HAL (Haemhorroidal Artery Ligation)
HAL is generally used for grade 2 and 3 haemorrhoids and there is the option for HAL which is performed with a proctoscope modified to incorporate a Doppler transducer. There are two types of equipment in common use, known as HALO and THD. Both enable the detection of the feeder vessel to facilitate a targeted suture ligation of the Haemorrhoidal arteries. This procedure can be combined with a mucopexy suture for prolapsing haemorrhoids. HAL is performed under general anaesthetic as a day case procedure. The recovery can take up to 2 weeks during which the patient is likely to endure some discomfort. Time off work will be required. There is said to be a 30% recurrence rate with this process meaning that the symptoms might well recur with the procedure needing to be repeated. This is commonly offered privately and on the NHS.
Stapled Haemorrhoidectomy
Stapled haemorrhoidopexy is a technique that reduces the prolapse of haemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane above the dentate line, using a specific circular stapling device. This interrupts the blood supply to the haemorrhoids and reduces the potential for available rectal mucosa to prolapse. The procedure is referred to as a ‘pexy’ because the haemorrhoidal tissue is not excised as in conventional haemorrhoidectomy. Stapled haemorrhoidopexy is also known as ‘procedure for prolapse and haemorrhoids’ (PPH), stapled anopexy, stapled prolapsectomy and stapled mucosectomy. It has been used in the UK for several years. This is typically offered to treat the larger grade 4 prolapsing haemorrhoids and is carried out under general anaesthesia, most likely requiring an overnight stay in hospital.
Haemorrhoidectomy
Surgical haemorrhoidectomy is usually performed by the Milligan-Morgan (open) or Ferguson (closed) procedure. The Milligan-Morgan procedure involves dissection of the haemorrhoid and ligation of the vascular pedicle. The wounds are left open to heal naturally. The Milligan-Morgan procedure is thought to be relatively safe and effective for managing advanced haemorrhoidal disease, but because the anodermal wounds are left open healing is delayed, which may result in discomfort and prolonged postoperative morbidity. The Ferguson procedure is a modified version of the Milligan-Morgan technique, in which the wound is closed with a continuous suture to promote healing. A number of postoperative complications are associated with surgical haemorrhoidectomy. The short-term complications include pain, urinary retention, bleeding and perianal sepsis. Long-term complications may include anal fissure, anal stenosis, incontinence, fistula, and the recurrence of haemorrhoidal symptoms. Recovery can take at least 3 weeks (generally whilst suffering severe post-operative pain whilst the wound is allowed to heal). Haemorrhoidectomy is considered by NICE to be the gold standard in haemorrhoid treatment, with a relatively good success rate, but comes at the cost of considerable pain during and after the operation.
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