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| ARTICLE OF 3RD PRIZE WINNER IN VIDEO COMPETITION ON JANUARY 24 IN VIRTUAL HEMORRHOIDCON 2021 |
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| Year : 2021 | Volume
: 4
| Issue : 2 | Page : 56-57 |
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Hemorrhoidal artery ligation, laser hemorrhoidoplasty, and lis in a case of grade 3 hemorrhoids and chronic anal fissure
Sanjay Singla
Singla Hospital, Bhiwani, Haryana, India
| Date of Web Publication | 09-Nov-2021 |
Correspondence Address:
Dr. Sanjay Singla
Singla Hospital, Bhiwani, Haryana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2666-0784.330171
How to cite this article:
Singla S. Hemorrhoidal artery ligation, laser hemorrhoidoplasty, and lis in a case of grade 3 hemorrhoids and chronic anal fissure. Indian J Colo-Rectal Surg 2021;4:56-7 |
How to cite this URL:
Singla S. Hemorrhoidal artery ligation, laser hemorrhoidoplasty, and lis in a case of grade 3 hemorrhoids and chronic anal fissure. Indian J Colo-Rectal Surg [serial online] 2021 [cited 2021 Dec 4];4:56-7. Available from: https://www.ijcrsonweb.org/text.asp?2021/4/2/56/330171 |
Hemorrhoidal artery ligation and LASER hemorrhoidoplasty decrease pain and preserve anatomical and physiological important anorectal mucosa with less complications.
Video of a patient with grade 3 hemorrhoids and chronic anal fissure was presented on January 24 at Virtual Hemorrhoidocon 2021
| Technique | |  |
Under spinal anesthesia and in lithotomy position, gently lubricate the anal canal, and assess the piles on table. Instead of Doppler, finger is used to palpate the hemorrhoidal vessels. In the present case, one can see chronic anal fissure with sentinel tag along with grade III hemorrhoidal cushions [Figure 1].
Put the half-speculum and observe the dentate line. All palpable hemorrhoidal arteries are ligated by passing 2.0 vicryl suture over 5/8 curved round body needle, 1 cm above puborectalis sling to avoid missing submucosal branches of superior rectal artery[1] [Figure 2]. | Figure 2: Hemorrhoidal artery ligation 1 cm above the puborectalis sling
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Hold the needle holder as shown in [Figure 3]. Rotate the wrist along the curvature of the needle. | Figure 3: (a) Do not hold needle holder this way wrong way to handle needle holder. (b) Correct way to handle needle holder
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While ligating, we do rectal mucopexy to lift the cushion up. Confirm proper ligation of vessels by absent pulse, distal to ligature. When the hemorrhoids are large, press it with back of forceps. While you apply knot, assistant milks up the hemorrhoid mass to avoid venous congestion. After hemorrhoid artery ligation, LASER energy (1470 nm diode laser) is delivered in the submucosa of enlarged hemorrhoidal cushions, with conical tip LASER fiber [Figure 4]. We enter into the submucosal space by putting conical tip of the LASER fiber just below the dentate line, using 6 watt energy for I sec pulse. The LASER fiber is passed up till pedicle stitch. On withdrawal, the LASER energy delivered is 6 W in 3 s pulses in a fan-shaped manner and delivered on an average of 150-200 J per one cushion. Maximum limit is to be 500 J for whole anal canal. One should keep the LASER fiber tip at the center of the submucosal cushion to avoid any inadvertent injury [Figure 5]. | Figure 4: Conical tip of the probe facilitates entry in the submucosal cushion
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 | Figure 5: Laser probe at the center of submucosal cushion guided by intensity of red glow which should neither be very bright nor too dull
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For chronic fissure in ano, we did LASER lateral internal sphincterotomy.
Put the anal speculum and open it to stretch the sphincter for better definition of intersphincteric groove [Figure 6].
Open intersphincteric space by bare Laser fiber using 7 W energy continuous mode, pick the lower half of internal sphincter over an artery forceps and incise it [Figure 7]. | Figure 7: Internal anal sphincter below the dentate line lifted over the mosquito forceps
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We excised the hypertrophied anal papilla and sentinel tag also. Check proctoscopy is done. Put a small ice finger cot in the anal canal to decrease latent heat and postprocedure edema.
Postoperative care includes monitoring vitals and check for urine retention. NSAID usually suffices for pain control.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Ratto C, Parello A, Donisi L, Litta F, Zaccone G, Doglietto GB. Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications. Br J Surg 2012;99:112-8.  |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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