1. Other Haemorrhoid Operations Mo Saeed Consultant Surgeon Stepping Hill Hospital Stockport

2. Other Haemorrhoid Operations Doppler Guided Haemorrhoid Artery Ligation (DG- HAL) Morinaga et al Am J Gastroenterology 1995; 90:610-3 Ligasure Haemorrhoidectomy (LH) sayfan et al Ann Surg;2001:234:21-24)

3. DG-HAL Embolisation of superior rectal artery and its branches results in effective treatment of bleeding from chronic haemorrhoids (Galkin et al VRS 1994;4:52-56) Morinaga et al Am J Gastroenterology 1995; 90:610-3

4. DG-HAL The bases of this treatment underlies the arterial blood flow to the haemorrhoids The anal cushions or corpus cavernosus recti (CCR) are arterio-venous anastomosis which lies above the dentate line The functional effect of changes in arterial flow into the CCR results in a gas tight seal of the anal canal

5. DG-HAL Primary aim is to specifically locate & ligate terminal branches of the Superior rectal artery Reduction in haemorrhoidal arterial blood flow resulting in shrinkage of haemorrhoidal mass Fixate the mucosa with interruption of blood supply results in pulling up the prolapse

7. DG-HAL 116 patients treated for symptoms of pain, prolapse & bleeding 1 month follow up: treatment effect observed in 96% of patients with pain 78% with prolapse 95% with bleeding

8. What Degree of Haemorrhoids ? Can be used for grade II-IV Symptoms include : Bleeding Pain Prolapse Procedure performed under sedation

9. DG-HAL Recent longer term outcome data Felice et al DCR 2005; 48: 2090-2093 Greenberg et al DCR 2006; 49: 485-489

10. DG- HAL Felice et al 68 consecutive patients with grade III haemorrhoids treated with DG-HAL. Mean F/U 11 months (3-18) : pain completely resolve in 8/11 & improved in the remaining 3 bleeding completely resolved in 51/56 (91%) prolapse resolved in 64/68 (94%) Complications: 5 persistent pain > 2 day in 2 patients 2 patients had thrombosis of 1 haemorrhoid 1 patient developed 2 0 haemorrhage

11. DG-HAL Greenberg et al DCR 2006; 49: 485-489 Treated 100 patients with grade II (19) or III (81) haemorrhoids 42 males 58 females. F/U 3,6 & 12 months: 95 discharged after 2-4 hours 96 patients completed 1 year f/u & 85 were asymptomatic 11 patients had persistent bleeding & required further treatment

12. DG- HAL Anopexy- Changes to the design of the proctoscope now allows placement of a suture to lift the prolapsing tissue. This will improve results for prolapse but may be associated with patient discomfort

13. DG-HAL Effective minimally invasive treatment for haemorrhoids Can be performed under sedation Randomised controlled trial vs other treatments needed Longer term F/U

14. Ligasure Haemorrhoidectomy The underlying principle of ligasure haemorrhoidectomy is the same as that for the standard Ferguson method with the only difference being the choice of diathermy Ligasure is a bipolar diathermy that provides energy and pressure to seals vessels and tissue bundles It produces minimal sticking,charring or thermal spread to adjacent tissues

15. Ligasure Haemorrhoidectomy (LH) First described by sayfan et al Ann Surg;2001:234:21-24) Several randomised controlled trials comparing Ligasure TM haemorrhoidectomy with conventional diathermy haemorrhoidectomy

16. Ligasure Haemorrhoidectomy Franklin et al DCR 2003; 46:1380-1383 compared ligasure with conventional diatherny haemorrhoidectomy: Main findings were reduced 1. operating time (6vs11mins) 2. post op pain at days 1 & 14 In the ligasure group

17. Ligasure Haemorrhoidectomy Palazzo et al BJS 2002;89:154-157 Ligasure haemorrhoidectomy reduced operating time and analgesic requirements but the postoperative pain was similar to that with conventional diathermy haemorrhoidectomy

18. Ligasure Haemorrhoidectomy Jayne et al BJS 2002: 89;428-32 Demonstrated reduced blood loss, shortened operating time & reduced pain for ligasure compared to conventional diathermy haemorrhoidectomy facilitating sameday discharge

19. Ligasure Haemorrhoidectomy Kraemer et al DCR 2005;48:1517-1522 Prospective randomised study comparing PPH with Ligasure haemorrhoidectomy 50 patients No differences in post op pain, patient satisfaction or length of operation between the two techniques

20. Ligasure Haemorrhoidectomy Ligasure haemorrhoidectomy is safe & effective technique for the treatment of grade 3 & 4 haemorrhoids Cost of the equipment can be offset by daycase treatment of patients