Minimally Invasive Hemorrhoid Surgery: Comparing THD, HALO-RAR, and Stapled Hemorrhoidopexy Techniques

Introduction

Hemorrhoidal disease remains a prevalent condition causing significant discomfort and impacting the quality of life for millions worldwide. While conservative management and office-based procedures like rubber band ligation are effective for lower-grade hemorrhoids, surgical intervention is often necessary for patients with advanced (Grade III and IV) or refractory symptomatic disease. Traditional excisional hemorrhoidectomy, although highly effective, is associated with considerable postoperative pain, prolonged recovery times, and potential complications such as anal stenosis or incontinence. This has driven the development and adoption of minimally invasive surgical techniques aimed at reducing pain, accelerating recovery, and preserving anal function while effectively addressing hemorrhoidal symptoms.

Over the past two decades, several innovative minimally invasive surgical approaches have emerged as alternatives to conventional hemorrhoidectomy. Among the most prominent are Transanal Hemorrhoidal Dearterialization (THD), Hemorrhoidal Artery Ligation with Recto-Anal Repair (HALO-RAR), and Stapled Hemorrhoidopexy (Procedure for Prolapse and Hemorrhoids – PPH). These techniques share the common goal of treating hemorrhoids with less tissue excision and trauma compared to traditional methods, but they differ significantly in their underlying principles, technical execution, and specific indications.

THD and HALO-RAR are based on the principle of reducing arterial inflow to the hemorrhoidal cushions by ligating the terminal branches of the superior rectal artery, guided by Doppler ultrasound. HALO-RAR adds a mucopexy component to address prolapse. Stapled hemorrhoidopexy, conversely, utilizes a circular stapling device to excise a ring of redundant rectal mucosa above the dentate line, simultaneously lifting the prolapsed hemorrhoidal tissue back into its anatomical position and interrupting blood supply.

Each of these minimally invasive techniques offers potential advantages, including reduced postoperative pain, faster return to normal activities, and lower risk of certain complications compared to excisional surgery. However, they also have unique learning curves, specific equipment requirements, potential complications, and varying long-term efficacy profiles, particularly concerning recurrence rates. The choice of procedure depends on various factors, including the grade and morphology of the hemorrhoids, the presence and severity of prolapse, surgeon experience, patient factors, and available resources.

This comprehensive review aims to provide a detailed comparison of THD, HALO-RAR, and Stapled Hemorrhoidopexy. We will delve into the technical principles, procedural steps, required instrumentation, clinical outcomes, advantages, disadvantages, and appropriate patient selection criteria for each technique. By synthesizing the current evidence, this article seeks to equip surgeons and healthcare providers with the knowledge needed to make informed decisions regarding the optimal minimally invasive surgical approach for individual patients suffering from advanced hemorrhoidal disease.

Medical Disclaimer: This content is for informational and educational purposes only and does not constitute medical advice. It is not intended for diagnosing or treating health problems. Invamed provides this information to enhance understanding of medical technologies. Always consult a qualified healthcare provider for any medical concerns or treatment decisions.

Principles and Mechanisms of Action

Transanal Hemorrhoidal Dearterialization (THD)

1. Core Principle: Reduction of arterial hyperflow to the hemorrhoidal plexus.
2. Mechanism: Ligation of the terminal branches of the superior rectal artery supplying the hemorrhoidal cushions.
3. Guidance: Doppler ultrasound probe integrated into a specialized anoscope to precisely locate the arteries.
4. Target Vessels: Typically 6 main arterial branches located in the submucosa above the dentate line.
5. Effect: Decreased blood flow leads to shrinkage of the hemorrhoidal cushions and resolution of bleeding.
6. Mucopexy (Optional but Common): Often combined with plication/lifting of prolapsed tissue (mucopexy) to address the prolapse component.
7. Tissue Preservation: Avoids excision of hemorrhoidal tissue, preserving the anal cushions.
8. Physiological Approach: Aims to restore normal anatomy and physiology by addressing the underlying vascular cause.

Hemorrhoidal Artery Ligation with Recto-Anal Repair (HALO-RAR)

1. Core Principle: Combines arterial ligation with mucopexy for prolapse.
2. Mechanism (HAL): Similar to THD, involves Doppler-guided ligation of hemorrhoidal arteries to reduce blood flow.
3. Mechanism (RAR): Recto-Anal Repair involves placing longitudinal sutures (mucopexy) to lift and fix the prolapsed hemorrhoidal tissue back into the anal canal.
4. Guidance: Utilizes a specialized proctoscope with an integrated Doppler transducer.
5. Dual Action: Addresses both bleeding (via HAL) and prolapse (via RAR).
6. Staged Approach: Arterial ligation is typically performed first, followed by the mucopexy.
7. Tissue Preservation: Like THD, it avoids tissue excision.
8. Comprehensive Treatment: Aims to address both the vascular and mechanical (prolapse) aspects of hemorrhoidal disease.

Stapled Hemorrhoidopexy (PPH – Procedure for Prolapse and Hemorrhoids)

1. Core Principle: Excision of redundant rectal mucosa and submucosa above the dentate line with simultaneous repositioning (pexy) of prolapsed hemorrhoids.
2. Mechanism: A circular stapling device is used to resect a circumferential strip of tissue approximately 2-4 cm above the dentate line.
3. Effect (Pexy): The stapled anastomosis lifts the prolapsed hemorrhoidal cushions back into their normal anatomical position within the anal canal.
4. Effect (Blood Flow): The resection interrupts the submucosal arterial branches supplying the hemorrhoids, reducing blood flow.
5. Tissue Resection: Involves tissue removal, but specifically of the rectal mucosa/submucosa, not the hemorrhoidal cushions themselves.
6. Location of Anastomosis: The staple line is located in the relatively insensate rectal mucosa, theoretically reducing pain compared to excisions near the sensitive anoderm.
7. Device-Dependent: Relies entirely on the proper use of a specialized circular stapler kit.
8. Primary Indication: Primarily designed for circumferential prolapsing internal hemorrhoids (Grade III and IV).

Comparative Overview

| Feature | THD | HALO-RAR | Stapled Hemorrhoidopexy (PPH) |
| :—————- | :—————————————- | :—————————————- | :—————————————— |
| Primary Goal | Reduce arterial flow | Reduce arterial flow + Fix prolapse | Resect redundant mucosa + Fix prolapse |
| Mechanism | Arterial Ligation (+/- Mucopexy) | Arterial Ligation + Mucopexy | Circumferential Mucosal Resection & Stapling |
| Guidance | Doppler Ultrasound | Doppler Ultrasound | None (Anatomical Landmarks) |
| Tissue Effect | No Excision | No Excision | Mucosal/Submucosal Excision |
| Device | Specialized Doppler Anoscope/Proctoscope | Specialized Doppler Proctoscope | Circular Stapler Kit |
| Pain Location | Sutures above dentate line | Sutures above dentate line | Staple line above dentate line |
| Addresses | Bleeding (+/- Prolapse) | Bleeding + Prolapse | Prolapse + Bleeding |

Instrumentation and Equipment

THD Equipment

1. THD Proctoscope/Anoscope: Specialized device with a window for suture placement.
2. Doppler Transducer: Integrated or attachable probe (e.g., 8 MHz) to identify arterial signals.
3. Light Source: Adequate illumination, often integrated.
4. Suture Material: Absorbable sutures (e.g., 2-0 or 3-0 Vicryl or PDS) on a specific needle type.
5. Needle Holder: Specialized long needle holder designed for use with the THD device.
6. Electrocautery: Available for hemostasis if needed.
7. Standard Anorectal Tray: Lubricant, gauze, etc.
8. Optional Mucopexy Suture: May require different suture/needle if performed.

HALO-RAR Equipment

1. HALO Proctoscope: Specifically designed anoscope with integrated Doppler probe and light source.
2. Doppler Unit: External unit connected to the probe.
3. Suture Material (HAL): Absorbable suture (e.g., 2-0 Vicryl) for arterial ligation.
4. Suture Material (RAR): Absorbable suture (e.g., 0 or 2-0 PDS or Vicryl) for mucopexy.
5. Needle Holder: Long, specialized needle holder.
6. Knot Pusher: May be used to secure knots deep within the anal canal.
7. Electrocautery: For potential bleeding.
8. Standard Anorectal Tray.

Stapled Hemorrhoidopexy (PPH) Equipment

1. PPH Stapler Kit: Contains the circular stapler (e.g., 33mm diameter), anoscope, purse-string suture anoscope, and suture threader.
2. Circular Stapler: Single-use device (e.g., Ethicon PPH03, Medtronic EEA Hemorrhoidal Stapler).
3. Anoscope/Dilator: Specific to the kit, used for insertion and visualization.
4. Purse-String Suture Anoscope: Slotted anoscope to facilitate placement of the purse-string suture.
5. Suture Threader: Assists in pulling suture ends through the stapler housing.
6. Suture Material: Typically 2-0 Prolene or similar non-absorbable/long-lasting absorbable suture for the purse-string.
7. Grasping Forceps: To inspect the excised tissue ring (“,donut”).
8. Electrocautery/Hemostatic Agents: For managing bleeding from the staple line.
9. Standard Anorectal Tray.

Comparative Equipment Needs

• Doppler Guidance: Essential for THD and HALO-RAR, not used in PPH.
• Specialized Scopes: Required for all three, but designs differ significantly.
• Stapling Device: Unique to PPH.
• Suture Focus: Central to THD and HALO-RAR, used only for the purse-string in PPH.
• Capital Investment: Doppler units (THD/HALO) vs. cost of disposable stapler kits (PPH).
• Reusability: Some THD/HALO components may be reusable after sterilization; PPH staplers are single-use.

Procedural Techniques

THD Procedure Steps

1. Anesthesia: Typically general anesthesia or deep sedation/regional block.
2. Positioning: Lithotomy or prone jackknife position.
3. Device Insertion: Lubricated THD anoscope/proctoscope inserted.
4. Artery Identification: Doppler probe used to systematically scan the circumference (usually at 6 main positions: 1, 3, 5, 7, 9, 11 o’clock) 2-3 cm above the dentate line to locate arteries.
5. Suture Ligation: Once an artery is identified, a figure-of-eight or simple suture is placed through the anoscope window to ligate the vessel. Sutures are tied securely.
6. Confirmation: Doppler signal obliteration is confirmed post-ligation.
7. Repeat: Process repeated for all identified arteries (typically 6).
8. Mucopexy (if performed): After ligation, longitudinal plicating sutures may be placed to lift prolapsing tissue, starting distally and running proximally, tied above the ligated artery site.
9. Final Inspection: Check for hemostasis.

HALO-RAR Procedure Steps

1. Anesthesia: General, regional, or sedation.
2. Positioning: Lithotomy or prone jackknife.
3. Device Insertion: Lubricated HALO proctoscope inserted.
4. Artery Identification (HAL): Similar to THD, Doppler identifies arteries 2-3 cm above the dentate line.
5. Ligation (HAL): Suture ligation performed through the proctoscope window.
6. Confirmation (HAL): Doppler confirms loss of signal.
7. Repeat (HAL): Process repeated for all main arteries (usually 6).
8. Mucopexy (RAR): For each prolapsing segment, a running suture is placed starting just above the dentate line and extending proximally for 3-4 cm. The suture incorporates the mucosa and submucosa.
9. Tightening (RAR): The running suture is tightened, lifting the prolapsed tissue. The suture is tied proximally.
10. Repeat (RAR): Mucopexy performed for all significantly prolapsing segments.
11. Final Inspection: Check for hemostasis and adequate lifting.

Stapled Hemorrhoidopexy (PPH) Procedure Steps

1. Anesthesia: General, regional, or sedation.
2. Positioning: Lithotomy or prone jackknife.
3. Anal Dilatation: Gentle dilatation may be performed.
4. Purse-String Suture Placement: The purse-string anoscope is inserted. A purse-string suture (e.g., 2-0 Prolene) is placed circumferentially in the mucosa and submucosa, 3-4 cm above the dentate line.
5. Stapler Insertion: The circular stapler head is opened and inserted proximal to the purse-string suture. The anoscope is removed.
6. Tightening Purse-String: The purse-string suture is tied securely around the central rod of the stapler, drawing the redundant mucosa into the stapler housing.
7. Stapler Closure and Firing: The stapler is closed to the appropriate tissue compression thickness and fired. This simultaneously cuts and staples the tissue.
8. Stapler Removal: The stapler is gently opened and removed.
9. Inspection of Staple Line: The anastomosis line is carefully inspected for bleeding using the anoscope. Any bleeding points are managed (e.g., suture ligation, cautery).
10. Inspection of “,Donut”: The excised ring of tissue is examined to ensure it is complete and contains only mucosa/submucosa (no muscle).

Key Technical Differences

• Guidance: Doppler (THD/HALO) vs. anatomical landmarks (PPH).
• Primary Action: Ligation/Plication (THD/HALO) vs. Resection/Anastomosis (PPH).
• Tissue Removal: None (THD/HALO) vs. Yes (PPH).
• Instrumentation: Suture-based (THD/HALO) vs. Stapler-based (PPH).
• Learning Curve: Associated with Doppler use and suturing depth (THD/HALO) vs. purse-string placement and stapler operation (PPH).

Clinical Outcomes and Evidence

Efficacy (Symptom Resolution)

1. Bleeding Control: All three techniques generally show good to excellent control of bleeding in the short to medium term. THD/HALO directly target the feeding arteries. PPH interrupts blood supply via resection.
2. Prolapse Control: PPH was specifically designed for prolapse and generally shows good initial results. HALO-RAR incorporates mucopexy to address prolapse effectively. THD with mucopexy also addresses prolapse, though perhaps less aggressively than PPH or HALO-RAR.
3. Long-Term Recurrence: This is a key differentiator. Some studies suggest higher recurrence rates (especially of prolapse) after THD/HALO compared to PPH or excisional hemorrhoidectomy, although results vary. PPH may have lower recurrence than THD/HALO but potentially higher than excisional surgery in the long term.
4. Grade Specificity: PPH is often favored for Grade III/IV circumferential prolapse. THD/HALO-RAR are effective for Grade II/III, particularly where bleeding is prominent.

Postoperative Pain

1. General Finding: All three minimally invasive techniques are associated with significantly less postoperative pain compared to conventional excisional hemorrhoidectomy.
2. THD/HALO-RAR vs. PPH: Pain levels are often reported as similar or potentially slightly lower after THD/HALO-RAR compared to PPH, as PPH involves tissue excision and a staple line, though still less painful than excision.
3. Pain Mechanism: Pain in THD/HALO is related to suture placement and tissue reaction. Pain in PPH relates to the staple line, potential muscle involvement, and tissue tension.
4. Analgesic Requirements: Patients undergoing these minimally invasive procedures typically require fewer analgesics and for a shorter duration than after excisional surgery.

Recovery and Return to Activity

1. Hospital Stay: Often performed as day surgery or with a short overnight stay for all three techniques.
2. Return to Work/Normal Activity: Significantly faster compared to excisional hemorrhoidectomy. Patients may return to work within a few days to a week, compared to several weeks for excision.
3. Comparison: Recovery times may be slightly faster after THD/HALO-RAR compared to PPH in some studies, but all are much quicker than traditional surgery.

Complications

1. Common Minor Issues (All): Temporary bleeding, pain, urinary retention, fecal urgency, thrombosis of residual hemorrhoids.
2. THD/HALO-RAR Specific: Suture site pain/discomfort, minor bleeding, potential for inadequate ligation/mucopexy leading to recurrence. Rare: rectal perforation, pelvic sepsis.
3. PPH Specific: Staple line bleeding (can be significant), staple line stenosis/stricture, persistent pain (proctalgia), fecal urgency/incontinence (rare, potentially due to nerve/muscle injury), rectal perforation, retro-rectal hematoma/sepsis, staple migration/retention. Anorectal/vaginal fistula formation is a rare but severe complication.
4. Severe Complications: While rare, life-threatening complications like pelvic sepsis have been reported for all techniques, perhaps slightly more emphasized in early PPH reports.
5. Long-Term Complications: Stenosis and persistent pain/urgency are more associated with PPH. Recurrence is more associated with THD/HALO-RAR in some series.

Comparative Studies and Meta-Analyses

• Numerous studies and meta-analyses have compared these techniques against each other and against conventional hemorrhoidectomy.
• Pain: Consistently less pain with THD, HALO-RAR, and PPH compared to excision.
• Recovery: Consistently faster recovery with minimally invasive techniques.
• Recurrence: Variable results. Some meta-analyses show higher recurrence (especially prolapse) with THD/HALO vs. PPH or excision. PPH recurrence may be higher than excision long-term.
• Complications: Different profiles. PPH has unique risks related to the staple line (bleeding, stenosis, urgency, rare fistula). THD/HALO risks relate more to suture placement and potential inadequacy.
• Patient Satisfaction: Generally high for all minimally invasive techniques due to reduced pain and faster recovery, but can be affected by recurrence or specific complications.

Advantages and Disadvantages

THD/HALO-RAR

Advantages:
* Significantly less postoperative pain than excision.
* Rapid recovery and return to activities.
* No tissue excision, preserves anal cushions.
* Addresses the vascular component directly (bleeding).
* HALO-RAR effectively addresses prolapse via mucopexy.
* Low risk of stenosis or major incontinence.
* Can be performed in various anesthetic settings.

Disadvantages:
* Requires specialized Doppler equipment and training.
* Learning curve associated with Doppler use and suture placement.
* Potentially higher recurrence rates (especially prolapse) compared to PPH or excision in some studies.
* May not be suitable for large, fibrotic external components.
* Postoperative pain/discomfort from sutures can still occur.
* Fecal urgency can occur temporarily.

Stapled Hemorrhoidopexy (PPH)

Advantages:
* Significantly less postoperative pain than excision.
* Rapid recovery and return to activities.
* Effective for circumferential prolapsing hemorrhoids (Grade III/IV).
* Standardized technique using a dedicated kit.
* No external wounds.

Disadvantages:
* Requires purchase of expensive single-use stapler kits.
* Specific and potentially severe complications related to the staple line (bleeding, stenosis, chronic pain, urgency, rare fistula).
* Learning curve associated with purse-string placement and stapler use.
* Not suitable for patients with significant external hemorrhoids or anal stenosis.
* Potential for higher recurrence than excisional surgery long-term.
* Risk of incomplete tissue “donut” or incorporating muscle layer.

Patient Selection Criteria

Ideal Candidates for THD/HALO-RAR

• Symptomatic internal hemorrhoids Grade II or III.
• Prominent symptom is bleeding.
• Presence of moderate prolapse (especially for HALO-RAR).
• Patients who wish to avoid tissue excision.
• Patients prioritizing lower pain and faster recovery over the lowest possible recurrence rate.
• Recurrent hemorrhoids after banding.

Ideal Candidates for Stapled Hemorrhoidopexy (PPH)

• Symptomatic internal hemorrhoids Grade III or IV.
• Circumferential prolapse is the dominant feature.
• Minimal or manageable external component.
• Patients seeking less pain and faster recovery than excision.
• Adequate anal canal diameter to accommodate the stapler.
• No significant fibrosis or previous complex anorectal surgery.

Factors Influencing Choice

• Hemorrhoid Grade and Morphology: PPH for advanced circumferential prolapse; THD/HALO-RAR for bleeding-predominant Grade II/III +/- moderate prolapse.
• Dominant Symptom: Bleeding favors THD/HALO; Prolapse favors PPH or HALO-RAR.
• Surgeon Experience and Training: Familiarity and expertise with a specific technique are crucial.
• Equipment Availability: Access to Doppler units (THD/HALO) or PPH kits.
• Patient Preference: Discussion of risks, benefits, recovery, and recurrence rates.
• Cost Considerations: Doppler equipment vs. disposable stapler costs.
• Presence of External Components: Significant external tags/thrombosis may require separate excision regardless of the internal technique chosen.

Conclusion

Minimally invasive surgical techniques – Transanal Hemorrhoidal Dearterialization (THD), Hemorrhoidal Artery Ligation with Recto-Anal Repair (HALO-RAR), and Stapled Hemorrhoidopexy (PPH) – have revolutionized the treatment of advanced hemorrhoidal disease. They offer significant advantages over traditional excisional hemorrhoidectomy, primarily in terms of reduced postoperative pain and faster recovery times, leading to high patient satisfaction in the short term.

THD and HALO-RAR represent a physiological approach, targeting the arterial hyperflow that contributes to hemorrhoid development and symptoms, with HALO-RAR adding a specific repair for prolapse. They avoid tissue excision, preserving the natural anal cushions. Stapled hemorrhoidopexy, while involving mucosal resection, effectively addresses significant prolapse by repositioning the hemorrhoidal tissue and interrupting blood supply via a circular staple line placed in a less sensitive area.

However, the choice between these techniques is not straightforward and requires careful consideration of several factors. PPH appears particularly suited for patients with high-grade, circumferential prolapse, while THD/HALO-RAR may be preferred for bleeding-predominant Grade II/III hemorrhoids, with HALO-RAR offering a robust solution for associated prolapse. Long-term recurrence, especially of prolapse, may be a greater concern with THD/HALO-RAR compared to PPH or excision, according to some studies. Conversely, PPH carries unique risks associated with the staple line, including bleeding, stenosis, and persistent urgency or pain, which are less common with THD/HALO-RAR.

Surgeon experience, equipment availability, and a thorough discussion with the patient regarding the specific characteristics of their disease, expected outcomes, recovery profile, and potential risks of each procedure are paramount. Ongoing research and long-term follow-up studies continue to refine our understanding of the optimal application for each of these valuable minimally invasive techniques. Ultimately, the goal is to select the procedure that best matches the individual patient’s anatomy, symptoms, and priorities, maximizing efficacy while minimizing morbidity.

Medical Disclaimer: This information is for educational purposes only and not a substitute for professional medical advice. Consult a qualified healthcare provider for diagnosis and treatment. Invamed provides this content for informational purposes regarding medical technologies.