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.
THD treatment for hemorrhoids
Transanal Hemorrhoidal De-Arterialisation (THD) is a minimally invasive surgical procedure used to treat hemorrhoids (piles). It can also be called Hemorrhoid Ligation, Hemorrhoidal Artery Ligation or Doppler guided Ligation.
The THD procedure is an innovative surgical treatment for hemorrhoids, approved by the National Institute for Clinical Excellence (NICE) and designed to cure hemorrhoids in a gentle way while focusing on excellent long term results.
THD uses a doppler to locate the terminating branches of the hemorrhoidal arteries. Once the artery is located the surgeon uses an absorbable suture to ligate or “tie-off” the arterial blood flow. The venous “out flow” remains to “shrink” the cushion. This is done without excision of tissue. If necessary the surgeon will perform a hemorrhoidopexy to repair the prolapse. Again, this is done with suture and no excision of tissue. This repair restores and “lifts” the tissue back to its anatomical position.
The THD Procedure
Transanal hemorrhoidal dearterialization (THD) uses a specially developed anoscope combined with a Doppler transducer to identify the hemorrhoidal arteries (originating from the superior rectal artery) 2–3 cm above the pectinate line. Once the superior rectal arteries are identified through the Doppler, a suture ligation is performed to effectively decrease the blood flow to the hemorrhoidal plexus. In case of redundant prolapse, the prolapsed mucosal membrane is lifted and sutured (with the last suture minimum 5 mm above the pectinate line), repositioning hemorrhoidal cushions in situ. This is different from a traditional hemorrhoidectomy, which focused on excising the hemorrhoidal bundle. In this procedure there is no tissue excision. Because the suture line is above the pectinate line, post-operative pain is minimized for patients. THD can be performed with conscious sedation, local or general anesthesia.
During the THD procedure, the hemorrhoid’s feeding arteries are precisely located via a Doppler ultrasound probe, mounted on a specially designed proctoscope. Each of these arteries is then sutured through a small operating window of the same proctoscope, making this technique minimally invasive.
The procedure is carried out in the area above the dentate line, (an area without sensory nerves); the patient doesn’t feel any stitches during or after the intervention. The THD procedure can also re-position prolapsed tissue, restoring normal anatomy and physiology.
The THD procedure differs from other surgical techniques in the following ways:
- It uses the same fine instrument for locating the arteries, suturing them and applying, if necessary, subtle stitches to any prolapsed piles (the instrument always remains in the same position while working through the small window, making the procedure extremely gentle)
- It does not cut or remove any hemorrhoidal tissue, hence post-operative complications are significantly reduced compared to hemorrhoidectomy
- Since the blood-supplying arteries are not only tied off with rubber bands (which can slip and cause bleedings), but sutured, the THD procedure has been associated with far less post-operative complications and better long-term results
- In most cases, patients resume their normal activities within 24 – 48 hours
- After the procedure, some patients mayt feel a slight discomfort in the rectal area which usually disappears within a few days. If any prolapse has been sutured, some patients may feel a slight urge to defecate, which is related to the repaired prolapse and which is gradually disappearing as well.
THD does not cut or remove any hemorrhoidal tissue; hence pain and post-operative complications are significantly reduced, with long term positive outcome. In most cases, patients resume their normal activities within 24–48 hours. After the intervention, some patients might feel a slight discomfort in the rectal area which usually disappears within a few days.
After surgery, a high-fiber diet with plenty of liquids (approx. two litres per day) is recommended. For most patients, normal activities can be resumed on average two to three days post-op. The affected areas usually restore their normal anatomy after two to three months.
Reports on this procedure showed low complication rates and lower postoperative pain. Postoperative bleeding and constipation were included among some of the arising complications.
THD Surgery Risks
As with any surgical procedure, there are potential risks involved. The minor and temporary risks associated with THD include bleeding, mucous discharge, and urinary retention.