Al-ZAFER Hospital KSA JEDDAH . الدكتور نزار أحمد الأسود استشاري جراحة عامة من فرنسا Dr. Nizar Al Aswad Consultant surgeon

Transanal Hemorrhoidal Dearterialization Hemorroidal Artries ligation T.H.D/ H.A.L A new concepts in hemorroidal surgery الجديد في العلاج الجراحي للبواسير

Internal hemorrhoidal plexus Histologically : the internal Hemorrhoidal plexus : appears like a structure of large vascular spaces, arteriovenous shunts, fusiform, saccular or serpiginous dilatations, the so-called corpus cavernosum recti (CCR) The CCR; it therefore has erectile properties , located above the dentate line, 3-5 cm from the anal verge. surrounded by connective tissue, within/below the rectal mucosa. These structures are anchored by fibers to the internal sphincter, the so-called Parks ligament .The hemorroidal prolapce due to repeted tering to thes ligament

Blood supply The blood supply to the rectum and the anal canal is provided by 3 arteries, the superior rectal artery, a branch of the inferior mesenteric artery; the middle rectal artery, a branch of the internal iliac artery; and the inferior rectal artery, a branch of internal pudental artery. The internal hemorrhoidal plexus receives its blood supply exclusivly from the terminal branches of the superior rectal artery. They constitute the exclusive arterial blood supply to fills the hemorrhoids Recent studies using color Doppler ultrasound technology, have demonstrated that . It is a functional blood supply that fills this cavernous network, forming a gas-tight seal of the anal canal. It therefore plays an essential role in the pathogenesis of hemorrhoidal patholog.

Hypertension of the hemorrhoidal plexus enhances the rupture of the corpus cavernosum recti (CCR) , that may bleed spontaneously , during defecation or exertion. The bright red color , arteriography , and the pH study of the blood, during the hemorrhoidal bleeding, cofirme it is arterial natur .

A new method Studies have proved that : Hemorrhoids are important anatomical and physiological structures for continence,that’s why considerable numbers of patients who underwent traditional hemorrhoidectomy develop at least air incontinence. Also coloured-doppler studies have identified six hemorrhoidal branches of the superior rectal artery located in add even numbers , at positions 1,3,5,7,9 & 11. oclock . ( If observed in lithotomic position ) . The procedure is resolutive and pain-free since there is no wounds or cuts . Arterial ligation is above the dentate line. It can be done as day case and the pt can drive his car back to home.

The HAL , hemorroidal artries ligation , is the last invasive one , it uses a specially designed instrument The proctoscop is equipped with a doppler transducer (A) , and light sorces to locate the terminal branches (up to six) of the superior rectal artery, which are then ligated, through an opposite slit (B) in the INSTRUMENT, 2-3 cm. above the dentate line. Therfore, the arterial flow to the hemorrhoids is reduced and they shrink.

Results Hemorroids are not a disease but they got diseased Hemorrhoids are not a frequently discussed topic. Most people simply tolerate the problem and are often frightened by the thought of traditional surgery. It is estimated that 50% of Americans will, at some point in their lives, suffer from their hemorrhoids . The hemorroidal artries ligation HAL a procedure offers a minimally invasive surgical approach to treat the pathology affecting the hemorrhoids. HAL is offered as an out patient procedure . Moreover, in the rare case of partial failure due to incomplete artery ligation, the procedure can be easily repeated. It is the best operative technique indecated for all hemorroidal lesions stages, also for the recurrentce of hemorroidal pathology after conventional surgery . Clinical results have shown that patients who have HAL may encounter less pain, less risk of complications , less sequels , and faster return to activities (24-48 hrs). It’s time to forget the pain and get back to life! . And the surgeon become relieved from the patiets complications and complaints , after the classical hemorroidal surgery . Hemorroids are not a disease but they got diseased

Selective injection of branch of the superior hemorrhoidal artery: active hemorrhage

Arrest of hemorrhage following embolization: embolized branch

Hemorroids are not a disease but they got diseased البواسير ليست مرضا وإنما هي التي تصاب بالمرض البواسر ليست مرضا وإنما هي التي تصاب بالمرض د.نزار الأسود شكرا

مستشفى القصيم الوطني

THANK YOU Dr. Nizar Al Aswad E-mail : drnizaralaswad@yahoo.com Mobil : 00966 503719833