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Comparative Study of Blood Loss and Hemostasis in Doppler-Guided Hemorrhoidal Artery Ligation Versus Open
Muhammad Usama Talib1, Faiza Hameed2, Qambar A Laghari3
1General Surgery, University Hospitals of Morecambe Bay NHS Foundation Trust, Kendal, GBR.
Background Hemorrhoidal disease is among the most commonly seen anorectal disorders. Surgical treatment is routinely indicated in advanced stages or when conservative measures fail. Although conventional open hemorrhoidectomy remains an effective procedure, it is often accompanied by considerable intraoperative bleeding and postoperative hemorrhagic complications. Doppler-guided hemorrhoidal artery ligation (DGHAL) is a minimally invasive approach that targets the arterial supply of hemorrhoidal tissue and has been proposed to improve hemostatic control. This study aimed to compare intraoperative blood loss and bleeding-related outcomes between DGHAL and open hemorrhoidectomy. Methods This prospective, observational, non-randomized comparative study was conducted from March 2023 to February 2025 at Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan. Adults aged 18-65 years with grade II-IV hemorrhoids were enrolled using non-probability consecutive sampling. Grade II cases were included only after documented failure of conservative therapy or rubber band ligation, or in the presence of recurrent bleeding, symptomatic prolapse, or hemorrhoid-related anemia. Patients underwent Doppler-guided hemorrhoidal artery ligation (DGHAL) or open hemorrhoidectomy according to predefined institutional protocols; allocation was non-random and based on disease severity, prolapse extent, bleeding severity, patient preference, and Doppler availability. Intraoperative blood loss was measured using suction volume and sponge weight difference. Additional hemostatic intervention was defined as persistent bleeding lasting >30 seconds or visible arterial spurting requiring sutures or electrocautery. Clinically significant postoperative bleeding was recorded within 24 hours and 14 days. Data were analyzed using SPSS version 26 (IBM Corp., Armonk, New York, USA) with multivariable regression adjustment. Results A total of 140 patients were analyzed, with 70 individuals in each treatment group. Demographic and baseline clinical characteristics were similar between groups. The mean intraoperative blood loss was significantly lower in patients undergoing DGHAL compared with those treated by open hemorrhoidectomy (32.4 ± 14.8 mL vs 68.9 ± 22.6 mL; p < 0.001). Patients in the DGHAL group required fewer supplementary hemostatic interventions and had significantly shorter operative times (p < 0.001). Both early and late postoperative bleeding events occurred less frequently following DGHAL, and the reduction in postoperative hemoglobin levels was also significantly smaller (p < 0.001). Multivariable analysis identified the type of surgical procedure as the most significant independent determinant of blood loss. Conclusion Doppler-guided hemorrhoidal artery ligation was associated with significantly lower intraoperative blood loss and improved short-term hemostatic outcomes compared to open hemorrhoidectomy. These findings support DGHAL as an effective alternative for achieving better perioperative bleeding control; however, they reflect short-term hemostatic advantages rather than overall procedural superiority.
Background Hemorrhoidal disease is among the most commonly seen anorectal disorders. Surgical treatment is routinely indicated in advanced stages or when conservative measures fail. Although conventional open hemorrhoidectomy remains an effective procedure, it is often accompanied by considerable intraoperative bleeding and postoperative hemorrhagic complications. Doppler-guided hemorrhoidal artery ligation (DGHAL) is a minimally invasive approach that targets the arterial supply of hemorrhoidal tissue and has been proposed to improve hemostatic control. This study aimed to compare intraoperative blood loss and bleeding-related outcomes between DGHAL and open hemorrhoidectomy. Methods This prospective, observational, non-randomized comparative study was conducted from March 2023 to February 2025 at Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan. Adults aged 18-65 years with grade II-IV hemorrhoids were enrolled using non-probability consecutive sampling. Grade II cases were included only after documented failure of conservative therapy or rubber band ligation, or in the presence of recurrent bleeding, symptomatic prolapse, or hemorrhoid-related anemia. Patients underwent Doppler-guided hemorrhoidal artery ligation (DGHAL) or open hemorrhoidectomy according to predefined institutional protocols; allocation was non-random and based on disease severity, prolapse extent, bleeding severity, patient preference, and Doppler availability. Intraoperative blood loss was measured using suction volume and sponge weight difference. Additional hemostatic intervention was defined as persistent bleeding lasting >30 seconds or visible arterial spurting requiring sutures or electrocautery. Clinically significant postoperative bleeding was recorded within 24 hours and 14 days. Data were analyzed using SPSS version 26 (IBM Corp., Armonk, New York, USA) with multivariable regression adjustment. Results A total of 140 patients were analyzed, with 70 individuals in each treatment group. Demographic and baseline clinical characteristics were similar between groups. The mean intraoperative blood loss was significantly lower in patients undergoing DGHAL compared with those treated by open hemorrhoidectomy (32.4 ± 14.8 mL vs 68.9 ± 22.6 mL; p < 0.001). Patients in the DGHAL group required fewer supplementary hemostatic interventions and had significantly shorter operative times (p < 0.001). Both early and late postoperative bleeding events occurred less frequently following DGHAL, and the reduction in postoperative hemoglobin levels was also significantly smaller (p < 0.001). Multivariable analysis identified the type of surgical procedure as the most significant independent determinant of blood loss. Conclusion Doppler-guided hemorrhoidal artery ligation was associated with significantly lower intraoperative blood loss and improved short-term hemostatic outcomes compared to open hemorrhoidectomy. These findings support DGHAL as an effective alternative for achieving better perioperative bleeding control; however, they reflect short-term hemostatic advantages rather than overall procedural superiority.
