Hemorrhoids pp 345-367 | Cite as

Dearterialization of Hemorrhoids and Mucopexy: Techniques and Results

  • Carlo RattoEmail author
  • Angelo Parello
  • Francesco Litta
  • Veronica De Simone
Reference work entry
Part of the Coloproctology book series (COLOPROCT, volume 2)


The ligation of hemorrhoidal arteries and pexy of prolapsing rectal mucosa/submucosa seem to be one of the most effective therapeutic approaches in the treatment of hemorrhoidal disease. This surgical procedure is primarily aimed toward the management of the main symptoms, i.e., bleeding, prolapse, and pain, intervening on its pathophysiological processes. It is based on two technical steps: first, the targeted ligation of hemorrhoidal arteries (called “dearterialization”); second, the plication and lifting of redundant and prolapsing rectal mucosa/submucosa (called “mucopexy”). This chapter examines technical aspects and perioperative management of the procedure. Moreover, results of dearterialization of hemorrhoids and mucopexy, as described in the Literature, are critically evaluated.


  1. Aigner F, Bodner G, Conrad F, Mbaka G, Kreczy A, Fritsch H (2004) The superior rectal artery and its branching pattern with regard to its clinical influence on ligation techniques for internal hemorrhoids. Am J Surg 187:102–108CrossRefPubMedPubMedCentralGoogle Scholar
  2. Aigner F, Bodner G, Gruber H, Conrad F, Fritsch H, Margreiter R, Bonatti H (2006) The vascular nature of hemorrhoids. J Gastrointest Surg 10:1044–1050CrossRefPubMedPubMedCentralGoogle Scholar
  3. Aigner F, Gruber H, Conrad F, Eder J, Wedel T, Zelger B et al (2009) Revised morphology and hemodynamics of the anorectal vascular plexus: impact on the course of hemorrhoidal disease. Int J Color Dis 24:105–113CrossRefGoogle Scholar
  4. Aigner F, Bonatti H, Peer S, Conrad F, Fritsch H, Margreiter R, Gruber H (2010) Vascular considerations for stapled haemorrhoidopexy. Color Dis 12:452–458CrossRefGoogle Scholar
  5. Arnold S, Antonietti E, Rollinger G, Scheyer M (2002) Doppler ultrasound assisted hemorrhoid artery ligation. A new therapy in symptomatic hemorrhoids. Chirurg 73:269–273CrossRefPubMedPubMedCentralGoogle Scholar
  6. Béliard A, Labbé F, de Faucal D, Fabreguette JM, Pouderoux P, Borie F (2014) A prospective and comparative study between stapled hemorrhoidopexy and hemorrhoidal artery ligation with mucopexy. J Visc Surg 151:257–262CrossRefPubMedPubMedCentralGoogle Scholar
  7. Burch J, Epstein D, Sari AB, Weatherly H, Jayne D, Fox D, Woolacott N (2009) Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review. Color Dis 11:233–243CrossRefGoogle Scholar
  8. Cantero R, Balibrea JM, Ferrigni C, Sanz M, García Pérez JC, Pérez R, Lufflego A, Forero RG, Balibrea JL (2008) Doppler-guided transanal haemorrhoidal dearterialisation. An alternative treatment for haemorrhoids. Cir Esp 83:252–255CrossRefPubMedGoogle Scholar
  9. Corman ML, Gravié JF, Hager T, Loudon MA, Mascagni D, Nyström PO, Seow-Choen F, Abcarian H, Marcello P, Weiss E, Longo A (2003) Stapled haemorrhoidopexy: a consensus position paper by an international working party – indications, contra-indications and technique. Color Dis 5:304–310CrossRefGoogle Scholar
  10. Dal Monte PP, Tagariello C, Sarago M, Giordano P, Shafi A, Cudazzo E, Franzini M (2007) Transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease. Tech Coloproctol 11:333–338CrossRefPubMedPubMedCentralGoogle Scholar
  11. De Nardi P, Capretti G, Corsaro A, Staudacher C (2014) A prospective, randomized trial comparing the short- and long-term results of doppler-guided transanal hemorrhoid dearterialization with mucopexy versus excision hemorrhoidectomy for grade III hemorrhoids. Dis Colon Rectum 57:348–353CrossRefPubMedPubMedCentralGoogle Scholar
  12. Denoya PI, Fakhoury M, Chang K, Fakhoury J, Bergamaschi R (2013) Dearterialization with mucopexy vs haemorrhoidectomy for grade III or IV haemorrhoids: short-term results of a double-blind randomized controlled trial. Color Dis 15:1281–1288CrossRefGoogle Scholar
  13. Denoya P, Tam J, Bergamaschi R (2014) Hemorrhoidal dearterialization with mucopexy versus hemorrhoidectomy: 3-year follow-up assessment of a randomized controlled trial. Tech Coloproctol 18: 1081–1085CrossRefPubMedPubMedCentralGoogle Scholar
  14. DiDio LJ, Diaz-Franco C, Schemainda R, Bezerra AJ (1986) Morphology of the middle rectal arteries. A study of 30 cadaveric dissections. Surg Radiol Anat 8:229–236CrossRefPubMedGoogle Scholar
  15. Elmér SE, Nygren JO, Lenander CE (2013) A randomized trial of transanal hemorrhoidal dearterialization with anopexy compared with open hemorrhoidectomy in the treatment of hemorrhoids. Dis Colon Rectum 56:484–490CrossRefPubMedPubMedCentralGoogle Scholar
  16. Faucheron JL, Voirin D, Abba J (2012) Rectal perforation with life-threatening peritonitis following stapled haemorrhoidopexy. Br J Surg 99:746–753CrossRefPubMedPubMedCentralGoogle Scholar
  17. Festen S, van Hoogstraten MJ, van Geloven AA, Gerhards MF (2009) Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results. Int J Color Dis 24:1401–1405CrossRefGoogle Scholar
  18. Gass OC, Adams J (1950) Hemorrhoids: etiology and pathology. Am J Surg 29:40–43CrossRefGoogle Scholar
  19. Giordano P, Overton J, Madeddu F, Zaman S, Gravante G (2009) Transanal hemorrhoidal dearterialization: a systematic review. Dis Colon Rectum 52:1665–1671CrossRefPubMedPubMedCentralGoogle Scholar
  20. Giordano P, Nastro P, Davies A, Gravante G (2011) Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes. Tech Coloproctol 15:67–73CrossRefPubMedPubMedCentralGoogle Scholar
  21. Giordano P, Tomasi I, Pascariello A, Mills E, Elahi S (2014) Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids. Color Dis 16:373–376CrossRefGoogle Scholar
  22. Greenberg R, Karin E, Avital S, Skornick Y, Werbin N (2006) First 100 cases with Doppler-guided hemorrhoidal artery ligation. Dis Colon Rectum 49:485–489CrossRefPubMedPubMedCentralGoogle Scholar
  23. Haas PA, Fox TA Jr, Haas GP (1984) The pathogenesis of hemorrhoids. Dis Colon Rectum 27:442–450CrossRefPubMedPubMedCentralGoogle Scholar
  24. Infantino A, Bellomo R, Dal Monte PP, Salafia C, Tagariello C, Tonizzo CA, Spazzafumo L, Romano G, Altomare DF (2010) Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study. Color Dis 12:804–809CrossRefGoogle Scholar
  25. Infantino A, Altomare DF, Bottini C, Bonanno M, Mancini S, THD group of the SICCR (Italian Society of Colorectal Surgery), Yalti T, Giamundo P, Hoch J, El Gaddal A, Pagano C (2012) Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler-guided transanal haemorrhoid dearterialization for third-degree haemorrhoids. Color Dis 14:205–211CrossRefGoogle Scholar
  26. Jackson CC, Robertson E (1965) Etiologic aspects of hemorrhoidal disease. Dis Colon Rectum 8:185–189CrossRefPubMedGoogle Scholar
  27. Jayaraman S, Colquhoun PH, Malthaner RA (2006) Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev 4:CD005393Google Scholar
  28. Johanson JF, Sonnenberg A (1990) The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology 98:380–386CrossRefPubMedPubMedCentralGoogle Scholar
  29. Kaidar-Person O, Person B, Wexner SD (2007) Hemorrhoidal disease: a comprehensive review. J Am Coll Surg 204:102–117CrossRefPubMedGoogle Scholar
  30. Keighley MR, Williams NS (2008) Haemorrhoidal disease. In: Keighley MR, Williams NS (eds) Surgery of the anus, rectum and colon, 3rd edn. Elsevier/Saunders, Edinburgh, pp 321–381Google Scholar
  31. Klink C, Binnebösel M, Kämmer D, Willis S, Prescher A, Klinge U, Schumpelick V (2009) Haemorrhoids are related to changes of cell function in mucosa and submucosa. Int J Color Dis 24:1389–1394CrossRefGoogle Scholar
  32. LaBella GD, Main WPL, Hussain LR (2015) Evaluation of transanal hemorrhoidal dearterialization: a single surgeon experience. Tech Coloproctol 19:153–157CrossRefPubMedPubMedCentralGoogle Scholar
  33. Loder PB, Kamm MA, Nicholls RJ, Phillips RK (1994) Haemorrhoids: pathology, pathophysiology and aetiology. Br J Surg 81:946–954CrossRefPubMedPubMedCentralGoogle Scholar
  34. Lucha PA (2009) Pathophysiology of hemorroidal disease. In: Khubchandani I, Paonessa N, Azimuddin K (eds) Surgical treatment of hemorrhoids. Springer, London, pp 15–17CrossRefGoogle Scholar
  35. Ohana G, Myslovaty B, Ariche A, Dreznik Z, Koren R, Rath-Wolfson L (2007) Mid-term results of stapled hemorrhoidopexy for third- and fourth-degree hemorrhoids – correlation with the histological features of the resected tissue. World J Surg 31:1336–1342CrossRefPubMedGoogle Scholar
  36. Pescatori M, Gagliardi G (2008) Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol 12:7–19CrossRefPubMedPubMedCentralGoogle Scholar
  37. Pol RA, van der Zwet WC, Hoornenborg D, Makkinga B, Kaijser M, Eeftinck Schattenkerk M, Eddes EH (2010) Results of 244 consecutive patients with hemorrhoids treated with doppler-guided hemorrhoidal artery ligation. Dig Surg 27:279–284CrossRefPubMedGoogle Scholar
  38. Pucher PH, Sodergren MH, Lord AC, Darzi A, Ziprin P (2013) Clinical outcome following Doppler-guided haemorrhoidal artery ligation: a systematic review. Color Dis 15:e284–e294CrossRefGoogle Scholar
  39. Ratto C (2014) THD doppler procedure for hemorrhoids: the surgical technique. Tech Coloproctol 18:291–298CrossRefPubMedGoogle Scholar
  40. Ratto C, Donisi L, Parello A, Litta F, Doglietto GB (2010) Evaluation of transanal hemorrhoidal dearterialization as a minimally invasive therapeutic approach to hemorrhoids. Dis Colon Rectum 53:803–811CrossRefPubMedPubMedCentralGoogle Scholar
  41. Ratto C, Giordano P, Donisi L, Parello A, Litta F, Doglietto GB (2011a) Transanal haemorrhoidal dearterialization (THD) for selected fourth-degree haemorrhoids. Tech Coloproctol 15:191–197CrossRefPubMedPubMedCentralGoogle Scholar
  42. Ratto C, Parello A, Donisi L, Litta F, Doglietto GB (2011b) Anorectal physiology is not changed following transanal haemorrhoidal dearterialization for haemorrhoidal disease: clinical, manometric and endosonographic features. Color Dis 13:e243–e245CrossRefGoogle Scholar
  43. Ratto C, Donisi L, Parello A, Litta F, Zaccone G, De Simone V (2012a) Distal Doppler-guided dearterialization’ is highly effective in treating haemorrhoids by transanal haemorrhoidal dearterialization. Color Dis 14:e786–e789CrossRefGoogle Scholar
  44. Ratto C, Parello A, Donisi L, Litta F, Zaccone G, Doglietto GB (2012b) Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications. Br J Surg 99:112–118CrossRefPubMedPubMedCentralGoogle Scholar
  45. Ratto C, Parello A, Veronese E, Cudazzo E, D’Agostino E, Pagano C, Cavazzoni E, Brugnano L, Litta F (2015) Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial. Color Dis 17:O10–O19CrossRefGoogle Scholar
  46. Rivadeneira DE, Steele SR, Ternent C, Chalasani S, Buie WD, Rafferty JL (2011) Standards practice task force of the American society of colon rectal surgeons. Practice parameters for the treatment of hemorrhoids (revised 2010). Dis Colon Rectum 54:1059–1064CrossRefPubMedPubMedCentralGoogle Scholar
  47. Rubbini M, Tartari V (2015) Doppler-guided hemorrhoidal artery ligation with hemorrhoidopexy: source and prevention of postoperative pain. Int J Colorectal Dis 30:625–630CrossRefPubMedGoogle Scholar
  48. Sajid MS, Parampalli U, Whitehouse P, Sains P, McFall MR, Baig MK (2012) A systematic review comparing transanal haemorrhoidal de-arterialisation to stapled haemorrhoidopexy in the management of haemorrhoidal disease. Tech Coloproctol 16:1–8CrossRefPubMedPubMedCentralGoogle Scholar
  49. Scheyer M, Antonietti E, Rollinger G, Mall H, Arnold S (2006) Doppler-guided hemorrhoidal artery ligation. Am J Surg 191:89–93CrossRefPubMedPubMedCentralGoogle Scholar
  50. Schuurman JP, Go PM, Bleys RL (2009) Anatomical branches of the superior rectal artery in the distal rectum. Color Dis 11:967–971CrossRefGoogle Scholar
  51. Schuurman JP, Rinkes I, Go P (2012) Hemorrhoidal artery ligation procedure with or without doppler transducer in grade II and III hemorrhoidal disease. Ann Surg 255:840–845CrossRefPubMedPubMedCentralGoogle Scholar
  52. Shafik A (1984) The pathogenesis of hemorrhoids and their treatment by anorectal bandotomy. J Clin Gastroenterol 6:129–137CrossRefPubMedGoogle Scholar
  53. Shafik A (2009) Surgical anatomy of hemorrhoids. In: Khubchandani I, Paonessa N, Azimuddin K (eds) Surgical treatment of hemorrhoids. Springer, London, pp 7–13CrossRefGoogle Scholar
  54. Shafik A, Mostafa H (1996) Study of the arterial pattern of the rectum and its clinical application. Acta Anat (Basel) 157:80–86CrossRefGoogle Scholar
  55. Shao WJ (2008) Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy. Br J Surg 95:147–160CrossRefPubMedPubMedCentralGoogle Scholar
  56. Stelzner F, Staubesand J, Machleidt H (1962) The corpus cavernosum recti – basis of internal hemorrhoids. Langenbecks Arch Klin Chir Ver Dtsch Z Chir 299: 302–312PubMedGoogle Scholar
  57. Tagart RE (1974) Haemorrhoids and palpable ano-rectal lesions. Practitioner 212:221–238PubMedGoogle Scholar
  58. Taweevisit M, Wisadeopas N, Phumsuk U, Thorner PS (2008) Increased mast cell density in haemorrhoid venous blood vessels suggests a role in pathogenesis. Singap Med J 49:977–979Google Scholar
  59. Tempel MB, Pearson EG, Page M, Pollock D, Gilmore-Lynch K, Peche W, Sklow B, Snyder M (2014) Survey of patient satisfaction after Doppler-guided transanal hemorrhoidal dearterialization performed in ambulatory settings. Tech Coloproctol 18:607–610CrossRefPubMedPubMedCentralGoogle Scholar
  60. Theodoropoulos GE, Sevrisarianos N, Papaconstantinou J, Panoussopoulos SG, Dardamanis D, Stamoploulos P, Bramis K, Spiliotis J, Datsis A, Leandros E (2010) Doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III-IV haemorrhoids: a multicenter prospective study of safety and efficacy. Color Dis 12:125–134CrossRefGoogle Scholar
  61. Thomson WH (1981) The anatomy and nature of piles. In: Kaufman HD (ed) The haemorrhoid syndrome. Abacus Press, Tunbridge Wells, pp 15–33Google Scholar
  62. Tiernan JP, Hind D, Brown SR (2013) Evaluating the efficacy of treatments for haemorrhoids: time for a standardised definition of recurrence? Color Dis 15:1449–1450CrossRefGoogle Scholar
  63. Vyslouzil K, Zboril P, Skalicky P, Vomackova K (2010) Effect of hemorrhoidectomy on anorectal physiology. Int J Color Dis 25:259–265CrossRefGoogle Scholar
  64. Wałega P, Scheyer M, Kenig J, Herman RM, Arnold S, Nowak M, Cegielny T (2008) Two-center experience in the treatment of hemorrhoidal disease using Doppler-guided hemorrhoidal artery ligation: functional results after 1-year follow-up. Surg Endosc 22:2379–2383CrossRefPubMedGoogle Scholar
  65. Walega P, Krokowicz P, Romaniszyn M, Kenig J, Salówka J, Nowakowski M, Herman RM, Nowak W (2010) Doppler guided haemorrhoidal arterial ligation with recto-anal-repair (RAR) for the treatment of advanced haemorrhoidal disease. Color Dis 12:e326–e329CrossRefGoogle Scholar
  66. Wallis de Vries BM, van der Beek ES, de Wijkerslooth LR, van der Zwet WC, van der Hoeven JA, Eeftinck Schattenkerk M, Eddes EH (2007) Treatment of grade 2 and 3 hemorrhoids with Doppler-guided hemorrhoidal artery ligation. Dig Surg 24:436–440CrossRefPubMedGoogle Scholar
  67. Zampieri N, Castellani R, Andreoli R, Geccherle A (2012) Long-term results and quality of life in patients treated with hemorrhoidectomy using two different techniques: Ligasure versus transanal hemorrhoidal dearterialization. Am J Surg 204:684–688CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Carlo Ratto
    • 1
    Email author
  • Angelo Parello
    • 1
  • Francesco Litta
    • 1
  • Veronica De Simone
    • 1
  1. 1.Proctology Unit, University Hospital “A. Gemelli”Catholic UniversityRomeItaly

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