What is a Haemorrhoid Artery Ligation Operation?

This is an operation to reduce the flow of blood to your haemorrhoid (piles). The aim of this operation is to cut off the blood flow to the haemorrhoids to reduce discomfort, bleeding and their size.

This type of procedure may also be referred to as a Haemorrhoid Artery Ligation Recto Anal Repair (HALO-RAR).

What is a haemorrhoid?

Haemorrhoids (piles) are swellings that develop from the lining of the anus and lower rectum (back passage). Symptoms range from temporary and mild to persistent and painful.

What causes haemorrhoids?

There is a network of small veins (blood vessels) within the inside lining of the anus and lower rectum. These veins sometimes become wider and swell with more blood than usual.

These swelled veins and the tissue near them may form into one or two more swellings, called haemorrhoids.

If the pressure in and around the anus is increased, this can lead to haemorrhoids developing.

Common causes for haemorrhoids

• Constipation – The pressure in and around the veins in the anus increases. This is a common cause for haemorrhoids developing. This is made worse with straining on the toilet.

• Pregnancy – This can cause haemorrhoids as the baby lying above the rectum and anus can cause pressure. Changes to hormones can also have an effect on the veins.

• Ageing – The tissue in the lining of the anus may not be as supportive as you get older.

Some haemorrhoids seem to develop for no reason.

Grades of haemorrhoids

Haemorrhoids are graded according to how bad they are, ranged from Grade 1 which is the least severe to Grade 4 being the most severe.

Grade 1: The internal haemorrhoid bulges into the lining of your back passage (anus). They do not prolapse (hang outside of your anus). These may bleed.

Grade 2: The haemorrhoid goes past the anal opening with straining for a bowel movement or passage of wind, but return to their original internal position once the straining has stopped.

Grade 3: The haemorrhoid may protrude past the anal opening without any straining and requires the patient to push them inside.

Grade 4: This is where the haemorrhoid is permanently prolapsed (outside of the anus).

Grade 1 and 2 haemorrhoids may be treated by dietary changes and medicines. These medicines include creams and suppositories (medicine inserted into your back passage).

If these treatments don’t help, other treatments include:

• Rubber band ligation (tying) of the haemorrhoids, to prevent bleeding. This is a minimally invasive procedure.

• Special injections into the haemorrhoid.

Grade 3 and 4 haemorrhoids, which hang outside your anus, will require surgical removal, or their blood supply will need to be tied off.

Symptoms of haemorrhoids

• Bleeding from the anus
• Anal itching
• Pain the anal area
• Swelling and feeling a lump at the anus.

How will the operation help me?

The aim of this operation is to reduce discomfort and bleeding caused to you by the haemorrhoids.

Are there any risks or possible complications?

These risks apply to all surgery:

• Bleeding: Bleeding from the operation site can happen for up to 1 week. If this bleeding continues and shows no signs of stopping, you may need another operation to stop the bleeding. 

• Risks associated with general anaesthetic: You will be directed to online information, which will explain all about your anaesthesia. Your Anaesthetist (a Doctor with special training in anaesthetics) will discuss this with you.

• Deep Vein Thrombosis – DVT (blood clots in the leg veins) or Pulmonary Embolism – PE (blood clots in the lungs) All adult patients will have their risk of developing a blood clot assessed within 12 hours of admission. Patients who are being admitted for planned surgery may have their risk assessed at a pre-assessment visit.
  
  The Nurse or Doctor who carries out the risk assessment will discuss your risk factors with you and talk you through treatment to reduce your risk.
  
  You will also be given a leaflet, which will give advice about how to reduce your risk of developing a blood clot while you are in hospital.
  
• Infection: Signs of an infection include generally feeling unwell, a temperature or a very smelly discharge from your rectum that is not a poo. This can be treated with a course of antibiotics and you may need to stay in hospital for longer. 

• Incontinence: You may have some leakage of mucus or faeces after your operation, which can cause staining on your underwear. This is due to the gentle stretching of the anus (opening to the back passage) during the operation. This can last for a few weeks and usually needs no treatment. You could wear pant liners to help with this.
  
• Recurrence (further haemorrhoids developing): If this happens, you may need further treatment or another operation.

• Injury to nearby organs, nerves or tissues: If this happens, you may need further treatment or another operation.

• Narrowing of the anal canal. This could mean that passing a poo could be more difficult.

• Faecal incontinence (leakage of stools): This can be temporary or permanent.

• Faecal impaction or constipation: This is where hardened poo becomes lodged in the rectum (back passage). This may be because of discomfort after your surgery, which can worsen after passing poo.
  
  This may make you hold your poo in to try to stop the pain. Holding in a poo is a common cause of constipation. Morphine based pain medicines may also cause constipation.
  
  Drinking plenty of fluids, eating food that is high in fibre, such as bran, will help keep your bowels moving. As well as taking medicines, such as Lactulose or Movicol, which will soften your poo and encourage bowel movement.

What will happen at the pre-assessment clinic?

About 2 weeks before your operation, you will be sent an appointment to attend a pre-assessment clinic. Although on occasion you may have already had your pre-assessment clinic after your outpatient appointment. If this is the case, you will not need another appointment at the pre-assessment clinic.

Your Nurse will tell you if you need to stop taking any of your medication before your operation. Samples of your blood will be taken and you may be sent for an X-ray and an ECG (a heart tracing).

You will be asked about your general health. Your blood pressure, pulse and weight will be checked.

Please remember to bring a fresh sample of your urine with you and all tablets, medicines, inhalers and creams you are using. 

What do I need to do before the operation?

Preparing your bowel is very important before this operation. You might be asked to come in the day before your operation, or on the morning of your operation.

You will be given either oral medication or an enema (medication to empty the bowel). This helps your surgeon to be able to perform the surgery more effectively.

Routine blood tests may have been done in pre-assessment, but if not they will be done before your operation.

You will be given some anti-embolism stockings ‘TED stockings’ to wear before, during and after the operation, this is to help prevent blood clots forming in your legs. After the operation you may be given an injection every day for 4 to 6 weeks which will also help prevent clots after surgery.

Why am I asked not to eat or drink before my operation?

Your Nurse will tell you when you must stop eating or drinking before your procedure. This is very important. You must follow the instructions. Nothing means nothing at all.

If you forget and you do eat or drink anything, you must tell your Doctor or Nurse, as your procedure may need to be postponed (put off) for your safety. This is because when you are unconscious, if your stomach contains food or drink, you may be sick. The vomit could get into your lungs, affect your breathing and cause an infection.

What will happen during my operation?

Your theatre Nurse will check your details again before taking you into the anaesthetic room. If your temperature is below 36°C (98.6°F), the procedure will not start until you are warm. A warm air blanket or jacket may be used to raise your temperature.

In the anaesthetic room, you will meet your Anaesthetist again. A cannula (fine needle) will be placed in the back of your hand or arm so we can give you medication. Sometimes, when medication is injected, it may feel cold and it may sting a little.

An intravenous drip(fluids given directly into your vein) may be attached to your cannula. Your blood pressure will be measured.

Your pulse will be taken and the amount of oxygen in your blood will be measured by attaching a special clip to your finger. This does not hurt.

Your heart rate will be monitored by placing sticky pads on your chest. These are attached to some leads to show a tracing of your heart on a monitor. This is routine and nothing to worry about.

The operation will be carried out under a general anaesthetic (a state of carefully controlled and supervised unconsciousness that means you are unable to feel any pain) or spinal anaesthetic.

HALO: A small narrow plastic tube, known as a proctoscope, with an embedded micro-doppler ultrasound, is placed in the anus. The ultrasound probe is used to locate the exact position of the artery (vessel) supplying blood to the haemorrhoid. This vessel will be located within the rectum (bottom).

Once located, a small dissolvable suture (stitch) will be placed around the vessel that supplies the blood flow. By stopping the blood flow, this should shrink the haemorrhoid, stop any bleeding and reduce pain.

Rectoanal Repair (RAR): This is when the Doppler probe is removed and a running stitch is placed along the length of the prolapsed haemorrhoid. This fixes the prolapsing part of the haemorrhoid by lifting it up and stitching it back to its normal place inside the rectum.

HALO-RAR: This has the combined effect of making a large, sagging haemorrhoid shrink and drawing up the prolapsed haemorrhoid to its correct place within the rectum.

What will happen after the operation?

You will be taken to the recovery room. Specially trained nursing staff will look after you until you are ready to return to your ward.

If at any time you are in pain or feel sick, please let one of the Nurses know and they will give you medication to help relieve it.

You will have an intravenous drip in your hand or arm, through which you will receive fluids to prevent you from dehydrating, until you are able to eat and drink normally again.

Patients are encouraged to keep mobile (within their ability) after the procedure.

You are likely to experience some discomfort following this procedure when the local anaesthetic wears off. The discomfort will get better, but may take up to 6 weeks to resolve completely. Painkillers, laxatives and a 5 day course of antibiotics will be prescribed to take home.

You may experience some bleeding, which is normal. You are likely to see blood on the first bowel movement following the operation.

If you have a bath, we recommend taking a warm water bath several times a day. As this can help reduce the discomfort in your anal area. Do not add bubble bath or soap to the water as this may lead to infection or cause irritation to the area.

You may also find that you have the feeling that you need to have a poo, but you cannot. This feeling may last for up to two weeks. It is important that you do not sit on the toilet to pass something that is not there, as this can lead to further complications.

For the next two weeks, please follow the instructions below. This will help you to heal and to try and avoid putting pressure on your wound:

• No strenuous activity.
• No lifting items over 10lbs (5kg) such as children or heavy bags of shopping.
• No exercise beyond a gentle walk.
• Bathe the area with warm water to soothe and keep it clean.
• Do not apply any creams or ointments, unless they have been prescribed by your surgeon.

Will I be able to open my bowels?

Your bowels will have been emptied prior to your operation. The feeling of not wanting to pass any bowel motion may last for a few days.

You may experience a little discomfort and slight bleeding the first few times you empty your bowel. This is normal and can be expected.

You may also pass some mucus from your anus for about 1 week. 

You may be advised to wear a pad to protect your clothing until these symptoms have settled down.

You should avoid straining when trying to open your bowels. You may be given laxatives to help soften your stools and stimulate (encourage) a bowel motion from the day of your operation.

How long will I be in hospital for?

Every patient is different and recovery times will vary. We recommend that you stay in hospital until you are reasonably comfortable when passing poo. This can take up to 3 to 4 days after the operation.

It is important to try to be mobile as soon as you feel safe to do so. Having good hygiene is important to try to prevent any infection. You are able to take a shower the day after the procedure.

Will I have any sutures (stitches) that will need to be removed?

No. Dissolvable stitches will have been used. There is no need to have these removed, as your body will absorb them over the following weeks.

How long will I need to be off work?

This may vary, but you can usually return to work around 2 weeks after your operation, depending upon the type of work that you do. You should ask your Doctor or GP for advice. If you are taking any medication that makes you drowsy, you must not drive or operate machinery.

You should try to avoid any lifting that may require straining. Most patients require 2 weeks off work, however every patient is different. You should only do what you feel able to do and give your body time to heal.

If you require a ‘Fit note’ for work, please let a member of staff know before you are discharged from hospital.

What should I look out for when I go home?

When you go home, if you notice any of the following:

• Severe pain in the lower abdomen, rectum or lower back or lower back passage.

• High temperature.

• Persistent nausea or vomiting.

• Persistent bleeding from the rectum.

You must contact the specialist colorectal Nurse or seek medical help immediately. Refer to Contacts Section at the end of the leaflet.

How can I help myself?

If you have trouble in controlling your motions(poos) or you have problems with leakage, this may not improve straight away. In some cases, exercises will be recommended and you will be given advice from a Specialist Colorectal Nurse to help with these symptoms.

To help prevent the prolapse returning you should:

• Increase the amount of fluid you drink to at least 6 to 8 glasses a day. This can include water, tea, coffee, fruit juice or soup.

• Try not to become constipated. You may need to consider taking a fibre supplement, such as Fybogel to help prevent constipation.

• Avoid straining.

• Take special care not to become constipated if you become pregnant.

You should increase the amount of fibre in your diet gradually as a sudden increase can cause abdominal discomfort and wind. Below are a few examples of the foods you could introduce into your diet.

• Wholemeal bread, pasta and rice
• Beans
• Lentils
• Vegetables and fruit
• Nuts
• Seeds
• High fibre cereals.

When can I drive again?

You can drive 2 weeks after the operation. However, if you do not feel ready, you should wait until you do.

You should check with your insurance company as policies may vary with individual companies.

When can I play sport again?

You should not go swimming or do strenuous exercise until the area has healed and you feel comfortable to do so.

Lifting heavy weights will have to be avoided following the operation, as this could cause strain.

How long should I wait before I have sexual intercourse?

You should not have vaginal sexual intercourse for a minimum of two weeks after the operation. You should not have anal sexual intercourse for a minimum of six weeks after the operation.

If you have sexual intercourse before this time, it is possible that this will disturb the operation site, delay healing and may even undo the operation.

You should not insert anything into your rectum or vagina (such as tampons) during this time. This is to avoid an increase of pressure on your rectal area, caused by the tampon pushing against it.

Will I have a follow up appointment?

You will have a follow up appointment 8 to 12 weeks after the operation. If you haven’t received an appointment, please call the outpatient department or the ward which you were discharged from, they will be able to check this for you.

Who do I contact if I need any advice?

Any concerns you may have during the 24 hours following your discharge from hospital, please phone the ward to which you were admitted. After 24 hours; please seek advice from your GP.

NHS 111 offers medical help and advice from fully trained advisors supported by experienced nurses and paramedics. Available over the phone 24 hours a day, contact 111.

NHS Choices provides online information and guidance on all aspects of health and health care, to help you make choices about your health.

This patient leaflet has been adapted from information from St Marks Hospital for Colorectal Diseases.

Contact numbers

If you have any worries or concerns during the first 24 hours following your discharge from hospital, please phone the ward to which you were admitted.

After 24 hours, please seek advice from your GP.

University Hospital of North Tees

Ward 28
Telephone: 01642 382828
24 hours a day, 7 days a week

Ward 31
Telephone: 01642 382831
24 hours a day, 7 days a week

Day Case Unit
Telephone: 01642 624168
Monday to Friday, 8:00am to 5:00pm

Specialist Colorectal Nurses
Telephone: 01642 624399
Monday to Friday, 9:00am to 4.30pm

Outpatient Department
Telephone: 01642 383838
Monday to Friday, 9:00am to 4:00pm

University Hospital of Hartlepool

Ward 4
Telephone: 01429 382809
24 hours, 7 days a week

Day Case Unit
Telephone: 01429 522949
Monday to Friday 8:00am to 5:00pm
Non-urgent messages can be left on the answering machine.

This patient leaflet is attributed to St Marks Hospital for Colorectal Diseases.

Patient Experience

North Tees and Hartlepool NHS Foundation Trust would like your feedback. If you would like to share your experience about your care and treatment or on behalf of a patient, please contact The Patient Experience Team who will help you to do this.

This service is based at the University Hospital of North Tees but also covers the University Hospital of Hartlepool, our community hospitals and community health services.