Original Article

Transanal Doppler-guided Hemorrhoidal Artery Ligation and Recto Anal Repair vs Closed Hemorrhoidectomy for treatment of grade III-IV hemorrhoids. A randomized trial


Pelviperineology 2011;30(4):107-112


HAL-RAR is a technique whereby Doppler-guided ligation of hemorrhoidal arteries is combined with a mucopexy of the mucosal prolapse, known as Recto Anal Repair (RAR). HAL-RAR is presented here as an alternative to hemorrhoidectomy. Early and 1-year follow-up results of the procedure are presented and compared with those of closed-scissors hemorrhoidectomy (CH) in a prospective randomized study.

Patients and methods:

One hundred and thirty-five patients with grade III-IV hemorrhoids were randomized for HAL-RAR (n - 65) or CH (n - 70). All operations were done under general anesthesia and local block as day-case surgery.


Comparing the two groups, there was no significant difference between them in terms of the operating time (36.2±2.3 vs 35.5±3.1 p>0.05), or when the first postoperative bowel movement occurred. The median pain score was higher for the CH group during the first ten days (p<0.05). The average need for minor analgesics was 32.3±12.6 mg (ketatorolac trometamin) in the HAL-RAR group, and 46.1±7.7 mg in the CH group (p<0.001). Patients in the HAL-RAR-group spent 18.3±3.5 hours in the hospital postoperatively, and those in the CH-group 62.0±12.4 hours. Patients in the HAL-RAR group returned to normal daily activities after 2.8±0.7days, and those in the CH group after 21.1±2.7days (p<0.001). Complications occurred in a total of five patients within 30 days of surgery: three patients from the CH group suffered from urinary retention, one patient from the CH group from bleeding, and one from the HAL-RAR group from a thrombosed hemorrhoid. The appearance of skin tags (HAL-RAR 9 vs. CH 1, p=0.047) significantly differed between the groups. Neither the re-appearance of prolapse (3HAL-RAR vs. 0 CH patients) nor the recurrence of the symptoms bleeding (HAL-RAR 2 vs. 1 CH patients) or pain (HAL-RAR 0 vs. 1 CH patients) differed significantly between the two groups.


HAL-RAR appears to cause less postoperative pain and results in better patient-satisfaction in the early postoperative period than closed hemorrhoidectomy. Doppler-guided hemorrhoidal artery ligation fulfills the requirements of minimally invasive surgery and appears to be ideal for 1-day surgery.

Keywords: Hemorrhoids; Doppler-guided hemorrhoidal artery ligation; Transanal rectal mucopexy; Prolapse; Rectal bleeding.