Multiple hemorrhoidal ligation: a prospective, randomized trial evaluating a new technique

A modified anoscope was developed, with lateral apertures at the left lateral, right anterior, and right posterior quadrants, to enable synchronous exposure and ligation of all three internal hemorrhoids. Results were compared with those for conventional multiple ligation.

Postligation pain, complications, and outcomes were compared between synchronous ligation with the new anoscope (synchronous group) and three-quadrant ligation with a conventional anoscope with similar overall dimensions (conventional group).

Twenty-five patients were prospectively randomized to each group. Postligation pain and analgesic requirements were recorded up to 28 days, and postligation complications and outcomes were evaluated for a minimum of 6 months. Narcotic requirements were lower in the synchronous group, but this difference did not achieve statistical significance (P > 0.05, Student's t-test). Secondary hemorrhage occurred in 1 patient (4 percent) in the conventional group but resolved spontaneously. The synchronous group experienced significantly less pain during the ligation procedure and for 2 days afterward (P < 0.01, Wilcoxon's test). External hemorrhoidal thrombosis developed in 4 percent of the synchronous group and 12 percent of conventionally treated patients, all of whom responded to conservative treatment. Repeat ligation was required less often in the synchronous group (16 percent) than with conventional ligation (28 percent). Surgery (completion hemorrhoidectomy for external thrombosis) was necessary in one patient (4 percent) in each group. Anal stenosis developed in one patient in the synchronous group.

The new anoscope provides improved exposure of all three internal hemorrhoids and permits optimal placement of the rubber bands; this may account for the decreased postligation pain and lower repeat ligation rates. Synchronous hemorrhoidal ligation is a less painful method of multiple hemorrhoidal ligation and may improve outcomes compared with conventional multiple ligation.