The Haemorrhoidal Artery Ligation – Recto Anal Repair (HAL-RAR) is an operation designed to eradicate haemorrhoids using a doppler guided probe to locate and ligate all the arteries supplying the haemorrhoids.

What are Hemorrhoids?

Hemorrhoids are small vascular arteriovenous pads in the last part of the rectum which is called the anal canal, and they secure the continence for gas and the stool. So everyone has hemorrhoid pads in the rectum. They may complain when they get swollen and inflamed and prolapse; it means when they come out from the anal verge. Hemorrhoids are the most detectable and easily diagnosed disease in surgery. The symptoms are quite simple, like bleeding, which is the most common symptom. The pain, the burning sensation, some wet anus feeling, anal discomfort, and some touchable lesion in the rectum, which was not there earlier. The most common population for hemorrhoids are female patients after many deliveries along with some prolapse. When the patients visit the doctor with these kind of hemorrhoid problems, they will be asked about the symptoms and they will be examined, which should consist of a visual supervision and a proctoscopy, which means a small transparent telescope which is usually inserted into the rectum and a thorough examination should be performed.

The evaluation of the hemorrhoid problem-how severe is it?

There are 4 grades regarding severity of symptoms and physical findings

1st grade hemorrhoid means that the patient has a swollen but normally functioning hemorrhoid pad in the anal canal, no prolapse, occasionally a very mild oozing and it does not cause any severe symptoms for the patient. It is manageable by changing life habits, changing the diet, and with some topical medication.

2nd grade hemorrhoid means when hemorrhoid comes out occasionally after straining on the toilet, but it retracts immediately, with bleeding, discomfort, some “wet anus “feeling. Normally, the gold standard for the 2nd grade hemorrhoid for treatment is conservative based therapy, started with anal preparation, suppositories, oral medicines .In case of bleeding patients require either rubber band ligation or surgery.

3rd grade hemorrhoids; the same symptoms as for the grade 2, but after bowel opening, there is permanent prolapse of hemorrhoids and they need to be manually reduced by the patient or by the doctor. It is a disturbing problem for the patient. Most of the cases are with bleeding, which should not be a life‑threatening bleeding. It is just a continuous oozing, wet anus, anal discomfort and some skin irritation from the continuous liquid discharge from the anal canal. This condition needs a surgical intervention. As this is not associating with a big prolapse, they need just a dearterialization, the Hal-Rar technique, or stapled hemorrhoidopexy.

4th grade hemorrhoid means massive hemorrhoid pad, all the time outside of the rectum, and a painful annoying problem for the patient along with wet anus, anal irritation and continuous bleeding. It definitely requires sure surgical procedure like stapled hemorrhoidopexy or a Hal-Rar hemorrhoid arterial ligation and recto-anal repair. Most of the hemorrhoid cases are associated with constipation and lazy bowel syndrome, so when we treat the hemorrhoid itself, we need to treat the chronic constipation, which on one hand is a psychological treatment and on the other hand high-fiber, containing food, plenty of fluids.

The investigation for Hemorrhoids

If declared and with the proctoscope we identify the hemorrhoid problem, then we need to ask necessary and obligatory questions from the patient, especially over 45 to 50-year-olds, regarding the change In bowel habit, any other weight loss, any history of colorectal cancers in close family, color of blood which noticed, previous history of abdominal pain, cramping pain, or episodes of bloating. If they have one of these symptoms and over 50 or something, then they may require a colonoscopy(camera test of large intestine by small telescopic investigation per anus) in advance, just to make sure no other major problems of cancers or any other problems are in the colon.

Treatments of Hemorrhoids

The basic treatment of hemorrhoid problem is changing the life habit arranging stool habit, which should not be constipated. The second step is the conservative treatment, which is recommended as a starting concept,every patient should be prescribed with some kind of topical creams which contain Lidocaine and some corticosteroids, high fiber containing liquid diet, and special medications. This is an oral anti-hemorrhoid treatment or called venotonicum.

Surgery has new and very smooth , painless answer for this challenging frequent problem.

The newest techniques called stapled hemorrhoidopexy, which means an internal, not painful surgery for the patient, with a circular stapler. It gives a permanent and very good result for the patient and a 100% cosmetic result also in the rectum. The other ways of treating hemorrhoids under a common name are dearterialization techniques. It means we just cut the arterial flow of these hemorrhoidal pads and they will be shrunk through the rectum to the anal canal automatically in 3 months time, but we can facilitate this with a couple of running stitches and shortening of the internal hemorrhoid mucosa. It means the recto-anal repair technique. Every patient needs complex vision and concept of treatment.

The most modern hemorrhoid surgery (piles)



The Haemorrhoidal Artery Ligation – Recto Anal Repair (HAL-RAR) is an operation designed to eradicate haemorrhoids using a doppler guided probe to locate and ligate all the arteries supplying the haemorrhoids.

The device has a small window which allows a stitch to be placed around the artery, cutting off the blood supply of the internal haemorrhoidal artery.In case of prolapsing(protruding internal parts of rectum outside) patients need RAR method which means shrinking to original position all structures from outside to inside by special overrunning stitches. Following a HAL-RAR operation most patients are back to work after 24-48 hours with only a minimum of discomfort.

The HAL-RAR technique is supported by extensive clinical evaluations which compare efficacy and safety to conventional methods. The HAL-RAR is minimally invasive, offers high patient satisfaction and has a very low complication rate.

Who is the ideal candidate for this method?

Designed and invented for 21 st century active people.Keywords pain less, quick recovery with maximum short and long tem results.

The HAL-RAR procedure is available in Medcare hospital ask appointment to Dr papp’s surgical clinic for consultation.

Stapled hemorrhoidopexy

as optional way of treatment of advanced piles, hemorrhoid cases


Stapled hemorrhoidectomy is surgical technique for treating hemorrhoids, and is the treatment of choice for third-degree hemorrhoids. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward.

For stapled hemorrhoidectomy, a circular, hollow tube is inserted into the anal canal. Through this tube, a suture (a long thread) is placed, actually woven, circumferentially within the anal canal above the internal hemorrhoids. The ends of the suture are brought out of the anus through the hollow tube. The stapler (a disposable instrument with a circular stapling device at the end) is placed through the first hollow tube and the ends of the suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their normal position within the anal canal. The stapler then is fired. When it fires, the stapler cuts off the circumferential ring of expanded hemorrhoidal tissue trapped within the stapler and at the same time staples together the upper and lower edges of the cut tissue.

Who is a good candidate for stapled hemorrhoidectomy?

Stapled hemorrhoidectomy, although it can be used to treat second degree hemorrhoids (hemorrhoids that extend outside the anus with a bowel movement, but return inside), usually is reserved for higher grades of hemorrhoids – third and fourth degree. Third degree hemorrhoids can be pushed back into the anus after a bowel movement. Fourth degree hemorrhoids are always outside. If in addition to internal hemorrhoids there are small external hemorrhoids that are causing a problem, the external hemorrhoids may become less problematic after the stapled hemorrhoidectomy. Another alternative is to do a stapled hemorrhoidectomy and a simple excision of the external hemorrhoids. If the external hemorrhoids are large, a standard surgical hemorrhoidectomy may need to be done to remove both the internal and external hemorrhoids.

PPH Stapled Haemorrhoidopexy

HAL-RAR Procedure for the Treatment of Haemorrhoids


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