Hemorrhoid Treatments With Surgery – DG-HAL & RAR

Some surgical hemorrhoid treatments come with a big name and this one certainly does. DG-HAL & RAR stands for Doppler-guided hemorrhoidal artery ligation and Recto anal repair. In reality this is two procedures that have been combined to achieve impressive results with minimum complications. What is this used for?

Internal and external hemorrhoids are broadly classified as belonging to one of four grades. Hemorrhoids that are classified as grade III or IV are the most serious and are the ones most likely to be treated by this combined procedure.

Conceptially, DG-HAL was first introduced in 1995 and is based on the theory that an imbalance exists between the blood flowing into and out of the hemorrhoid. Studies showed that a correlation existed between the formation of hemorrhoids and the presence of increased inflow to the vascular structures of the hemorrhoidal tissue rather than an outflow problem. On this bases, DG-HAL was developed to reduce the supply of blood from the rectal arteries to the hemorrhoidal cushions.

The DG-HAL procedure thus involves the use of a proctoscope (a tubular device) that has a built in doppler transducer (similar to a fishing depth finder), that can be inserted into the anus. As the device is slowly turned, the depth and location of the arterial structures feeding blood to the hemorrhoidal pillows are located. In turn select ones are ligated (that is tied off) thereby restricting part, but not all of the blood flow to each pillow. As one complete 360 degree turn is made, the proctoscope is pulled out a bit further and a second rotation is initiated. In this way, each of the three main hemorrhoidal pillows can be treated. The idea, again, is that by restricting but not eliminating blood flow to the hemorrhoids the doctor is removing the casual effect of why they formed.

When hemorrhoids prolapse, they not only extend out the anus, but they also distend or pull down the structures that held them in their proper positions. This is where RAR procedure then takes over. In fact, the RAR is really partly the DG-HAL procedure and partly a process called Mucopexy. Mucopexy involves lifting and securing the prolapsed hemorrhoidal tissue back into their proper places. This is done by essentially pushing the hemorrhoids back into place and sewing them into that position. Over time, the sutures will dissolve, and with the removal of the increased pressure due to the DG-HAL part of the procedure, the hemorrhoids are thus fixed.

Thus the two procedures attack two parts of the problems. DG-HAL permanently reduces inflow and thus the hemorrhoids naturally shrink over a period of 6-8 weeks and the RAR process immediately lifts and prevents the prolapsed hemorrhoids back into place so that they don’t push out of the anus again. Of most importance is the lack of surgical trauma to the tissue via excision and removal of hemorrhoidal tissue as is found in a conventional hemorrhoidectomy.

Studies have shown that the RAR procedure is very effective offering improved treatment of symptoms, lower pain levels, and shorter hospital stays. Of over 4000 HAL patients to date, not one major complication has been reported. Success rates for this combination of procedures stands at 93-96%. Patients usually leave the hospital the same day and can resume work by the next. This procedure is also known as transanal hemorrhoidal dearterialization (THD).

Surgery is never to be taken lightly. Thankfully, over the years, advances in research has greatly reduced the terrible pain associated with past procedures, but, as with any procedure there are always risks. Conservative treatment is always an option and involves simple changes that can eliminate the need surgical approaches.