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

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

Treatment Duration


25 Minutes

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60 Minutes

Treatment Cost



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

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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. 

Procedure Name 


Alternative Name 


Conditions Treated 


Benefits of the Procedure 

Minimally invasive, outpatient procedure, low recurrence rate 

Treated By 


What is HAL-RAR?

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.

Who needs HAL-RAR?

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)

HAL-RAR Procedure

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.

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Before and on the Day of HAL-RAR

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: 



Pre-op Assessments 

  1. Rectal exam 

  2. Visual inspection  

  3. Blood test 

Risk Evaluation 

  1. Allergies 

  2. Risks vs benefits 


Blood thinning medications 7-10 days before surgery 

Anaesthesia Selection 

General or spinal 


6-8 hours before the procedure 

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:





Surgical Preparation 

Changing into a hospital gown 

Physical Evaluation 

Vitals check-up (blood pressure, oxygen, temperature, etc.)

IV Line 

Yes, for fluids and medications 

Patient Positioning

Lithotomy (lying on the back with legs elevated and supported in stirrups)

After HAL-RAR and Recovery

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.

Benefits of HAL-RAR

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. 

Risks and Complications of HAL-RAR

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 

Risks of Delaying HAL-RAR

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. 

Procedure Name 

Estimated Cost Range

Haemorrhoidal Artery Ligation and Recto-anal Repair 

₹ 23,000 to ₹ 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! 

Suggested Reads

Rubber Band Ligation
Perianal Abscess
Non Surgical Treatment for Piles
Sclerotherapy for Piles

Frequently Asked Questions (FAQ)

The HAL-RAR method (haemorrhoidal artery ligation and recto-anal repair) is a minimally invasive procedure for treating haemorrhoids. It combines artery ligation to cut off blood supply and recto-anal repair to reposition prolapsed tissue.


According to a study by Turco and Trivedi, 2023, the success rate of HAL-RAR surgery is 93%. About 85% and 92% of patients experience a reduction in symptoms within one month and 12 months, respectively. The exact rate varies based on the severity of the condition and adherence to post-operative care.


The HAL-RAR surgery is performed under general or spinal anaesthesia. It is a two-step procedure which involves the following: 

  1. HAL: A proctoscope with a Doppler ultrasound probe is used to locate and ligate haemorrhoidal arteries. 

  2. RAR: The prolapsed haemorrhoidal tissue is sutured and repositioned to restore proper anatomy and reduce prolapse.


In the HALO or HAL-RAR procedure, a Doppler ultrasound identifies the arteries supplying blood to haemorrhoids, which are then tied off. The surgeon also lifts and secures prolapsed haemorrhoidal tissue back into the anal canal. This reduces symptoms and improves healing.


Haemorrhoidal artery ligation is recommended for patients with internal or prolapsed haemorrhoids (Grades II and III). It is suitable for those who experience significant bleeding, prolapse, or discomfort and have tried conservative treatments. The procedure provides a less invasive solution with a high success rate.


The haemorrhoidal artery ligation cost can vary widely based on location, surgeon experience, and facility fees but typically ranges from ₹ 23,000 to ₹ 60,000. Patients are advised to consult HexaHealth experts for up-to-date pricing details. 


HAL-RAR is particularly effective for patients with advanced haemorrhoid problems. It offers various benefits compared to traditional haemorrhoidectomy methods, which include the following: 

  1. Minimally invasive approach 

  2. Reduced pain and bleeding 

  3. Quicker recovery time 

  4. Lower recurrence rates


Haemorrhoidal ligation and recto-anal repair is generally considered a safe procedure. However, there are some risks associated with the surgery, which are as follows: 

  1. Bleeding 

  2. Infection 

  3. Urinary retention 

  4. Difficulty pooping 

  5. Recurrence of haemorrhoids


Recovery time for haemorrhoidal artery ligation is relatively short. Most patients can resume normal activities like work within a week. However, complete healing may take six weeks, depending on individual health and the extent of the procedure.


Post-operative care after HAL-RAR surgery is important to ensure the success of the process. It involves the following steps: 

  1. Managing pain with medications

  2. Maintaining hygiene in the anal area 

  3. Following dietary recommendations to prevent constipation 

  4. Attending regular follow-up visits to ensure healing


HAL-RAR surgery is generally not performed under local anaesthesia. The procedure is done under general or spinal anaesthesia to ensure patient comfort. 


You can resume normal activities within a week after HAL-RAR surgery, depending on the extent of the procedure and your overall health. Full recovery may take six weeks.


HAL-RAR surgery offers a long-term solution for haemorrhoids, but it is not guaranteed to be permanent. Healthy lifestyle choices and proper bowel management are essential to prevent recurrence.


The chances of recurrence after haemorrhoidal artery ligation and recto-anal repair are relatively low. According to a study by Lauricella et al., 2024, the recurrence rate one year after the procedure is 10.5%. 


After HAL-RAR surgery, a high-fibre diet is recommended to ensure soft stools and regular bowel movements. This may include the following: 

  1. Fruits (pear, banana, orange)

  2. Vegetables (broccoli, carrot, Brussels sprouts)

  3. Whole grains (brown rice, barley, oats)

  4. Nuts, seeds and legumes (lentils, almonds, chia seeds)

Avoiding acidic and spicy foods can also help minimise discomfort during recovery.


Yes, HAL-RAR surgery is performed as an outpatient procedure. Most patients go home the same day, which is convenient and reduces hospital stay costs.


Yes, there are alternative treatments available for HAL-RAR surgery, depending on the extent of the condition. These options include: 

  1. Pain medications to help relieve discomfort  

  2. Dietary changes like eating a high-fibre diet to avoid straining during bowel movements

  3. Minimally invasive procedures like rubber band ligation and sclerotherapy 

  4. Surgery like haemorrhoidectomy and haemorrhoid stapling



All the articles on HexaHealth are supported by verified medically-recognized sources such as; peer-reviewed academic research papers, research institutions, and medical journals. Our medical reviewers also check references of the articles to prioritize accuracy and relevance. Refer to our detailed editorial policy for more information.

  1. Agarwal N, Singh K, Sheikh P, Mittal K, Mathai V, Kumar A. Executive Summary - The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids—2016. Indian Journal of Surgery [Internet]. 2017 Jan 9;79(1):58–61. link
  2. Cleveland Clinic. The Anus [Internet]. Cleveland Clinic. 2023.link
  3. Banai Z, Harkai Z, Király L, Szekeres P, Ottlecz I. HAL-RAR-műtét – egy új, non-invasiv lehetőség az aranyerek kezelésére. Magyar Sebészet (Hungarian Journal of Surgery). 2019 Dec;72(4):161–6.link
  4. C Hoyuela, Carvajal F, Montserrat Juvany, Troyano D, Trias M, Antoni Martrat, et al. HAL-RAR (Doppler guided haemorrhoid artery ligation with recto-anal repair) is a safe and effective procedure for haemorrhoids. Results of a prospective study after two-years follow-up. 2016 Apr 1;28:39–44.link
  5. Hemorrhoidectomy Surgery: When You Might Need It, & What to Expect [Internet]. Cleveland Clinic.link
  6. Treatments [Internet]. patient.uwhealth.org. [cited 2024 May 14].link
  7. Turco JD, Trivedi A. Extensive subcutaneous emphysema and intra-abdominal sepsis following haemorrhoid operation: a rare complication of a novel procedure. Journal of surgical case reports. 2023 Apr 1;2023(4).link
  8. Mayo Clinic. Hemorrhoids - Symptoms and causes [Internet]. Mayo Clinic. 2018. link
  9. Lauricella S, Palmisano D, Brucchi F, Domenico Agoglitta, Fiume M, Luca Bottero, et al. Long-term results and quality of life after stapled hemorrhoidopexy vs Doppler-guided HAL-RAR: a propensity score matching analysis. International journal of colorectal disease. 2024 Feb 22;39(1).link
  10. Mayo Clinic. How much fiber is found in common foods? [Internet]. Mayo Clinic. 2021.link
Disclaimer: The information provided here is for educational and learning purposes only. It doesn't cover every medical condition and might not be relevant to your personal situation. This information isn't medical advice, isn't meant for diagnosing any condition, and shouldn't replace talking to a certified medical or healthcare professional.


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