HAL RAR Surgery: Procedure, Benefits, Side Effects & Recovery

According to a study by Niranjan Agarwal et al., 2017, haemorrhoids are a common condition that affects about 50% of adults at some point in their lives. Haemorrhoidal artery ligation, or HAL, is a minimally invasive procedure to alleviate symptoms. This approach, combined with recto-anal repair (RAR), provides an effective solution with reduced pain.

HAL-RAR is a safe alternative to traditional haemorrhoidectomy. It offers patients a faster return to daily activities and long-term relief from discomfort. The following blog discusses the procedure, its benefits, risks, and recovery. Read on. 

HAL-RAR (Haemorrhoidal Artery Ligation and Recto-Anal Repair) is a minimally invasive surgical procedure for treating haemorrhoids (piles). It uses a Doppler ultrasound to locate the affected haemorrhoidal artery. The surgery combines two techniques:

1. Haemorrhoidal Artery Ligation: It causes the haemorrhoids to shrink back to their normal size by reducing their blood supply. This helps alleviate the symptoms of haemorrhoidal disease. 

2. Recto-Anal Repair: For prolapsed haemorrhoids that protrude outside the anus, this step involves lifting and securing the prolapsed tissue back into place. 

Anatomy and Physiology of the Anus and Rectum

The rectum, which lies just above the anus, is the final five to six inches of the large intestine. The anus, which is 3-4 cm long, is the opening at the end of the digestive tract through which waste exits the body. It is surrounded by two muscle groups: 

1. Internal anal sphincter (a ring of involuntary muscle).

2. External anal sphincter (voluntary muscle).

The function of the anus and rectum is as follows: 

1. The rectum stores poop before it is expelled. 

2. When the rectum is full, the internal anal sphincter relaxes, pushing poop toward the anus. The external sphincter allows voluntary control over when to release.

Haemorrhoidal artery ligation and recto-anal repair are effective treatment options for those with grade II and grade III haemorrhoids. The symptoms and conditions that may require an individual to undergo HAL-RAR include: 

1. Proctitis (inflammation in the rectum)

2. Back pain from haemorrhoidal muscle pushing against the rectum 

3. Constant anal itching 

4. Piles that swell when sitting on hard surfaces 

5. Rectal prolapse (the rectum slips out of the anus)

The HAL-RAR surgery is performed under general or spinal anaesthesia to ensure comfort during the procedure. It takes about 25-60 minutes to complete and includes the following steps: 

1. Haemorrhoidal Artery Ligation: This procedure prevents the recurrence of piles by reducing blood flow. It involves the following: 

1. A proctoscope with a Doppler ultrasound probe is inserted into the anus. 

2. The probe handle is rotated to identify the arteries supplying blood to the haemorrhoids. 

3. Using the guidance of the Doppler signal, the surgeon ties off each artery (ligation) with sutures to cut off blood flow. This causes the haemorrhoids to shrink.

2. Recto-Anal Repair: It is used after HAL in cases where piles have reached a severe stage. The process of RAR includes: 

1. The handle of the device is placed in a similar position as for ligation. The ligation window is positioned to align with the prolapsed tissue. 

2. The surgeon makes an initial stitch as high up in the anal canal as possible.

3. The handle is adjusted to make a series of stitches along the prolapse, spaced about 7-10 mm apart. 

4. Next, the ends of the sutures are pulled and knotted together upwards toward the initial stitch. This method effectively lifts and secures the prolapsed hemorrhoidal tissue, restoring it to its proper position.

Doctors give detailed instructions on preparing for haemorrhoidal artery ligation and recto-anal repair. Following these guidelines before and on the day of the procedure is essential to ensure the success of the surgery.

Before HAL-RAR 

Patients meet their healthcare team two to four weeks before surgery for a pre-anaesthetic check-up. During this appointment, they also discuss other preparatory guidelines for the procedure. These include: 

On the Day of HAL-RAR 

On the day of the procedure, patients should ensure that someone is available to drive them home after the surgery. Upon arrival at the hospital, they will be guided through the pre-operative process, which includes:

Mild bleeding is common for four weeks after the procedure. Following the doctor’s instructions in the hospital and home can help ease recovery and relieve the symptoms. 

In Hospital Recovery

Haemorrhoidal artery ligation and recto-anal repair is generally an outpatient procedure. This means that patients can go home on the same day. They are usually in the hospital for an average of 11 hours. During this stay, individuals can expect the following: 

1. After the surgery, patients are taken to a recovery area where their vital signs, like temperature, pulse and blood pressure, are monitored until the anaesthesia wears off.

2. Pain medications are administered to manage discomfort. 

At-home Recovery

Individuals can resume work in a week after HAL-RAR. Most patients can expect complete resolution of discomfort six weeks post-surgery. During this period, they are advised to follow these guidelines: 

1. Rest for 24 hours after the procedure and restrict all physical activities.

2. Take sitz baths (a warm, shallow bath for the perineal region) 3-4 times daily after each bowel movement. It helps keep the anal area clean and relieve pain. 

3. Initial bowel movements may cause some discomfort. Pain medications and stool softeners will help alleviate this.

4. Eat high-fibre food and drink lots of water (6-8 glasses daily) to prevent constipation. 

Follow-up Appointment

The first follow-up visit is scheduled a week after the procedure to monitor healing and assess treatment success. The surgeon checks for any signs of infection or recurrence. The next visits are scheduled at 1 month, 6 months, 12 months, and then annually.

According to a study by Dr Amos et al., 2023, the patient satisfaction rate of HAL-RAR after six weeks post-procedure is 93.7%. The technique offers various benefits compared to traditional haemorrhoidectomy, which includes the following: 

1. Minimally Invasive: It is less invasive than hemorrhoidectomy, reducing tissue damage and leading to faster recovery with less pain.

2. Outpatient Procedure: Haemorrhoidal ligation and recto-anal repair often allow patients to return home the same day.

3. Low Recurrence Rates: The risk of haemorrhoid recurrence one year after the procedure is 10.5%.

4. Quick Recovery: Most patients can resume activities like work within a week. 

Haemorrhoidal artery ligation and recto-anal repair is a safe and effective procedure. However, like any surgical procedure, it has certain risks. According to a study by Turco and Trivedi, 2023, the complication rate after the procedure is 7.6%. These may include the following risks: 

1. Bleeding 

2. Infection 

3. Dyschezia (difficulty pooping) 

4. Urinary retention (temporary difficulty in urination)

5. Haemorrhoidal necrosis (death of tissue within haemorrhoids) 

When to call a doctor? 

After undergoing HAL-RAR, patients should look out for any signs of complications. It is important to consult a doctor if they experience the following: 

1. Intense pain that does not improve with medications 

2. Excessive bleeding 

3. Signs of infection like increased redness, swelling, and warmth at the surgical site 

4. Fever above 101 F 

5. Difficulty urinating 

Delaying haemorrhoidal artery ligation and recto-anal repair can lead to several complications associated with the progression of haemorrhoidal disease. The following are some potential risks of postponing this treatment:

1. Haemorrhoids may increase in size and severity, leading to anaemia, pain, discomfort, and bleeding. 

2. Advanced piles are more prone to complications such as thrombosis (blood clots within the haemorrhoid).

3. In extreme cases, untreated piles can lead to acute issues such as severe bleeding or strangulated haemorrhoids (blood supply to an internal haemorrhoid is interrupted). This requires emergency medical attention.

Cost of HAL-RAR 

The haemorrhoidal artery ligation cost in India varies widely based on multiple factors. The price generally starts from ₹ 23,000, with an average figure of ₹ 45,000. The maximum expense is ₹ 60,000. 

Note: These are estimated prices. For accurate costs, please speak to HexaHealth experts. 

Factors that affect the price of surgery include: 

1. Surgeon’s Fees: The medical expert’s experience and expertise can influence fees. Highly specialised surgeons often charge more.

2. Facility Charges: Private hospitals or surgical centres may be costlier than public facilities due to overhead expenditure and services provided.

3. Geographic Location: Expenses differ depending on the region or city due to variations in healthcare pricing and the cost of living.

4. Post-operative Care: Follow-up visits, medications, or additional treatments required post-surgery may add to the final bill.

5. Insurance: The extent of health insurance coverage and deductibles can significantly affect out-of-pocket costs.

Haemorrhoidal artery ligation and recto-anal repair is a modern procedure that treats haemorrhoids by targeting their blood supply and repairing prolapsed tissue. Its minimally invasive approach ensures a quick recovery, less pain, and minimal scarring. Patients benefit from precise treatment that significantly reduces the risk of recurrence.

HexaHealth provides comprehensive support for patients needing HAL-RAR, connecting them with experienced proctologists. Our network ensures personalised care from diagnosis to post-operative follow-ups. With us, you receive detailed guidance throughout your treatment for optimal recovery and improved quality of life. Get in touch today! 

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