Haemorrhoidal disease is one of the most common anorectal conditions encountered in daily practice by general practitioners, general surgeons, and gastrointestinal surgeons in India. It has been projected that about 50% of the population would have haemorrhoids at some point in their life, probably by the time they reach the age of 50, and approximately 5% of the population suffer from haemorrhoids at any given point in time.
While dietary and lifestyle modifications are usually sufficient for conservative management of early grade haemorrhoids, various surgical interventions are needed for higher grade haemorrhoids. Surgeons have been using various methods like closed Hemorrhoidectomy, Open Hemorrhoidectomy, Stapled Hemorrhoidopexy, Rubber band Ligation, Hemorrhoid laser procedure (LHP), etc over the last many decades to manage haemorrhoids. While some of these offer excellent long-term results, side effects and complications are not uncommon.
“Treatment today has become increasingly image-guided and evidence-based. Everything we do needs to be done to cause minimal harm, minimum invasion and improve patient outcomes. While we have seen and probably practised everything from open to staplers to lasers, one of the techniques that has come to prominence is the DG HAL-RAR (Doppler-guided hemorrhoidal artery ligation with recto-anal repair) technique ” said Dr Abhijit Paul, Medical Director of Practo, who also moderated the session.
Used frequently in the treatment of Grade II-IV haemorrhoids, the DG HAL-RAR technique is known to have a low rate of complications, low recurrence and evidence-based effectiveness, which has played a crucial role in its acceptance. However, this acceptance is not universal and is often punctured with uncertainty. Coloproctologists and surgeons are unsure of whether DG HAL-RAR could play a leading role as a primary treatment of haemorrhoids.
To address this concern and spread awareness about the DG HAL-RAR technique, its effectiveness and complications, Practo Care Surgeries organised its first-ever CME with some of India’s leading PCS surgeons who have been using the DG HAL-RAR technique in their practice for over a decade.
“Earlier we used to say that diet and habits, low fibre diet, straining, constipation, weakening of venous wall, venous obstruction, portal hypertension, pregnancy, ascites and ageing contributed to the aetiology of haemorrhoids. However, our lifestyle habits have led to another aetiology and that is using mobile phones in washrooms which invariably leads to straining,” said Dr C.M. Parameshwara, keynote speaker, PCS surgeon and founder of Smiles Institute of Gastroenterology, Bangalore. He further added that most patients who visit a coloproctologist these days spend a minimum of 30-40 minutes in the washroom.
Having used the DG HAL-RAR technique over the last 9 years and have helped thousands of patients in their health journey, Dr Parameshwara shared his vast experiences with the participants through a detailed presentation that covered some of the most commonly asked questions about the DG HAL RAR technique, most of which are covered below.
So, what is DG HAL RAR?
“DG HAL RAR is a minimally invasive and innovative procedure mainly used for Grade 2 and Grade 4 haemorrhoids. It aims at de-arterialisation of the internal hemorrhoidal plexus by ligation of the terminal branches of the superior rectal artery. The procedure is done using a special proctoscope and doppler ultrasound system for identifying the haemorrhoids and ligating them with special sutures material.”
Why do we need DG HAL RAR?
“The position of the superior rectal artery is unpredictable. Although commonly believed to be at 3, 7 and 11 o’clock positions, it can be elsewhere as well. Even at 3, 7 and 11 o’clock positions when you do a HAL without a doppler, 50% of the surgeons have missed out on the ligation of the artery because the depth and the distance from the dentate line can be miscalculated. However, with DG HAL, you can identify it easily.”
What type of anaesthesia is used for the procedure?
“Many people use General anaesthesia, spinal anaesthesia, saddle block of local anaesthesia. I strongly recommend all colorectal surgeons to use saddle blocks and stop using local anaesthesia.”
What are the possible complications?
“In my 9 years of experience of practising DG HAL RAR, I saw only one patient who experienced bleeding due to slipping of the ligature. The second complication is thrombosis of the external pile mass. When there is external pile mass, it is important to do a mucocutaneous excision of the pile mass otherwise there will be complications. I struggled with it initially but eventually, I identified that when there is a component of internal pile mass along with an external one, the best technique to use is DG HAL RAR with mucocutaneous excision of the pile mass.“
Why should you choose DG HAL RAR?
“Initially when I started, I took about 45 minutes to complete DG HAL RAR procedure but now, as time progressed and after having used it for 9 years, I take less than 15 minutes to complete the procedure. In addition to less operative time, DG HAL RAR also has less post-operative pain for patients, fewer analgesics, shorter hospital stay and patients can get back to work within 48 hours of the surgery. However, external components are very important. If you neglect that, despite using DG HAL RAR, patients might come back with the same problem.”
Renowned coloproctologist and PCS surgeon, Dr Harsh Kumar from Chandigarh also supported Dr Parmeshwaram’s insights by sharing his own experience using the video proctoscopes in his practice for the last 10 years. “One of the key advantages of DG HAL-RAR in my opinion is that, unlike other techniques, you can revise piles surgery done using DG-HAL. After trying all procedures and now DG HAL-RAR, for me, the best option is DG HAL. I don’t advocate any other procedure because it is minimally invasive,” said Dr Harsh, adding that “The only problem is in convincing the patients because it is relatively new.“
- Post-operative pain is relatively low and patients can be discharged within 12 hours. They can get back to their routine within 48 hours.
- DG HAL-RAR is minimally invasive and in line with today’s need for evidence-based medical practice.
- It has a relatively low rate of complications and recurrence.
- DG HAL-RAR is recommended by top coloproctologists as a primary treatment for Grade ll and Grade lll haemorrhoids.
For more detailed information on the process and technique of using DG-HAL, we recommend you watch the video linked above. In addition to virtual CMEs, Practo Care Surgeries will also be conducting hands-on training, webinars and meet-ups with Doctors on a regular basis. We request you to check your registered email ID for information on the next session.