*6.14.2 Doppler-Guided Hemorrhoid Artery Ligation (DG-HAL)*

DG-HAL, developed by Morinaga (Japan) in 1995, is to perform ligation of the distal branch of the superior rectal artery with the help of Doppler to detect the location of the artery so that the ligation will be accurate. From empirical experience, the hemorrhoids will shrink at 6 weeks' follow-up.

Initial experience showed that for grade III and IV hemorrhoids, this procedure did not give satisfactory results, the recurrent rate was still high, so in 2005, the

#### **Figure 9.**

*Stapler hemorrhoidopexy. a. purse-string suture on Morgani column in upper margin of internal hemorrhoids, b. thread knotted between anvil and stapler head, approximate both until save the position and then fire. c.After removing the stapler, the rest of the anal cushion retracted upside, (Illustrated by Kanaya) d. Accurate stapling if we have complete circular rectal tissue like donuts. (personal collection).*

DG-HAL procedure was added with rectoanal repair (RAR), (**Figure 10**), namely, performing continuous sutures to fix the anal cushion proximally. To make sure that the anal cushion can move and be fixed proximally, the first stitch in the proximal part should include the rectal muscle and then submucosally. To avoid severe pain, the last suture to fix the anal cushions should be placed above 1 cm from the dentate line [33]. **Figure 11a** and **b** show hemorrhoids before and after DG-HAL-RAR.

The small meta-analysis of 3 RCT, by comparing 70 SH with 80 DG-HAL-RAR, the baseline homogenous (P = 0.40), showed no difference regarding success rate (p = 0.19), operation time (P = 0.55), postoperative complications (p = 0.11), and recurrence rate (P = 0.46), and the only difference is postoperative pain. DG-HAL causes less postoperative pain (P < 0.00001) [34]. A 705-patient multicenter study in Brazil found that a one-year follow-up after DG-HAL-RAR was significantly better in grades II and III compared to grade IV. Recurrence of prolapse, recurrence of bleeding, and thrombosis of grade II-III versus grade IV were 2.36% vs 26.54%, 1.01% vs 7.96%, and 1.35% vs 10.61%, respectively [35].

It should be noted that several conditions can contribute to increased pain after DG-HAL-RAR, namely the additional excision of thrombus of internal and external hemorrhoids, the presence of anal fissures, or laceration of the anal canal of the skin. This encourages caution during probe insertion. Additional local anesthetic infiltration will help to reduce postoperative pain [36]. In the case of large grade III and IV internal hemorrhoids, additional minimucosal excision is advised if any nodule remains after DG-HAL-RAR [37].

#### **Figure 10.**

*DG-HAL-RAR a. Position of the probe to detect a branch of the superior rectal artery b. The number of arterial sutures varies from 5 to 8 and is not at the same level. c-d. Continues suturing for rectoanal repair. e. After the suture has been knotted, the final position. (Illustrated) by Kanaya).*

#### **Figure 11.**

*a. Prior to surgery, Grade III Internal Hemorrhoid, and b. After DG-HAL-RAR. (personal collection).*

#### **Figure 12.**

*a. large circular Grade IV internal hemorrhoid, b. normal mucosal bridges are still visible after removal of three main piles (Milligan-Morgan Procedure). c. After DG-HAL-RAR of prominent visible mucosal bridges. d. 17 months postoperatively. (Personal collection).*

In developing countries, cases of large circular Grade IV internal hemorrhoids occur very often (**Figure 12a**). Since the Whitehead procedure has already been abandoned due to its complications, the Morgan Milligan procedure is the only choice. However, after removing 3 main piles, the normal mucosal bridges are still prominent (**Figure 12b**). The addition of DG-HAL-RAR to prominent mucosal bridges gives a good result (**Figure 12c**). Followed up for 17 months, with a good appearance and no complaints (**Figure 12d**) [38].

#### **6.15 Post-surgical care**

For patients with instrumentation or surgery that only repositions the anal cushion, no special treatment is needed. Consuming high fiber and drinking lots of water will facilitate defecation, which is the standard for managing hemorrhoids, either conservatively or operatively, and also must be carried out postoperatively. The administration of analgesia is more tailored to the patient's needs because excision hemorrhoidectomy causes greater pain, so the need for analgesics is extra [2, 3]. Flavonoids, in this case, MPFF given post-surgery, have been proven by a meta-analysis of RCTs to reduce the risk of bleeding and post-surgical pain [14].

For excision hemorrhoidectomy, because the wound in the anal area, it requires special care. The anal area is a dirty area due to contamination with feces. Because of the pain, the patient will prefer not to wipe cleanly after defecation. Soaking in warm water with disinfectant will greatly help to clean the wound from contaminants, thereby helping reduce infection and speed healing. Soaking in warm water is also beneficial for reducing pain [8].

Changes in diet, method of defecation, and control of identified risk factors for the patients (chronic cough, shortness of breath, constipation, urinary difficulties, weight lifting, etc.) are important factors in preventing recurrence [8].
