DGHAL-RAR IN MANAGEMENT
OF INTERNAL HEMORRHOID
Ignatius Riwanto
Dept. of Surger y, Digestive div. Diponegoro
Medical Faculty
SYMPOSIUM
KONAS PABI
PALEMBANG 2 APRIL 2018
HEMORRHOID
Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
THE FUNCTION OF ANAL CUSHION
Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
PATHOLOGY OF HEMORRHOID
Microscopic:
abnormal dilatation and distortion
of the vascular channel,
destructive changes in the
supporting connective tissue within
the anal cushion (Treitz muscle &
Park ligament)
an inflammatory reaction
vascular hyperplasia
Complications:
urinary retention (2-36%),
bleeding (0.03-6%),
anal stenosis (0-6%),
infection (0.5-5%),
incontinence (2- 12%).
Sc h ube r t E T AL. Wo rl d J G a s t ro e nte ro l 2 0 0 9
Retained volume in the liquid continence test
Group A: < 900 ml
Group B: 900-1200 ml
Group C: > 1200 ml
REDUCE POST OPERATIVE PAIN &
COMPLICATION?
MINIMALLY INVASIVE
HEMORRHOID SURGERY?
Normal: a sphincter-
like structure, formed
by thickened tunica
media containing 5-
15 layers of smooth
muscle cells, between
the vascular plexus
within the sub
epithelial space of
the anal transitional
zone
World J Gastroenterol 2012 May 7; 18(17): 2009-2017
VASCULAR STRUCTURE
IN HEMORRHOID
Hemorrhoids: remarkably
dilated, thin-walled vessels
within the submucosal
arteriovenous plexus, with
absent or nearly -flat
sphincter-like constriction on
the vessels
smooth muscle sphincter
helps in reducing the
arterial inflow, thus
facilitating an effective
venous drainage
Study Groups Caliber of the vessels (SRA) Flow in the vessels (SRA)
14
THE VASCULAR NATURE OF
HEMORRHOIDS
( F. A I G N E R E T A L . , 2 0 0 6 , G A S T R O I N T E S T S U R G . )
15
MORPHOLOGY AND HEMODYNAMICS OF THE
ANORECTAL VASCULAR PLEXUS
STAPPLER HEMORRHOIDOPEXY
DOPLER GUIDED HEMORRHOID ARTERY
LIGATION & RECTO-ANAL REPAIR
RAR =
Proctoplasty/
mucopexy is lifting
the hemorrhoid
back to where the
belong for grade III-
IV
. The American Journal of Surgery, 2006
MULTICENTER TRIAL DOPPLER-GUIDED
THD (WITH ANOPEXY)
803 patients
mean follow-up of 11.1 + 9.2 mo.
Overall success rate of 90.7%
recurrence of hemorrhoidal prolapse 6,3%
bleeding 2,4%
both recurrence and bleeding 0,6%
Te c h C o l o p r o c t o l . 2 0 1 2 F e b ; 1 6 ( 1 ) : 1 - 8 ( A b s t r a c t ) .
Cohort study
Baseline (age, gender, classification, recurrent &
symptomatology) comparable
• Hemorrhoids symptoms
score preoperative was
comparable between
DGHAL-RAR and CH
• Hemorrhoid symptoms
score post operative was
comparable between
DGHAL-RAR and CH
CURRENT POSITION OF
HEMORRHOID ARTERY LIGATION
AND RECTO ANAL REPAIR IN
INDONESIA
• Course HAL-RAR 10th May
2012
• Semarang Indonesia start
HAL-RAR August 2012
• First Indonesian HAL-RAR
course, Semarang Digestive
Week Oct 2014
NUMBER OF CERTIFIED SURGEON FOR HAL -
RAR OPERATION AND NUMBER PROBES SOLD
1000
900
180
CERTIFIED DOCTORS - HAL 800
TAHUN PROBES
RAR
700
DOPPLER-ASSISTED LOCALIZATION IS
IMPORTANT IN CORRECTLY LOCATING THE ARTERIES
If during HAL-RAR,
there is still:
some prolapse
Excessive skin
component
mini mucocutanous
excision (MME)
Skin tag/ hypertrophy
of anal papilla
excision
. Colorectal Dis. 2010 Feb;12(2):125-34.
COMBINATION EXCISIONAL
HEMORRHOIDECTOMY AND HAL-RAR
Prominent grade IV
internal hemorrhoid
Impossible to be
operated with
minimally invasive
Morgan Milligan may
left prominent normal
skin-mucosa bridge
Addition with HAL-RAR
for prominent mucosal
bridge improve the
result
SUMMARY (1)