Haemorrhoidal Artery Ligation and Recto-Anal Repair (HAL-RAR)

Procedure HAL

Hemorrhoidal artery ligation (HAL) is a surgical intervention to ligate a hemorrhoidal artery that results in reduced blood flow and decongestion of the hemorrhoidal plexus. It prevents the recurrence of internal haemorrhoid bleeding by disrupting the natural course of the blood supply.

1. HAL interrupts and sometimes even reverses the low-grade collateral circulation. It often occurs within 100 microns of the origin or point of proximal attachment, from which hemorrhoidal blood is shed.
2. A flexible handle is inserted into the rectum and slowly rotated to find the arteries. When the handle finds the artery, it will be ligated.
3. With the gradual turning of the handles, more arteries are found that can be ligated. In general, five to eight arteries are ligated. However, the count may vary from patient to patient.

Procedures of RAR

1. Recto anal repair is particularly used for hemorrhoidal diseases that have reached an extreme stage.
2. RAR is conducted after HAL ligates the arteries with the help of two or more mucoceles of prolapsing mucosa. The handle is placed in a similar position as for ligation.
3. The handle should be positioned towards the ligation window, i.e., the prolapse place required for treatment.
4. After making a primary stitch, the handles are turned to clear mucosa. Leaving at least a 7-10 mm distance between the stitch, the handle will be turned gradually.
5. Once the last stitch is made, the needle will be cut, and a knot is created at the initial stitch. It allows the prolapsing tissue to pull towards the stitch and stay secured.

What To Expect Before The Procedure?

1. Hemorrhoidal artery ligation is one of the most common treatments for haemorrhoids. However, before undergoing this procedure, there may be other factors to consider, such as your health and lifestyle.
2. Your doctor should examine you to look for signs of other underlying problems that might need to be addressed. For example, suppose you experience chronic symptoms such as fever or body aches and blood in your stools or urine during the recovery process. In that case, it can signify a problem requiring medical care rather than an operation.
3. Before the procedure, your doctor must examine your anus to see if your internal haemorrhoids are thrombosed (Blood Clotting in the Anus).
4. At least a year before the surgery, you need to deal with the diet and those other issues that can positively contribute to your post-HAL life, such as eating disorders, poor stress management, or primary medical and surgical complications.
5. Discuss pre-HAL considerations (pre-HAL exercise plan) with your coach or personal trainer before beginning.
6. If you're getting yourself into professional athletic shape, don't do too much of what you do outside the gym.

What To Expect During The Procedure?

1. Hemorrhoidal Artery Ligation is an outpatient procedure used to close off the artery that gives rise to internal haemorrhoids.
2. This procedure has a low risk and should be done laparoscopically, meaning the surgeon will perform minimally-invasive surgery with a help of a laparoscopic device called a Doppler-guided probe.
3. The patient typically goes home within six hours from their surgery. Here are the things you should expect during the HAL procedure:
4. You should expect to feel discomfort at the Novocaine injection site until the numbing wears off. Pain is to be expected, and it may last a while before anything major happens.
5. You may experience some bleeding after your surgery, depending on the severity of the haemorrhoids. This can be controlled with medication.
6. All movements are restricted related to physical activity for 24 hours after your procedure.
7. You will have about two weeks off of normal activity. Afterwards, you may find small blood clots on your stool or urination while getting more used to the new routine.

What To Expect After The Procedure?

1. Hemorrhoidal tissue can grow back if you don't treat the problem, but this is seen as less likely with a HAL procedure as the chances of the tissue coming back on its own are minimal to none. Here are the things you should expect after the HAL procedure:
2. Irritation and Pain. The initial discomfort of a Hemorrhoidal tissue bleed will be intense and localised. There is tightness in the area; you may feel numbness, pain, or loss of sensation.
3. Some of the extreme post-surgery scenarios include swollen external haemorrhoid area, bleeding from the anal canal, discomfort during excretion after a bowel movement, etc. Some people experience loose stools for about 2-3 weeks post-op if the relaxants used for the HAL procedure aren't sufficient or effective enough.
4. You will urinate quite frequently. Expect to have to go every 30-60 minutes or so until your body is used to having to pee frequently and pushes the blood clots together for easy urination/excretion.
5. After surgery, you may notice increased gas in the intestine (flatulence). This should decrease as your intestines start amassing more food.

First Follow Up Appointment

The first follow-up appointment for a patient after a Hemorrhoidal Artery Ligation is usually scheduled six weeks later, although this schedule is not perpetual and some doctor typically recommends a longer period, so it is important to talk to the doctor before surgery, regarding the follow up.

1. Bleeding. Some degree of bleeding is expected for up to 4 weeks post operatively but the risk of significant bleeding requiring return to theatre is very small.
2. Acute prolapse. ...
3. Infection. ...
4. Urinary retention.