Comparison of open haemoridectomy (Milligan-Morgan) and HAL-RAR in the treatment of grade III and IV haemorrhoids

Background & Objective: Hemorrhoidectomy (HD), either open (Milligan-Morgan) or closed (Ferguson), is the conventional treatment for stages 3 and 4 of the condition. HAL-RAR therapy, a minimally invasive treatment for high-grade hemorrhoids, involves the integration of HAL (hemorrhoidal artery ligation) with a procedure known as mucopexy, which lifts the hemorrhoidal prolapses. The study objective was to compare the efficacy of open hemorrhoidectomy against haemorrhoid artery ligation with recto-anal repair (HAL-RAR). Methods: A comparative randomized controlled trial was conducted at general surgery department of Pakistan Aeronautical Complex Hospital Kamra and Pakistan Air Force Hospital Islamabad between June 2021 and December 2022. Total 30 patients diagnosed with hemorrhoids of grades III–IV were assigned randomly to either HAL-RAR (n=15) or hemorrhoidectomy (n=15). Every procedure was a day surgery performed under spinal anesthesia. After 15 days, 30 days, and 6 months patients were re-evaluated. Patients rated their own pain on a visual analog scale. All the data was analyzed by SPSS v 26. Results: Mean age of the participants was 51.3±6.67 years. HAL-RAR group addressed a greater number of prolapsed hemorrhoidal cushions compared to the hemorrhoidectomy group (2.9 vs 2.02, p = 0.001), and the operation took longer in HAL-RAR group (40 min vs 24 min, p = 0.001). HAL-RAR group had less discomfort in the first 30 days after surgery (p = 0.001). In addition, higher number of patients in HAL-RAR group reported experiencing relief from pain (VAS = 0) after day 7. By day 15, HAL-RAR group had substantially better symptom resolution than the hemorrhoidectomy group. Resolution of bleeding, prolapse, itching, and soiling occurred sooner in HAL-RAR group than in hemorrhoidectomy group during the 30-day follow-up. Conclusion: The symptoms of haemorrhoids are resolved with less discomfort with HAL-RAR than after hemorrhoidectomy, and recovery time is shorter.