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8.4 Hybrid Procedure: ACombination ofFinger- Guided Hemorrhoidal Artery Ligation andLaser...
99
8.4.2 Instrument Required (Figs.8.1
and8.2) Steps
• Half-cut proctoscope 33.5mm
• Two-needle holders 9″ each
• Vicryl 2-0 5/8 round body on 27mm needle
(Fig.8.3)
• Laser equipment 1470nm
• Eye protection glasses
• Conical laser ber
• Allis forceps
• Scissors
• Non tooth forceps
Prophylactic Antibiotic Cefuroxime 30 min
before surgery by intravenous route.
8.4.3 Finger-Guided Hemorrhoidal
Artery Ligation - An Introduction
The rst step in laser hemorrhoidoplasty is
FGHAL.The concept is based on the fact that:
• The site of the rectal arteries is unpredictable.
• The arterial blood ow is relevant for the
pathogenesis of hemorrhoids.
• Ligations may be effective in the distal part of
the rectum.
• HAL is an effective ligating procedure.
• HAL is responsible for the cure of
symptoms.
A Japanese surgeon, Morinaga, gave the con-
cept of DGHAL in 1995 (Fig.8.4a, b). He developed a technique of identifying the hemorrhoidal
arteries by Doppler and ligating them 2–4 cm
above the dentate line, considering the innervation and thus avoiding pain [5]. The principle
behind the procedure is “Dearterialization” [6].
In FGHAL, the vessels can be easily pal-
pated above the dentate line with the tip of the
index nger, and ligation can be carried out
effectively (Fig.8.5). Accordingly, a new name,
“Finger- Guided Hemorrhoidal Artery Ligation
(FGHAL),” was coined [7–9]. The most signicant benet of not using Doppler is its costefciency. The results with both the procedures,
whether DGHAL or FGHAL, remain the same
[9]. When we use DGHAL or FGHAL as a
stand- alone procedure, the chances of recurrence are very high. The recurrence rate after
DGHAL is up to 40% [10], with the greatest
Fig. 8.3 Hemorrhoidal
artery ligation suture
Fig. 8.4 (a, b) Doppler-guided hemorrhoidal artery ligation equipment
100
Point of hemorrhoidal
Fig. 8.5 Point of
ligation for ngerguided hemorrhoidal
artery ligation
6 cm
5 cm
4 cm
3 cm
2 cm
1 cm
0 cm
Dentate line
8 Laser Hemorrhoidoplasty
artery ligation
prevalence in individuals with fourth degree
hemorrhoids.
8.4.3.1 Technique
The patient is placed in a lithotomy position
under spinal anesthesia (Fig.8.6).
Assessment of Grades of Hemorrhoids
Three pieces of rolled gauze are inserted inside
the anal canal and carefully pulled out to determine the exact degree of hemorrhoids (Fig.8.7).
Since there is perineal descent under spinal anesthesia, grade 2 hemorrhoids may sometimes
appear as grade 3, or grade 3 hemorrhoids may
appear as grade 4.
Role of Injection Hylase
For grade 4 hemorrhoids with edema, Injection
Hylase (Hyaluronidase) can be injected into the
submucosa of the hemorrhoids (Fig. 8.8a, b).
Injection Hyaluronidase increases the tissue permeability and therefore decreases edema. The
syringe piston is pulled before injecting the solution into the hemorrhoid tissue to ensure that
Hylase is not injected directly into the blood vessel. Injection Hylase comes in a powder form. One
can obtain a solution by dissolving the powder in
1mL of distilled water or saline. Each mL contains 1500IU of Hyaluronidase. About 1–2mL of
hylase can be injected into each hemorrhoidal
mass (Fig. 8.8a). Immediately after injection of
hylase, regression of the hemorrhoidal tissue can
be observed on the operating table. After the
edema has diminished, the hemorrhoidal mass can
be pushed back into the anal canal lumen, and further surgical steps can be performed (Fig.8.8b).
Learning Point: Role of Hylase
Hyaluronidase improves tissue permeability
by catalyzing the hydrolysis of hyaluronic
acid. It diminishes the edema and swelling of
the hemorrhoids. Once the edema is reduced,
the internal hemorrhoidal tissue can be
pushed back into the anal canal.
Complication of Hylase
Allergic reactions have been reported
occurring in 0.05–0.69% of cases, according to clinical trials [11]. The following are
some of the signs:
• Erythema
• Itching and pain
• Urticaria and angioedema [12, 13]
8.4 Hybrid Procedure: ACombination ofFinger- Guided Hemorrhoidal Artery Ligation andLaser...
Fig. 8.6 Lithotomy
position
Fig. 8.7 Assessment of
the hemorrhoids by
inserting rolled gauge
pieces inside the anal
canal
101
Fig. 8.8 (a) Injecting hylase into the hemorrhoids. (b) Immediate regression
102
ab
cd
8 Laser Hemorrhoidoplasty
Technique of Hemorrhoidal Artery Ligation
The next step is FGHAL (Fig.8.9a–h). The head
side of the operating table should be 15° lower.
The hemorrhoidal tissue is massaged to reduce
engorgement. After thoroughly lubricating with
lignocaine hydrochloride jelly, a half-cut proctoscope is introduced into the anal canal (Fig.8.9a).
The ligation of the branches of SHA is started at
3 o’clock position. The Allis forceps are applied
at the anal verge at 3 o’clock, and the hemorrhoid
e f
g h
Fig. 8.9 (a) Hemorrhoidal mass as seen through half-cut
proctoscope. (b) Dentate line as seen through proctoscope. (c) Palpation of superior hemorrhoidal artery with
the tip of nger. (d) Taking a gure of eight stitches. (e)
Ligation of arteries by Vicryl 2-0, 27mm 5/8 round body
needle. (f) Milking of the hemorrhoidal tissue. (g, h)
Palpation and ligation of vessels at other positions
8.4 Hybrid Procedure: ACombination ofFinger- Guided Hemorrhoidal Artery Ligation andLaser...
103
tissue is slowly pulled outwards. The dentate line
is identied, and the left-hand index nger is
inserted about 2–4 cm above the hemorrhoidal
tissue. The SHA branches are palpated starting
from 3 o’clock (Fig.8.9b).
Sometimes, one may not be able to palpate the
vessel precisely at the 3 o’clock position, as the
position of the superior hemorrhoidal artery
branches is not constant. Once the vessel has
been palpated, ligation is done using Vicryl 2-0,
27mm 5/8 round body needle by taking a gure
of eight stitch (Fig.8.9c–e). In almost all cases,
the needle depth is roughly 5mm. Taking the gure of eight stitches is not for the ligation of the
vessel per se. It compresses the surrounding tissue to squeeze the vessel, leading to dearterialization. Some bers of the internal sphincter are
always taken along. Before tying the knot, ask
the assistant to do milking of the hemorrhoidal
tissue to reduce the engorgement (Fig. 8.9f).
While ligating, ensure not to puncture the blood
vessel with the needle. If the vessel is pierced, a
hematoma appears immediately.
After ligation, try palpating the ligated vessel
again to ensure that an effective ligation has been
achieved.
After the ligation is performed at 3 o’clock,
turn the half-cut proctoscope clockwise and
continue palpating and ligating the vessels
(Fig. 8.9g, h). Ideally, it should be possible to
ligate 4–6 branches.
Once all the ligations are complete, rotate the
proctoscope 360° to ensure all the branches of
SHA have been appropriately ligated. Then,
remove the proctoscope and reinsert the three
rolled-up gauze pieces inside the lumen. A reduction in the size of the hemorrhoids can be seen on
the operating table in the case of grade 3 or 4
hemorrhoids.
8.4.4 Laser Hemorrhoidoplasty
8.4.4.1 Energy! Dosage! Fiber! Mode
Energy
• The overall dose should not exceed 150–200J
per hemorrhoidal mass.
Dosage
• At the time of ber insertion: 6W, 1-s pulse
• At the time of ber activation: 6W, 3-s pulse
The dosage is calculated as follows:
Watt×time in second=Joule (1W=1Joule
per second (1W=1J/s))
Probe (Tip of Lasers)—Sharp tip conical
Mode: Pulse mode
8.4.4.2 Point ofEntry ofFiber
The point of entry of laser ber is the mucocutaneous junction (white line of Hilton). This is
because the anastomosis between the superior
and inferior hemorrhoidal artery is present over
there. The submucosa ends at the dentate line,
and it is known that the anal cushions are disruptions of submucosa at 3, 7, or 11 o’clock positions. Theoretically, entering the submucosal
space from the dentate line makes sense. With
experience, one can appreciate that the regression
of the hemorrhoidal mass is much faster if one
enters the mucocutaneous junction instead of the
dentate line (Fig.8.10a, b).
8.4.4.3 The Technique ofLaser
Hemorrhoidoplasty
After inserting a half-cut proctoscope inside the
anal canal, apply the Allis forceps at the anal
verge at 3 o’clock (Fig.8.11a–e). Pull the Allis
forceps outwards and insert the laser ber
across the mucocutaneous junction into the
submucosal space (Fig.8.11a). Once inside the
submucosal space, the ber stops at the distal
end, where the HAL was performed (Fig.8.11b).
The energy dose at the ber entry point is
6W×1s.
The red light can be seen inside the submucosa of the anal cushions. Ensure that the light is
neither too bright nor too dim. Too bright light
indicates that the ber tip is too close to the
mucous membrane, which can be damaged by
thermal energy. A dim light indicates that the tip
of the ber lies somewhere inside the internal
sphincter, which may cause damage to the
sphincters after activation, followed by brosis.
Furthermore, ensure there is no resistance while
104
Conjoined longitudinal
Mucocutaneous junction
a
Fig. 8.10 (a) Mucocu-
taneous junction. (b)
Submucosal space from
dentate line
muscle
External anal
sphincter
Internal anal
sphincter
8 Laser Hemorrhoidoplasty
Internal hemorrhoidal
plexus
Anastomosis between
superior and inferior
hemorrhoidal arteries
pushing the ber into the submucosal space. It
should be emphasized that if one feels resistance,
the ber is in the wrong plane.
Once inside the submucosal hemorrhoidal tissue, release the laser beam in pulse mode at
6W × 3s. Once the ber is activated, crackling
sounds are heard due to the release of hydrogen
ions. Keep withdrawing the ber every 5 mm
because the ber covers approximately 4mm distance in one activation. It is advisable to slowly
rotate the ber during activation to prevent it from
sticking to the tissue (Fig.8.11c). In the case of a
large hemorrhoidal mass, one can use a fan-shaped
technique to release more energy (Fig. 8.11d).
Remember that the total amount of energy should
not exceed 150–200J for each pile mass.
b
Levator ani
External anal
Internal anal
External hemorrhoidal
plexus
Dentate line
sphincter
sphincter
Submucosal
space
After the hemorrhoidal mass is dealt with at 3
o’clock, the same procedure is repeated at 7 and
11 o’clock. If present, the accessory hemorrhoids
are dealt with the same way. An ice nger is
inserted inside the anal canal for 8–10 min to
reduce postoperative edema (Fig.8.11e).
Sometimes, hemorrhoidal tissue does not
reduce substantially in grade 3 or 4 hemorrhoids,
even after performing HAL and LHP.Mucopexy
or rectoanal repair (RAR) may be performed in
such cases. Performing Blaisdell or Farag’s technique of mucopexy leads to dearterialization and
a better cosmetic effect. This technique takes
three interrupted sutures through the mucosa and
submucosa above the dentate line, leading to
mucosal xation (Fig.8.12a–c).
8.4 Hybrid Procedure: ACombination ofFinger- Guided Hemorrhoidal Artery Ligation andLaser...
a b
105
c
e
Fig. 8.11 (a) Entry point of laser ber from mucocutane-
ous junction. (b) Activation of ber inside submucosal
space of anal cushions (LHP). (c) Drawing of laser ber
d
every 5mm. (d) Activating ber in a fan-shaped manner.
(e) Insertion of ice nger
8.4.4.4 Postoperative Care
• Antibiotics: Cefuroxime for 5days
• Laxatives: Polyethylene glycol
• Diclofenac suppository as an analgesic
• Sitz bath twice a day to be started after 24h
• Flavonoids (MPFF)
• Topical ointments
The patient is reluctant to defecate postopera-
tively when a surgical procedure is conducted in
the anorectal area. Moreover, patients with hemorrhoids usually suffer from chronic constipation. Laxatives take care of constipation and
soften the stools, allowing easy passage and
reducing postoperative discomfort during defecation. Flavonoids help reduce inammation and
lymphatic stasis. Topical ointment, a combination of sucralfate, lignocaine, and metronidazole, reduces postoperative pain and prevents
local infection.
106
8 Laser Hemorrhoidoplasty
a
b
c
Fig. 8.12 (a) Grade 4 hemorrhoids before FGHAL and LHP. (b) Mucopexy by taking three interrupted suture by
Blaisdell technique. (c) Final picture after mucopexy
8.5 Hemorrhoids inPatients
withAnticoagulants
over 3–5 days. However, Ecosprin is the most
prescribed antiplatelet drug to prevent cardiovas-
cular disorders [14, 15]. Despite Ecosprin’s short
A surgeon must evaluate the complete medical
history and always consider the risk-benet ratio
of withdrawal of anticoagulants. The decision to
discontinue the antiplatelet drug prior to surgery
should only be made after consultation with the
cardiologist. A daily dosage of 75mg of clopidogrel causes a 60% reduction in platelet function
half-life (3–6h), its irreversible effects would last
the platelet’s entire lifespan (8–9days) [14, 15].
Therefore, stopping the antiplatelet well before
the surgical procedure is always advisable.
In most cases, a history of bleeding disorders
is often overlooked. Surprisingly, sometimes
patients may have a history of hemophilia.
8.6 Why Recurrence After Surgical Procedures forHemorrhoids?
107
8.6 Why Recurrence After
Surgical Procedures
forHemorrhoids?
“Recurrence” may occur after any surgical procedure for hemorrhoids, be it hemorrhoidectomy,
DGHAL/FGHAL, Stapled hemorrhoidopexy
(PPH), or laser hemorrhoidoplasty. However, the
recurrence rate of different procedures varies
(Table8.1).
Three factors may contribute to the
recurrence:
1. Formation of collaterals
2. Persistence of the larger caliber of SHA arter-
ies in hemorrhoids
3. Inability to ligate posterolateral branches of
SHA
8.6.1 Diversion ofBlood Flow
andFormation ofCollaterals
After an excisional hemorrhoidectomy, it is almost
impossible for anal cushions to regrow. That is why
primary hemorrhoids will never form. However,
accessory hemorrhoids are likely to occur in all
locations where superior hemorrhoidal artery
branches are present, including the position of primary hemorrhoids. The reason is that after the
SHA branches have been ligated at the pedicle
where the excision has been performed, the blood
ow is diverted to other branches because of acceleration velocity, as explained by Aigner etal. [20,
21]. Another reason can be collateral circulation
(Fig.8.13), which develops over a while.
8.6.2 Persistence oftheGreater
Caliber oftheSuperior
Hemorrhoidal Artery
inHemorrhoidal Disease
The large diameter leads to a greater blood ow
to SHA in hemorrhoidal disease (HD) patients,
even after surgical removal of hemorrhoids.
Nothing can be done to decrease the already
dilated caliber of the vessels.
8.6.3 Inability toLigate
Posterolateral Branches
ofSHA
DGHAL/FGHAL/Stapled hemorrhoidopexy is
based on the principle of dearterialization,
which leads to subsequent brosis. Although
the branches of SHA present in the submucosa
can be ligated, the posterolateral branches of
SHA are too high and too deep [20, 21]. Hence,
complete blood circulation interruption to the
hemorrhoidal mass is impossible. Further, the
transmural and extramural branches of SHA
Table 8.1 The recurrence rate after various procedures
Author No. of patients Procedure name Year Recurrence rate
Kim etal. [16]
Randomized control trial
Lienert M. [17]
Literature review
Tjandra etal. [18]
25 Randomized control trial
Keck T. [19]
A cohort study
130 Milligan Morgan vs. stapled
hemorrhoidopexy
5315 DGHAL with mucopexy 11 Up to 40%
1918 Stapled hemorrhoidopexy 15 25.3%
497 LHP 5 8.8%
5 MM: 23%
SHP: 18%
108
Normal flow Collateral flow
No collateral circulation
Midzone Midzone Midzone
Fig. 8.13 Formation of collateral circulation
Table 8.2 The recurrence rate for laser hemorrhoids using different wavelength
No. of
Author
Plapler etal. [22]
Clinical trial
Moloku etal. [23]
Comparison trial
Poskus etal. [24]
Double-blinded
randomized control trial
De etal. [25]
A prospective clinical
study
Gupta etal. [7]
A retrospective cohort
study
patients
16 LHP Laser equipment used 810nm 6.6
20 LHP A 980-diode laser is sent via a 1000-nm
20 LHP Laser equipment used 1470nm 10
75 LHP-
346 LHP with
Procedure
name Dosage
optic ber in a pulsed mode
Laser equipment used 1470nm 5.33
FGHAL
Laser equipment used 1470nm 1.8
FGHAL
8 Laser Hemorrhoidoplasty
Recurrence rate
(%)
2
also participate in the formation of corpus cavernosum recti, but there is no way to ligate
them.
8.7 Recurrence After Laser Hemorrhoidoplasty
Laser hemorrhoidoplasty with FGHAL as a
hybrid procedure appears to be a better choice
leading to a lesser recurrence (Table8.2).
8.8 Complications Following
FGHAL andLHP: Why
andHow toManage?
8.8.1 Hematoma Formation at
theSite ofHAL
This can occur while ligating the vessel. Since
this is a blind procedure, the vessel may be
pierced with the needle leading to hematoma formation (Fig.8.14).