CURRENT STATUS OF

DGHAL-RAR IN MANAGEMENT
OF INTERNAL HEMORRHOID

Ignatius Riwanto
Dept. of Surger y, Digestive div. Diponegoro
Medical Faculty

SYMPOSIUM
KONAS PABI
PALEMBANG 2 APRIL 2018
 HEMORRHOID

 The symptomatic enlargement and distal

displacement of the normal anal cushions
World J Gastroenterol 2012 May 7; 18(17): 2009-2017

 Discontinuous series of cushions  3

main cushions: left lateral, right
anterior, right posterior

 Anal cushion secured by Parks’ ligament

(ficibroelast network coming from int.
sphincter, muscularis propia) and
Treitz’s muscle (coming from
muscularis mucosa of the rectum)

Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
 THE FUNCTION OF ANAL CUSHION

 Protect anal canal from injury

during defecation
 Play an important role in
accomplishing anal
continence, especially with
respect to liquids.(Provide
15-20% resting pressure of
the anal canal)
 The muscularis submucosa The anchoring and supporting
and its connective tissue
tissue deteriorates with
fibers return to the anal
canal lining to its initial aging,  produces venous
position af ter temporary distention, erosion, bleeding
downward displacement and thrombosis
occur during defecation.

Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
 PATHOLOGY OF HEMORRHOID

 Microscopic:
abnormal dilatation and distortion
of the vascular channel,
destructive changes in the
supporting connective tissue within
the anal cushion (Treitz muscle &
Park ligament)
an inflammatory reaction
vascular hyperplasia

World J Gastroenterol 2012 May 7; 18(17): 2009-2017

EXCISIONAL OF HEMORRHOIDAL TISSUE
(CONVENTIONAL HEMORRHOIDECTOMY)
 GRADE III & IV
 MOSTLY REMOVING PRIMARILY ANAL CUSHION
 INTACT MUCOSAL BRIDGE IS IMPORTANT TO
PREVENT STRICTURE
 RISK OF SPHINCTER INJURY
 NEED WOUND CARE
 PAINFUL
 PROBLEM & COMPLICATIONS OF
CONVENTIONAL HEMORRHOIDECTOMY
Problem:
Post-operative pain

Complications:
 urinary retention (2-36%),
 bleeding (0.03-6%),
 anal stenosis (0-6%),
 infection (0.5-5%),
 incontinence (2- 12%).
Sc h ube r t E T AL. Wo rl d J G a s t ro e nte ro l 2 0 0 9
Retained volume in the liquid continence test
Group A: < 900 ml
Group B: 900-1200 ml
Group C: > 1200 ml
REDUCE POST OPERATIVE PAIN &
COMPLICATION?

MINIMALLY INVASIVE
HEMORRHOID SURGERY?

ANAL CUSHION PRESERVING

SURGERY?
INERVATION OF ANAL CANAL SKIN &
MUCOSA
 Pain sensation is passing
through free nerve ending
 Anal canal rich of free nerve
ending, function: sampling
mechanism
 Every intervention that hitting
anal canal will produce pain.
 Complete removing anal cushion:
sampling mechanism
disturbances
 Conserve anal cushion
& anal canal skin:
 reduce pain significantly
 holding the anal canal
function
ARTERIO-VENOUS SHUNT IN HEMORRHOID
 VASCULAR STRUCTURE IN
NORMAL ANAL CUSHION

Normal: a sphincter-
like structure, formed
by thickened tunica
media containing 5-
15 layers of smooth
muscle cells, between
the vascular plexus
within the sub
epithelial space of
the anal transitional
zone
World J Gastroenterol 2012 May 7; 18(17): 2009-2017
 VASCULAR STRUCTURE
IN HEMORRHOID

Hemorrhoids: remarkably
dilated, thin-walled vessels
within the submucosal
arteriovenous plexus, with
absent or nearly -flat
sphincter-like constriction on
the vessels
 smooth muscle sphincter
helps in reducing the
arterial inflow, thus
facilitating an effective
venous drainage

World J Gastroenterol 2012 May 7; 18(17): 2009-2017

 THE VASCULAR NATURE OF
HEMORRHOIDS
( F. A I G N E R E T A L . , 2 0 0 6 , G A S T R O I N T E S T S U R G . )

Study Groups Caliber of the vessels (SRA) Flow in the vessels (SRA)

41 patients with 1.87 mm 33.9 cm/s

symptomatic hemorrhoids
17 healthy volunteers 0.92 mm 11.9 cm/s

14
 THE VASCULAR NATURE OF
HEMORRHOIDS
( F. A I G N E R E T A L . , 2 0 0 6 , G A S T R O I N T E S T S U R G . )

 “ strong evidence that the arterial

blood supply is of relevance in the
development of hemorrhoidal
cushions. “

 “Vascular dilation and increased blood

flow suggest that there might exist an
increased arterial inflow rather than a
venous stasis or outflow problem
supporting the development of
hemorrhoids.“

15
 MORPHOLOGY AND HEMODYNAMICS OF THE
ANORECTAL VASCULAR PLEXUS

 The anorectal vascular plexus was characterized by a network

of submucosal vessels with multiple thickened venous vessels
separated by distinct sphincter -like constrictions
 Flow differences in peak velocities of afferent vessels,
control group : 6.8 +/- 1.3 cm/s
hemorrhoidal disease: 10.7 +/- 1.5 cm/s; P = 0.026
 Acceleration velocities of afferent vessels,
control group: 51 +/- 4 ms
hemorrhoidal disease: 94 +/- 11 ms; P = 0.001
 Conclusion: Coordinated filling and drainage of the anorectal
vascular plexus is regulated by intrinsic vascular sphincter
mechanisms. Both morphological and functional failure of this
vascular system may contribute to the development of
hemorrhoidal disease.

Int J Colorectal Dis. 2009 Jan;24(1):105-13

 MINIMALLY INVASIVE SURGERY FOR
GRADE III-IV HEMORRHOID

STAPPLER HEMORRHOIDOPEXY
DOPLER GUIDED HEMORRHOID ARTERY
LIGATION & RECTO-ANAL REPAIR

ANAL CUSHION PRESERVING SURGERY

STAPPLER HEMORRHOIDOPEXY

o PECK 1986, DEVELOPED BY LONGO

o BASED ON THE THEORY OF
INCREASE LAXITY OF
HEMORRHOIDAL SUPPORT TISSUE
o CIRCULAR REMOVAL OF THE RECTAL
MUCOSA PROXIMAL TO
HEMORRHOIDAL TISSUE (4CM
ABOVE DENTATE LINE)  UPWARD
MOVEMENT OF THE PROLAPSING
HEMORRHOID
o IS TARGET TO CUT ALL THE RECTAL
ARTERY IS ALWAYS ACHIEVED?
 HEMORRHOID ARTERY (HA)
NETWORK
Color duplex imaging examination
Determine the location of HA above the ano-
rectal junction (AAJ) and the depth
AAJ HA External Intramusc Submucos
(cm) detected rectal (%) uler (%) a
(%) (%)
1 64.3 100
2 66.0 96.6
3 66.0 67.1
4 98.3 55
5 99.3 90.9
6 99.7 97.9
Ratto et.al. Br J Surg. 2012;99:112-118
 HEMORRHOID ARTERY INTERRUPTION IN
STAPPLED HEMORRHOIDECTOMY (SH)
Doppler hemorrhoid artery detection before
and one month after SH in 45 Hemorrhoid
patients.
Preoperatively: 100% three main branches of
the artery (3,7,11,o'clock), 67 % fourth, 16 %
a fifth and 13 % a sixth could be identified.
One month postoperatively: in 80 % of all
branches, 16 % of the cases two main vessels,
4 % only one main vessel could be identified.

Zentralbl Chir. 2002 Jan;1 27(1):19 -21 .

 DOPPLER GUIDED HEMORRHOID ARTERY
LIGATION (HAL)

HAL: first reported by

Morinaga (Japan) 1995
Because the arteries
carrying the blood
inflow are ligated,
internal pressure of the
plexus of hemorrhoid is
decreased, shrink and
become smaller.

. The American Journal of Surgery, 2006

 RESULT OF HEMORRHOID ARTERY
LIGATION (WITHOUT ANOPEXY)
 Morinaga et al (1) reported this first series with 112 patients,
obtaining:
satisfactory results in 78% of patients with prolapse,
resolution of pain in 96% of patients and
 Sohn et al (2) 60 pts
complete success in 92% of patients with prolapse,
88% of those with arrested bleeding and
71% of those with less pain.
 Giordano et al [3] published the first systematic review
concerning THD/DG-HAL in 2009, analyzing 17 papers from
1995 to 2008.
rate of recurrent prolapse 9% (0%-37%)
rate recurrent anal bleeding 7.8% 0%-21%
Early post-operative pain 18%
1. Am J Gastroenterol 1995; 90: 610-613 [PMID: 7717320]
2. Am J Surg 2001; 182: 515-519
3. Dis Colon Rectum 2009; 52: 1665-1671
 DOPPLER GUIDED HEMORRHOID ARTERY
LIGATION (HAL) & RECTOANAL REPAIR (RAR)

 HAL: high prolapse

recurrence in grade
IV  2005 RAR
(Recto-Anal Repair)

 RAR =
Proctoplasty/
mucopexy is lifting
the hemorrhoid
back to where the
belong for grade III-
IV
. The American Journal of Surgery, 2006
 MULTICENTER TRIAL DOPPLER-GUIDED
THD (WITH ANOPEXY)

 803 patients
 mean follow-up of 11.1 + 9.2 mo.
 Overall success rate of 90.7%
 recurrence of hemorrhoidal prolapse 6,3%
 bleeding 2,4%
 both recurrence and bleeding 0,6%

Ratto C, Colorectal Dis 2015; 17: O10 -O19

DG HAL-RAR VS CLOSED
HEMORRHOIDECTOMY
 A SYSTEMATI C R E VI EW C OM PARI NG T R A NSA NA L
H A E MORRH OIDA L D E - A RTERI ALI SATI ON ( T H D) TO S TA P LED
H A E MORRH OIDOP EX Y ( S H ) I N T H E M A NAG E MENT O F
H A E MORRHOIDA L D I SEA SE

 3 RCT 150 patients

 80 THD and 70 SH patients.
 Baseline homogen (P = 0.40)
 Statistically equivalent in success rate (P = 0.19),
operation time (P = 0.55), postoperative
complications (P = 0.11) and recurrence (P = 0.46)
 THD significantly less postoperative pain P <
0.00001 compared to SH.

Te c h C o l o p r o c t o l . 2 0 1 2 F e b ; 1 6 ( 1 ) : 1 - 8 ( A b s t r a c t ) .
 Cohort study
 Baseline (age, gender, classification, recurrent &
symptomatology) comparable
• Hemorrhoids symptoms
score preoperative was
comparable between
DGHAL-RAR and CH

• Hemorrhoid symptoms
score post operative was
comparable between
DGHAL-RAR and CH
 CURRENT POSITION OF
HEMORRHOID ARTERY LIGATION
AND RECTO ANAL REPAIR IN
INDONESIA
• Course HAL-RAR 10th May
2012
• Semarang Indonesia start
HAL-RAR August 2012
• First Indonesian HAL-RAR
course, Semarang Digestive
Week Oct 2014
 NUMBER OF CERTIFIED SURGEON FOR HAL -
RAR OPERATION AND NUMBER PROBES SOLD
1000
900
180
CERTIFIED DOCTORS - HAL 800
TAHUN PROBES
RAR
700

2014 138 5 600

500 120
2015 305 30
400 749
2016 455 120
30
300
2017 749 180
455
200
5 305
100
138
0
2014 2015 2016 2017

Source: Fahrenheit Alkes 2018 PROBES CERTIFIED DOCTORS - HAL RAR

 PERSONAL EXPERIENCE

 August 2012- January 2018 : 142 cases, patients come for

recurrence 3 cases within 4 weeks after surgery (2 cases
conservative, 1 case Morgan Milligan)
 October 2014: 61 cases have been evaluated and reported on
ICS meeting in Bali entitle:

Factors Affecting Post-operative Pain after Hemorrhoid

Artery Ligation and Recto-anal Repair (HAL-RAR) of
Internal Hemorrhoid

Sigit Adi Prasetyo, Ignatius Riwanto

Dept. of Surgery, Diponegoro Medical Faculty
 METHOD & RESULT

 Method. A series of 61 grade II-IV internal hemorrhoid

patients, underwent HAL-RAR in St Elizabeth Hospital,
Semarang Indonesia, period of August 2012 - March
2014 were analyzed prospectively.

 Result. After multivariate analysis variables that

significantly influence post operative pain on 24 hours
were removing of internal thrombosis , removing of anal
papilla hypertrophy and anal laceration, on 48 hours
were removing of external thrombosis, removing of anal
papilla hypertrophy and anal laceration and on 7 days
were the same with on 24 hours. 2 prolapsing on week 2
but disappear after 8 weeks FU.
 IS DOPPLER ASSISTED TO DETECT
ARTERY REALLY NEEDED?

Theoretically artery arteries are located in

six of the odd-numbered clock positions
around the anus (1, 3, 5, 7, 9 and 11 o’clock
Avital S (2012): one-third of the population
has at least one artery in an even-numbered
clock position.

DOPPLER-ASSISTED LOCALIZATION IS
IMPORTANT IN CORRECTLY LOCATING THE ARTERIES

Avital S. et al. Tech Coloproctol 2012; 16: 61-65

 CONVENTIONAL SURGERY THE ONLY
OPTION
 Prolapsing fibrotic
grade IV internal
hemorrhoid
 Strangulated grade IV
internal hemorrhoid
 Big circular grade IV
internal hemorrhoid
 Multiple thrombus and
excesive combination
with external (skin
component) in grade IV
hemorrhoid
 COMBINATION HAL-RAR & MINIMAL
MUCOCUTANEOUS EXCISION

 If during HAL-RAR,
there is still:
some prolapse
Excessive skin
component
 mini mucocutanous
excision (MME)
Skin tag/ hypertrophy
of anal papilla 
excision
. Colorectal Dis. 2010 Feb;12(2):125-34.
 COMBINATION EXCISIONAL
HEMORRHOIDECTOMY AND HAL-RAR

 Prominent grade IV
internal hemorrhoid
 Impossible to be
operated with
minimally invasive
 Morgan Milligan may
left prominent normal
skin-mucosa bridge
 Addition with HAL-RAR
for prominent mucosal
bridge improve the
result
 SUMMARY (1)

 Problem with conventional hemorrhoidectomy

are severe pain and complications that stimulate
surgeon to find method of hemorrhoid surgery
than painless and lower complication.
 Histologically there is a arteriovenous shunt in
anal cushion and there are rectal artery
enlargement and diminishing of sphincter like
muscle in hemorrhoid patient, destruction of
supportive tissue in anal cushion
 SUMMARY (2)

Surgery for hemorrhoid nowadays change from

removing the pile that more painful to ligating the
hemorrhoid artery and lifting the anal cushion to its
position (HAL-RAR) that more painless, and preserve
the anal cushion function
The benefit of HAL-RAR is less post-operative pain
while long term evaluation showed that relapse and
side effect are comparable between HAL-RAR and
conventional hemorrhoidectomy
Increasing number of Indonesian surgeon to do HAL-
RAR in managing grade III-IV of internal hemorrhoid.