الفهرس 
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Abstract
Haemorrhoidal disease is the most common disease of the rectum. Usually, patients do not seek early treatment given the nature of the disease but the prevalence is estimated to range between 4.4% and 36.4%. Approximately 10-20% of patients will require surgery.
Haemorrhoids are a physiological plexus of veins located between the lamina muscularis mucosa and sphincter muscle structures and consists of a superior (inner) and inferior (external) part divided by the dentate line. Because of arterial shunts and an extension of veins, this plexus becomes enlarged and plays an important role in “fine continence” of the anal canal.
Today, haemorrhoidal disease is considered as a typical “civilization” disease, and nutrition, hygiene, and constitution, plays an important role in its development. The main pathogenetic cause for haemorrhoidal disease is increased intraluminal blood pressure of the distal rectum. This results in an imbalance between arterial inflow and venous return.
Reasons for the increase in intraluminal blood pressure are multifactorial and most probably individually different. Fibrefree food, high tonus rates of the sphincter apparatus, stress and anatomic, physiologic and hereditary factors are currently considered possible causes.
Enlargement and displacement of haemorrhoids typically presents with symptoms such as bleeding, pruritus, prolapse, sensation of incomplete evacuation, soiling, recurrent thrombosis of piles, etc. (which are bothersome and difficult to attenuate). However, the grade of prolapse and haemorrhoidal symptoms are often poorly correlated.
The current well-accepted grading of haemorrhoids, also known as the Goligher’s classification, is based on the morphology of the but with bleeding; grade II = prolapsing piles with spontaneous repositioning of piles; grade III = manual repositioning of piles possible and required; grade IVa = prolapsing piles with acute incarceration and thrombosis; and grade IVb = repositioning of piles impossible, fibrotic prolapse occurs.
Initial treatment for grade 1, 2 haemorrhoids is conservative management, meaning dietary and lifestyle modifications for example fibre rich diet and better defecation discipline, followed by medical treatment with local application of ointments or oral medication or minimally invasive treatment like sclerotherapy, photocoagulation and cryotherapy.
If symptoms prevail, there is a wide range of surgical treatment modalities. A variety of surgical procedures are now available but no single technique has been universally accepted as superior. This is because the indication for treatment is not only based on the gradation of the haemorrhoids but mainly on the subjective severity of symptoms among patients and quality of life. While the choice of treatmentis based on the gradation of the haemorrhoids, local experience, surgeon’s preference and availability of specialized equipment.
Several therapeutic modalities are used to treat hemorrhoids; the most recent is a hemorrhoidal artery ligation. Historically, it is a Japanese surgeon, Kazumasa Morinaga, who had the idea of this technique in 1995, the principle is to identify and link in Doppler arterial branches that travel in the direction of the rectal wall hemorrhoidal internal network in order to relieve the internal hemorrhoidal tissue, its effectiveness is verified by the decrease in the Doppler signal.
The HAL concept approaches the problem using a different modality: the goal is to treat the patients’ symptoms without tissue destruction. By a Doppler guided selective ligation of the terminal branches of the superior haemorrhoidal artery (HAL) the blood supply is reduced (but never totally blocked), causing atrophy of the haemorrhoidal cushions. The second step is to perform a mucopexy to reintroduce and fix the haemorrhoids into the anal canal. Their atrophy and posterior fibrosis will keep them in their natural position preventing recurrence and increasing the results provided by the HAL technique if it is performed alone.
In addition, it is easy for the surgeon to learn it and acquire appropriate skills after a short learning curve. The HAL is a minimally invasive technique that is conceptually painless for patients since all manoeuvres and sutures are endoanal and above the dentate line; this helps an early recovery and allows an ambulatory procedure. We must bear in mind that postoperative pain is often the most common concern for patients and professionals dealing with haemorrhoids. The results of HAL in this study show a very low postoperative pain rate (two patients_ lower than 7 %); moreover, it is easily controlled with oral analgesia. One patient (3%) complained of mild costipation, which controlled by laxative.
The HAL concept approaches the problem using a different modality: the goal is to treat the patients’ symptoms without tissue destruction. By a Doppler guided selective ligation of the terminal branches of the superior haemorrhoidal artery (HAL) the blood supply is reduced (but never totally blocked), causing atrophy of the haemorrhoidal cushions. The second step is to perform a mucopexy to reintroduce and fix the haemorrhoids into the anal canal. Their atrophy and posterior fibrosis will keep them in their natural position preventing recurrence and increasing the results provided by the HAL technique if it is performed alone.
In addition, it is easy for the surgeon to learn it and acquire appropriate skills after a short learning curve. The HAL is a minimally invasive technique that is conceptually painless for patients since all manoeuvres and sutures are endoanal and above the dentate line; this helps an early recovery and allows an ambulatory procedure. We must bear in mind that postoperative pain is often the most common concern for patients and professionals dealing with haemorrhoids. The results of HAL in this study show a very low postoperative pain rate (two patients_ lower than 7 %); moreover, it is easily controlled with oral analgesia. One patient (3%) complained of mild costipation, which controlled by laxative.
DGHAL procedure offers excellent results in all stages of hemorrhoids. DGHAL is a safe, effective method, with a short learning curve of the procedure, and may offer an important alternative to operative hemorrhoidectomy with no risk of postoperative stool incontinence, minimal postoperative pain, and early return of patients to their normal activities, which can be applied as one-day surgery.