Surgery Today

https://doi.org/10.1007/s00595-020-02164-7

ORIGINAL ARTICLE

A new technique of doppler dearterialization for hemorrhoidal

disease: arterial detection ligation (ADL)
Serkan Zenger1   · Bulent Gurbuz1   · Ugur Can1   · Tunc Yalti1,2 

Received: 31 May 2020 / Accepted: 3 September 2020

© Springer Nature Singapore Pte Ltd. 2020

Abstract
Purpose  We describe the arterial detection ligation (ADL) technique, designed to find arteries at time-appropriate depth
for ligating, and report our preliminary results of using this technique to treat patients with the hemorrhoidal disease (HD).
Methods  The subjects of this retrospective analysis were patients with symptomatic grades 2 or 3 HD. We analyzed the
clinical characteristics, postoperative complications, recurrence, and patient satisfaction of the patients treated with ADL.
Results  A total of 75 patients were included in the study (male/female ratio 1.88; mean age 48 ± 19 years; mean BMI
24 ± 3 kg/m2). Thirty-nine patients (52%) did not require hospitalization and were discharged from the day clinic approxi-
mately 4 h postoperatively. Four patients (5.3%) suffered tenesmus for about 1 week postoperatively and two (2.7%) suffered
temporary rectal bleeding. The mean VAS scores 1 day postoperatively, then at 1 week, 1 month and 1 year were 2.9, 1.5, 0.4,
and 0, respectively. At the 1-month follow-up, there was no sign of recurrence and the satisfaction rate was 78.6% (n = 59).
At the 1-year follow-up, three patients (4%) had a recurrence and the satisfaction rate was 86.7% (n = 65).
Conclusion  Based on our preliminary findings, ADL is an effective technique for treating HD, generally as an outpatient
procedure, without serious morbidity. We anticipate that the incidence of tenesmus, which is encountered frequently after
other dearterialization methods, will be lower after the ADL technique, which avoids both mass ligation of hemorrhoidal
arteries deeper than 12 mm and running a long mucopexy suture line.

Keywords  Arterial detection ligation · ADL · Doppler dearterialization · Hemorrhoidal disease

Abbreviations Introduction
HD Hemorrhoidal disease
DGHAL Doppler-guided hemorrhoidal artery ligation Hemorrhoidal disease (HD) is a common disease of the
SRA Superior rectal artery anorectal region. The prevalence of symptomatic HD in the
ADL Arterial Detection Ligation general population is 4.4%, and it is usually seen in young
BMI Body mass index or middle-aged people [1]. Although a poor correlation
ASA American Society of Anesthesiologists between the grade of hemorrhoids and symptoms is often
VAS Visual Analogue Scale reported, the decision to perform surgery is usually based
on the Goligher HD classification [2–4]. Excisional hemor-
rhoidectomy has been the conventional procedure for many
years, but it is associated with complications such as post-
operative pain and bleeding. With improvements in technol-
ogy, alternative surgical methods such as stapled hemor-
rhoidopexy or doppler-guided hemorrhoidal artery ligation
(DGHAL) have been introduced and are being performed
* Serkan Zenger more frequently because of their effectiveness and fewer
serkanzen@hotmail.com complications [3, 5].
Recent studies have shown that excess blood flow to the
1
Department of General Surgery, VKF American Hospital, distal arms of the superior rectal artery (SRA) and/or the
Guzelbahce Street, No:20, Sisli, Istanbul, Turkey
development of dystrophic disorders in the ligamentous
2
Department of General Surgery, School of Medicine, Koc apparatus of the hemorrhoidal plexus play an important role
University, Istanbul, Turkey

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in the pathophysiology of HD [6, 7]. Based on this patho-
physiology, DGHAL was introduced in 1995 by Morinaga
[8] and subsequently proved by many studies to be effective
[9–11]. However, although these doppler devices can locate
the hemorrhoidal artery, they do not provide information
about the depth of the artery. In the Arterial Detection Liga-
tion (ADL) technique, both the location and the depth of the
hemorrhoidal arteries are identified by the newly developed
LDL-2 proctoscope and Angiodine-Procto device. Thus, it
is possible to ligate the hemorrhoidal arteries located at a
depth from 6 to 12 mm.
To our knowledge, this is the first study to evaluate the
ADL technique and report clinical results. Herein, we give
detailed technical information about ADL and report our
preliminary results of using the ADL technique to treat
patients with HD.
Materials and methods
Patients
We analyzed, retrospectively, the data of patients who under-
went surgery with the ADL technique by the same surgi-
cal team between April 2018 and December 2018 at the
American Hospital General Surgery Clinic. The patients
ranged in age from 18 to 80 years, had either symptomatic
grade 2 HD unresponsive to medical treatment or grade 3
HD treated only with the ADL technique. Patients who were
pregnant; those undergoing additional anal surgery such as
fissurectomy, fistulectomy, or abscess drainage; those who
had previously undergone surgery for anal diseases; those
with missing data; and those with a follow-up duration of
less than 1 year, were excluded from the study. Written
informed consent was obtained from all patients and the
Institutional Review Board of Koç University, School of
Medicine approved the study (2020.068.IRB1.016).
Patients were examined in terms of age, gender, body
mass index (BMI), American Society of Anesthesiologists
(ASA) score, operative time, length of hospital stay, Visual
Fig. 1  The equipment used for arterial detection ligation (ADL): The Angiodin Procto system (a); the LDL-2 proctoscope (b); and the foot pedal
allowing simultaneous mode switching and recording for the surgeon (c)
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Surgery Today
Analogue Scale (VAS) pain score, postoperative complica-
tions, recurrence, and satisfaction rates.
Preoperative preparation
Patients underwent rectal examination and anoscopy to clas-
sify the HD and to detect additional anorectal pathology or
functional disorder. A rectal enema was given 2 h before
surgery.
Surgical equipment
In the ADL technique, an ‘Angiodin-Procto (Comepa,
France)’ device and an ‘LDL-2 proctoscope (Comepa,
France)’ are used to locate the hemorrhoidal arteries by dop-
pler ultrasound (Fig. 1a, b). The LDL-2 proctoscope has
a translucent window allowing manipulation. The internal
doppler probe is located in the distal part of the window
to be manipulated and inclined 13 degrees to the window.
The proctoscope has several integrated LED illuminators
and the operating channel is 35 mm in diameter. The Angi-
odin-Procto device is a system that shows the location and
depth of the arterial signal location from the LDL-2 proc-
toscope with three different modes: Continous Wave (CW),
Pulsed Wave (PW), and Motion + Pulsed Wave (M + PW)
modes. With the universal foot pedal, the surgeon can switch
between modes, measure the depth, and record the proce-
dure, without using their hands (Fig. 1c).
Surgical technique
The surgical procedure is performed with the patient under
general anesthesia and in the lithotomy position. All opera-
tions were performed by the same surgeon (TY). After the
induction of anesthesia, the anus and distal rectum are re-
evaluated and the LDL-2 is placed on the anal canal by
applying gel to the tip of the proctoscope. To detect the hem-
orrhoidal arteries with doppler, the systolic blood pressure
should be at least 110 mm/Hg.
Surgery Today

The targeted hemorrhoidal artery is located using the

sound and image in the CW mode of the Angiodine Procto
device (Fig. 2a). The depth of the detected hemorrhoidal
artery is clear in the PW mode (Fig. 2b). In the M + PW
mode, arterial depth, image, and sound are checked simul-
taneously (Fig. 2c). The graphs of the device are evaluated,
with arterial blood flow pointed at the peak of the systolic
phase and flat in the diastolic phase. The hemorrhoidal
arteries located at a depth of 6–12 mm, as detected by the
surgeon, are ligated using a 5/8 needle with 2/0 absorbable
suture material with antibacterial properties. After ligation,
arterial flow is re-checked to establish that the amplitude
of the pulse wave has decreased or disappeared completely
according to the diameter of the ligated artery. Arteries with
a depth of more than 12 mm (the maximum depth that an
Fig. 3  Documentation of procedures according to the location of the
artery can be ligated with the curvature of the needle posi-
ligated hemorrhoidal arteries or mucopexy
tioned in the LDL-2 proctoscope) are not ligated and are
re-checked. They are ligated when they are confirmed to be
less than 12 mm deep. The procedure is repeated clockwise Postoperative management, follow‑up and data
for all arterial regions at levels 1, 3, 5, 7, 9, and 11. recording
For prolapsed hemorrhoid pouches, the needle of the
suture used for ligation at 0.5–0.8 cm intervals is passed Clear fluids are given 3 h postoperatively, and if tolerated, a
through the mucosa in the form of a continuous suture from full diet is introduced gradually. Diclofenac sodium 75 mg
the mucosa to 0.5 cm proximal to the dentate line to avoid (Voltaren, Novartis, Turkey) is given intramuscularly to all
penetration of the painful zone. It is then ligated with the patients 4 h postoperatively. If the pain is not controlled,
remainder of the suture used to ligate the artery, thereby Paracetamol (Perfalgan, 10 mg/ml 100 ml, Bristol-Myers
completing the mucopexy procedure. Short suture intervals Squibb, Istanbul, Turkey) is given intravenously. Patients are
may result in some tissue ischemia, but long suture intervals seen by the surgeon when adequate pain control, oral toler-
may cause tension in the suture or bleeding from tearing ance, and spontaneous urine output have been confirmed,
[12]. The ligation and mucopexy areas are marked on the and they are discharged if there are no signs of complica-
device by the surgeon using the foot pedal and documented tions. Oral NSAIDs, high-fiber stool softeners, and stomach-
in the patient’s file (Fig. 3). Finally, 20 mL bupivacaine protective drugs are prescribed to all patients at the time of
(0.5% Marcaine vial, Astra Zeneca, Turkey) is injected discharge.
clockwise at levels 3, 6, 9, and 12 to complete the procedure. A special questionnaire was prepared to follow up to eval-
uate pain, complications, recurrence, and satisfaction. The
patients were examined 1 day postoperatively and then at
1 week, 1 month, and 1 year, and the questionnaire responses
were recorded. To measure pain, the VAS score was used
from no pain (VAS: 0) to the worst pain imaginable (VAS:

Fig. 2  The different modes of the Angiodin Procto doppler device: Continous Wave (CW) mode (a); Pulsed Wave (PW) mode (b); and
Motion + Pulsed Wave (M + PW) mode (c)

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10). Patient satisfactions were assessed at 1  month and
1 year, with four categories: excellent, good, fair, and poor.
Definitions
Tenesmus is defined as ineffective and painful straining to
empty the bowels in response to the sensation of a desire to
defecate, without producing a significant quantity of feces.
In the study, urinary retention was defined as the inability to
urinate within 8 h postoperatively necessitating urinary cath-
eterization. Recurrence was defined as internal hemorrhoids
seen by the colorectal surgeon on anoscopic or proctoscopic
examination in patients with symptoms such as bleeding,
prolapse, and/or pain.
Statistical analysis
Continuous variables are expressed as means and standard
deviations and categorical variables are expressed as the
number of patients and percentages.
Fig. 4  Algorithm of patient
selection
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Surgery Today
Results
From a total 106 patients who underwent surgery with the
ADL technique and after the exclusion of those who did not
meet the study criteria, 75 patients were included in the final
analysis (Fig. 4). According to the Goligher Classification, 8
(10.6%) patients had grade 2 HD and 67 (89.4%) had grade
3 HD. The male to female ratio was 1.88, the mean age was
48 ± 19 years, and the mean BMI was 24 ± 3, kg/m2. The
mean operative time was 26 ± 7 min, and the mean number
of mucopexies performed was 2.8 ± 1.2. Thirty-nine patients
(52%) did not require hospitalization and were discharged
from the day clinic approximately 4 h postoperatively. Three
patients were discharged 2 days postoperatively, because of
bleeding in one and pain in two (Table 1). The mean follow-
up was 16 ± 3 months. Four patients (5.3%) had tenesmus
lasting 1 week postoperatively and two (2.7%) had rectal
bleeding, treated conservatively. In the early postoperative
period, three patients (4%) required urinary catheterization
for urinary retention. There were no late complications such
as urgency, soiling, or fecal incontinence. Two patients were
Surgery Today

Table 1  Clinical characteristics and surgical outcomes of the patients Table 3  Visual analogue scale (VAS) pain score, recurrence and
who underwent arterial detection ligation (ADL) patient satisfaction rates after arterial detection ligation (ADL)
ADL (n = 75) Postoperative follow-up

Gender 1st day 1st week 1st month 1st year

 Female, n (%) 26 (34.7)
Mean VAS score 2.9 1.5 0.4 0
 Male, n (%) 49 (65.3)
Recurrence, n (%) – – 0 3 (4)
Age, year, mean ± SD 48 ± 14
Patient satisfaction, – – 59 (78.6) 65 (86.7)
BMI, kg/m2, mean ± SD 24 ± 3 excellent or good,
ASA score, n (%) n (%)
 ASA I 42 (56)
VAS Visual Analogue Scale
 ASA II 18 (24)
 ASA III 15 (20)
Operative time, minutes, mean ± SD 26 ± 7
of serious complications and increased morbidity [13, 14].
Time of discharge, n (%)
On the other hand, in the DGHAL method, the terminal
 Outpatient 39 (52)
branches of the SRA are ligated selectively with specially
 1st day 33 (44)
prepared doppler devices to reduce blood flow to the hem-
 2nd day 3 (4)
orrhoidal plexus and ensure that the pads atrophy without
SD standard deviation, BMI Body Mass Index, ASA American Soci- disturbing the anatomy of the anal canal. In the second
ety of Anesthesiologists step, mucopexy or rectoanal repair is applied to place and
fix the prolapsed hemorrhoids back into the anal canal [4,
15]. Many studies have reported that DGHAL is effective
re-hospitalized on postoperative day 2 for prolonged anal and results in less pain, minimal complications, and similar
pain, which was treated successfully with analgesic medica- recurrence rates compared with other methods [16–19].
tion alone. None of the patients required re-operation in the The large diameter of the LDL-2 proctoscope used in
postoperative period (Table 2). the ADL technique (35 mm) and the window to be sutured
The mean VAS scores were 2.9, 1.5, 0.4, and 0, on post- allows for manipulation by the surgeon. The doppler probe
operative day 1, then at 1 week, 1 month, and 1 year. At placed distal to the proctoscope and inclined at 13 degrees
the 1-month follow-up, there was no recurrence and the makes it easier to find and ligate the proximal hemorrhoidal
satisfaction rate was stated as excellent or good by 78.7% artery. The integrated LED light source provides a better
(59/75) of the patients. At the 1-year follow-up, recurrence and more precise view. The positions and depth of the arter-
was detected as prolapse without bleeding in 3 (4%) patients ies are established using the CW, PW, and M modes in the
and the satisfaction rate was stated as excellent or good by Angiodin Procto system. With the universal foot pedal, the
86.7% (65/75) (Table 3). Angiodin-Procto system can be controlled and the areas of
ligation and mucopexy can be marked and recorded without
using hands.
Discussion The rate of tenesmus after DGHAL procedures using
different proctoscopes with the doppler feature is reported
With advances in technology, less invasive surgical proce- to range from 10 to 85.7%, which highlights this as an
dures are now preferred for the treatment of HD, to minimize important early postoperative complication of the proce-
postoperative pain and complications [3, 5]. Stapler hemor- dure [17, 20–23]. In our ADL series, in which we per-
rhoidopexy, one of these methods, is effective for reduc- formed ligation after measuring the depth of the hem-
ing postoperative pain but is associated with the possibility orrhoidal arteries, the incidence of tenesmus was 5.4%.
The reported rates of bleeding after the DGHAL proce-
dure range from 2 to 29%, which is similar to that in this
Table 2  Postoperative complications and course series (2.7%) [17, 21, 24–26]. Since the arteries found
ADL (n = 75) deeper than 12 mm tend to be located more proximal in
the anal canal, the resulting mucopexy suture line will be
Bleeding, n (%) 2 (2.7)
longer and with the mass ligation if these deeper arteries
Tenesmus, n (%) 4 (5.4)
are ligated, the tenesmus rate will be higher. Rotta et al.
Urinary retention, n (%) 3 (4)
reported a tenesmus rate of 85.7% in their study, and they
Rehospitalization, n (%) 2 (2.7)
attributed this high rate to suturing and fixation of the
Reoperation 0
prolapsed hemorrhoids [23]. Although the doppler devices

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currently used for ligation of the hemorrhoidal arteries
technically determine the approximate location of hemor-
rhoidal arteries, they do not provide information about the
depth of the arteries. Therefore, ligation of the arteries
above 12 mm should be the leading cause of tenesmus with
the increasing feeling of compression and stretching. Post-
operative pain may also be greater in deeply ligated arter-
ies because of the stretching effect. The newly developed
LDL-2 proctoscope and the Angiodin-Procto system make
it possible to detect the appropriate arteries between 6 and
12 mm. Another important factor is that since the curva-
ture of the needle inside the proctoscope can only ligate
the arteries at a maximum depth of 12 mm, the arteries
deeper than this may never be ligated based on guidance
by the audio of the ultrasound device.
Large series studies by Dal Monte [16], Ratto [17], and
La Bella [27] have reported recurrence rates of 7.5% in 330
patients, 9.3% in 803 patients, and 10.3% in 108 patients,
respectively. Patient satisfaction in the DGHAL technique
was reported to be between 80 and 88% [18, 28–30]. In our
series, the recurrence rate at the end of 1 year was 4% (n = 3)
and the satisfaction rate was 86.7% (n = 65). To our knowl-
edge, this is the first study to give detailed technical informa-
tion about the ADL technique and to report the preliminary
results. The limitations of this study are the retrospective
evaluation of the results of the patients with HD and no
comparison with a different technique, as well as a relatively
short follow-up period of 1 year.
In conclusion, our preliminary results show that ADL is
an effective technique to treat grades 2 and 3 HD without
serious morbidity, and it can often be accomplished as an
outpatient procedure. We anticipate that the rate of tenes-
mus, which is frequently seen after other DGHAL methods,
will be lower after the ADL technique by avoiding both mass
ligation of hemorrhoidal arteries deeper than 12 mm and
running a longer mucopexy suture line. Prospective rand-
omized studies with large series comparing other doppler
dearterialization techniques are required to evaluate the effi-
cacy and long-term results of the ADL technique.
Acknowledgements  The authors thank Damla Sen and Emel Basol
for the data collection.
Author contributions  SZ conceived and designed the report. SZ, BG,
and UC participated in the acquisition of data. SZ, BG, and UC ana-
lyzed and interpreted the data. SZ drafted the manuscript. SZ and TY
coordinated and critically revised the report. All the authors read and
approved the final manuscript.
Funding  No funding was received.
Compliance with ethical standards  15. Elmer SE, Nygren JO, Lenander CE. A randomized trial of transa-
Conflict of interest  We have no conflicts of interest to declare.
13
Surgery Today
Ethical approval  The study protocol was approved by the Institutional
Review Board of Koç University, School of Medicine (2020.068.
IRB1.016).
Informed consent  Written informed consent was obtained from all
patients.
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