Haemorrhoid Artery Ligation

What does HAL involve?

Haemorrhoid artery ligation (HAL) and Recto-anal repair (RAR) involves using an ultrasound doppler to find and tie off the haemorrhoidal arteries.


This technique works well for haemorrhoidal bleeding and grade 2 to 3 prolapse. However, for grade 4 haemorrhoids where the prolapse is more significant, we recommend a formal haemorrhoidectomy.

HAL-RAR is well tolerated and is associated with earlier return to work.

What are the risks of surgery?

Some degree of bleeding is expected for up to 4 weeks post operatively but the risk of significant bleeding requiring return to theatre is very small.

If the procedure is performed for larger prolapsed haemorrhoids, there is a small risk that the suture may be undone resulting in a prolapsed thrombosed haemorrhoid which can be very painful.

Infection is rare but can occur even several months later. A course of oral antibiotics (Flagyl) is prescribed after surgery to reduce this risk and ease post-operative pain.

Some patients find difficulty passing urine in the first 3 days after HAL-RAR and rarely patients may require a urinary catheter for a short period of time.

It is important that you mobilize early, avoid constipation and use regular pain-killers to avoid this problem. If you feel that you cannot empty your bladder, you should contact us as you may need to a bladder scan +/- a urinary catheter.

Before surgery

Fast from midnight for a morning procedure OR from 7am for an afternoon procedure.

You will be contacted by the hospital the day before your procedure to let you know what time to come in. This is usually 1-2 hours before your procedure to allow for the hospital check-in procedures.

You will be given a fleet enema about an hour before your procedure. This is to empty the rectum before operating.

After surgery

Expect some bleeding especially after opening your bowels for the first time. You will also pass a dressing called Spongistan which is placed inside the anus at the end of the procedure. This helps stop the bleeding and can resemble a large clot when passed into the toilet bowl when you first open your bowels.

There is significantly less pain than a haemorrhoidectomy.

Some degree of pain or stinging may last for up to four weeks after surgery (especially following defecation).

You should take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).

Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.

Stronger pain killers such as opioid anaelgesics (Endone, Codeine) may help in the first couple of days but should be taken sparingly as they can cause constipation which results in more pain when opening your bowels.

It is very important to maintain soft stools after haemorrhoid surgery. This is done by having an adequate intake of fluid and fibre (see Prevention of constipation) as well as taking regular Movicol (1 sachet 1-3 times a day).

Laxatives such as lactulose or coloxyl are not advisable as diarrhoea increases the chance of prolapse. The aim is to have soft stools NOT loose watery stools.

Most patients are worried about opening their bowels especially for the first time. You should not let fear of pain stop you from opening your bowels as this will only make things worse by hardening the stools and causing a spasm of the anal muscles.

If you are finding it difficult to pass soft stools, it may be due to a spasm of the anal sphincter. This can be treated with topical Rectogesic ointment 2-3 times a day. This is an over-the-counter ointment that should be applied into the first 1-2cm of the anus. The easiest way to do this is to wear a disposable non-sterile glove (plastic food-handling gloves are ok) then apply 1.5cm of the ointment using your index finger.

These are an excellent way of relieving the pain especially after opening your bowels. You should put a handful of salt into a shallow bath of warm water and sit in it for 15 minutes. This is both soothing and acts as an antiseptic.

There are no dressings apart from a pad that collects the post-operative blood. You may need to wear a pad for a couple of weeks to prevent staining your underwear.

Ladies’ sanitary pads work well for this purpose and can be used by men and women.

Patients can usually go home on the same day but some may need to be admitted overnight.

Follow up with your surgeon is usually within 4 weeks of your operation. You will be given an appointment before leaving the hospital. If, however, your operation finishes after hours, you will need to contact the rooms for a follow up appointment.

Please note that the full effect of the procedure is not seen before 4 weeks after the haemorrhoidal tissues shrink.