox

Key Concepts

• Surgical management for hemorrhoidal disease aims to provide a cure with a minimally invasive surgical technique.

• Corpus cavernosum recti (CCR) is the primary vascular component of anal cushions formed exclusively by the superior hemorrhoidal artery (SHA) branches.

• Excisional hemorrhoidectomy takes care of corpus cavernosum recti but creates large raw areas.

• DGHAL (Doppler-Guided Hemorrhoidal Artery Ligation) works on the principle of dearterialization but cannot ligate transmural and posterolateral branches of the SHA.

• Laser hemorrhoidoplasty (LHP) with Fingerguided hemorrhoidal artery ligation (FGHAL) is a hybrid procedure that leads to dearterialization of the internal hemorrhoidal plexus followed by brosis.

• The CCR formed by posterolateral and transmural branches of the SHA can be dealt with lasers, reducing the recurrence rate.

8.1 Introduction

One of the signicant breakthroughs in the technological era is the emergence of minimally invasive surgery. The patient and the surgeon seek a procedure that offers a good outcome with less morbidity. To date, no procedure fullls this cri-

terion. However, Laser hemorrhoidoplasty (LHP) has an upper edge since it is hemostatic, less painful, bactericidal, leads to faster healing, is associated with lesser complications, and maintains the physiology of the anal canal by preserving the anal cushions [1]. Plapler studied the effect of carbon dioxide (CO2) lasers on 350 patients with hemorrhoids and documented lasers to be less painful than conventional surgery [2]. Using a diode laser allowed the surgeon to operate on the varicose veins of lower limbs without cutting [3]. Later use of diode lasers in the hemorrhoidal mass was studied by Karahliloglu [2] and started gaining popularity over the years. Lasers can be used in two ways to treat hemorrhoids: First, by excising the hemorrhoidal mass, as with the CO2 laser, and second, by delivering the laser energy into the hemorrhoidal mass and causing brosis by initiating protein denaturation, a procedure known as “Laser Hemorrhoidoplasty.”

8.2 Principle ofLaser Energy

Photoablation Photoablation is tissue destruction by light, generally using a laser. As the laser light passes through water, the H2O bond is broken, and crackling noises can be heard due to the release of hydrogen ions. As soon as the bond is broken, shrinkage of the target tissue occurs [4].

8 Laser Hemorrhoidoplasty

Photocoagulation Photocoagulation occurs due

to protein denaturation induced by laser energy. Protein denaturation starts at 72.6°C and continues up to 132°C. Once the protein denaturation occurs, it seals the blood vessels feeding hemorrhoids, resulting in dearterialization [4].

Photovaporization Photovaporization occurs

when the target tissue absorbs the laser energy. Blood has 70% water, and a 1470nm diode laser uses water as a target. When the laser energy goes through blood, the water content evaporates at a temperature of 80–90 °C. Vaporization leads to shrinkage. The thin endothelial layer between the sinusoids, which form fenestrations, is also broken. All that is left behind is a coagulum. Fibrosis occurs after 6–8weeks, and the anal cushions are xed in their normal position, taking care of the prolapse [4].

8.3 Laser Hemorrhoidoplasty

8.3.1 Indications

• Laser hemorrhoidoplasty—takes care of nonvascular components in the anal cushions and the remaining CCR network, which is partially taken care of by FGHAL.

8.4.1 Procedure forFGHAL andLHP

It is carried out in three steps

1. Assessment of hemorrhoids

2. Finger-guided hemorrhoidal artery ligation

3. Laser hemorrhoidoplasty

• Internal hemorrhoids grade 2 to grade 4

8.3.2 Contraindications

• Strangulated hemorrhoids

• Ulcerated hemorrhoids

8.4 Hybrid Procedure:

ACombination ofFinger- Guided Hemorrhoidal Artery Ligation andLaser Hemorrhoidoplasty (FGHAL withLHP)

Hybrid means “a synergistic combination of two or more procedures for increasing their efcacy to yield a better outcome.” In the hybrid procedure for hemorrhoids, maximum efcacy is achieved by:

• Finger-guided hemorrhoidal artery ligation— leads to dearterialization.

Fig. 8.1 Special conical glass tip. Sharp tip for hemorrhoid puncture

Fig. 8.2 List of equipment for FGHAL and LHP

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