THD Doppler procedure for hemorrhoids: the surgical technique

Abstract

Transanal hemorrhoidal dearterialization (THD) is an effective treatment for hemorrhoidal disease. The ligation of hemorrhoidal arteries (called "dearterialization") can provide a significant reduction of the arterial overflow to the hemorrhoidal piles. Plication of the redundant rectal mucosa/submucosa (called "mucopexy") can provide a repositioning of prolapsing tissue to the anatomical site. In this paper, the surgical technique and perioperative patient management are illustrated. Following adequate clinical assessment, patients undergo THD under general or spinal anesthesia, in either the lithotomy or the prone position. In all patients, distal Doppler-guided dearterialization is performed, providing the selective ligation of hemorrhoidal arteries identified by Doppler. In patients with hemorrhoidal/muco-hemorrhoidal prolapse, the mucopexy is performed with a continuous suture including the redundant and prolapsing mucosa and submucosa. The description of the surgical procedure is complemented by an accompanying video (see supplementary material). In long-term follow-up, there is resolution of symptoms in the vast majority of patients. The most common complication is transient tenesmus, which sometimes can result in rectal discomfort or pain. Rectal bleeding occurs in a very limited number of patients. Neither fecal incontinence nor chronic pain should occur. Anorectal physiology parameters should be unaltered, and anal sphincters should not be injured by following this procedure. When accurately performed and for the correct indications, THD is a safe procedure and one of the most effective treatments for hemorrhoidal disease.

Fig. 1

Surgical instruments specifically designed for the THD procedure

Fig. 2

Schema justifying different Doppler signals occurring during THD as related to arterial blood flow. According to this physical law, the intensity of the Doppler signal is the inverse of the cosine of the angle between the ultrasound waves and blood flow. The more perpendicular the blood flow to the ultrasound waves (i.e., artery into the perirectal tissue or submucosa) the higher the Doppler signal; the more parallel the flow (i.e., artery perforating the rectal muscle) the lower the signal

Fig. 3

Schema of the anatomical course of a hemorrhoidal artery and different levels of Doppler signal related to the position of the artery

Fig. 4

Suture of a hemorrhoidal artery during DDD procedure

Fig. 5

Schema of mucopexy fixation point and continuous suture

Fig. 6

“Marker point” on the distal rectal mucosa to identify the best Doppler signal obtained from the submucosal hemorrhoidal artery

Fig. 7

Fixation Z point at the proximal edge of the mucopexy continuous suture

Fig. 8

Mucopexy continuous suture

Fig. 9

Passages of the mucopexy continuous suture above (a) and below (b) the marker point to entrap the hemorrhoidal artery

Fig. 10

Mucopexy suture is secured without including the hemorrhoid