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THD (Transanal Hemorrhoidal Dearterialization)

Minimally invasive hemorrhoid technique with Doppler-guided ligation of arteries supplying hemorrhoids and mucopexy for prolapse.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Genel Cerrahi department. Book Appointment →

What is THD (Transanal Hemorrhoidal Dearterialization)?

Transanal hemorrhoidal dearterialization (THD) is a minimally invasive technique developed by Antonio Longo (1998) using Doppler ultrasound for selective ligation of hemorrhoidal arteries.

Mechanism: ligation of 6 terminal branches of superior rectal artery 2–3 cm above the dentate line, reducing arterial inflow and decongesting hemorrhoidal cushions; combined with mucopexy lifts the prolapsed mucosa.

Indications: grade II and III internal hemorrhoids, grade IV in selected cases; particularly suitable for elderly patients, anticoagulated patients, those with high pain tolerance issues.

Advantages over Milligan-Morgan or stapled hemorrhoidopexy: less postoperative pain, no anal sphincter injury, lower stenosis risk, quicker return to activities; equivalent recurrence rates.

Symptoms

Bleeding hemorrhoids: bright red blood with defecation, blood on toilet paper, blood drips into toilet bowl
Hemorrhoid prolapse: tissue protruding from anus, requiring manual reduction (grade III), permanent prolapse (grade IV)
Anal pain (especially with thrombosis), itching, burning sensation
Mucous discharge, soiling, hygiene difficulties
Tenesmus, feeling of incomplete evacuation
Symptoms triggered by straining, prolonged sitting, constipation
Anemia signs in chronic blood loss (fatigue, pallor, pica)
Postoperative pain (less than traditional hemorrhoidectomy)
Mild postoperative bleeding, urinary retention (transient)

Risk Factors

Chronic constipation and straining
Pregnancy (especially third trimester)
Obesity
Sedentary lifestyle and prolonged sitting
Low-fiber diet
Heavy lifting, strenuous physical activity
Family history of hemorrhoids
Aging (increased risk after age 50)
Chronic diarrhea
Liver disease with portal hypertension
Anal intercourse

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Recurrent or persistent rectal bleeding (any age)
  • Painful hemorrhoid with thrombosis (urgent treatment within 72 hours)
  • Permanent prolapse not reducing manually (grade IV)
  • Anemia attributed to chronic hemorrhoidal bleeding
  • Symptoms not responding to lifestyle modifications and medical therapy
  • Suspected colorectal cancer or other GI pathology (rule out before hemorrhoid surgery >40 years)
  • Quality-of-life impairment due to chronic symptoms
  • Postoperative concerns: persistent pain, severe bleeding, urinary retention

Treatment Methods

01
Preoperative evaluation: detailed history, physical examination, anal inspection and digital rectal examination, anoscopy and proctosigmoidoscopy
02
Colonoscopy: in patients >40 years or with red flags (anemia, weight loss, family history) to rule out malignancy
03
Risk optimization: management of constipation (high-fiber diet, fluids, stool softeners), discontinuation of antiplatelets/anticoagulants per protocol
04
Anesthesia: general or spinal/epidural anesthesia preferred over local for patient comfort
05
Surgical technique: lithotomy or prone jackknife position, prophylactic antibiotics (cefazolin or metronidazole)
06
THD procedure: Doppler-equipped proctoscope inserted into anal canal, identification of arterial signal (6 hemorrhoidal arteries), suture ligation with absorbable suture (vicryl 2-0) 2–3 cm above dentate line
07
Mucopexy: continuous suturing for prolapsed mucosa lifting; especially useful in grade III–IV; longitudinal suture line
08
Confirmation of ligation: post-ligation Doppler verification of cessation of arterial signal
09
Postoperative care: same-day discharge or 24-hour stay, pain management with acetaminophen and NSAIDs (limited opioid need)
10
Bowel management: high-fiber diet, stool softeners (psyllium, lactulose), adequate fluid intake to prevent constipation
11
Sitz baths: warm water sitz baths 2–3 times daily for 7–10 days; soothing and hygiene benefit
12
Topical therapy: nitroglycerin 0.2% or diltiazem 2% ointment for sphincter spasm; lidocaine ointment for symptomatic relief
13
Recovery time course: return to work in 3–7 days (sedentary jobs), full recovery in 2–3 weeks, complete healing in 4–6 weeks
14
Follow-up: outpatient assessment at 2 and 6 weeks; symptom assessment, anal examination
15
Complications: pain (mild to moderate, less than other techniques), bleeding (5–10%, usually self-limited), urinary retention (5–10%, transient), thrombosis (1–3%), recurrence (5–15% over 5 years)
16
Long-term outcomes: success rate 80–95% for grade II–III at 5 years; recurrence higher in grade IV (15–25%)
17
Lifestyle modifications: maintain high-fiber diet (25–35 g/day), adequate fluid intake (8 glasses/day), regular physical exercise, avoid prolonged sitting
18
Patient education: warning signs of complications, importance of bowel habits, when to seek medical attention
19
Multidisciplinary follow-up: colorectal surgery, gastroenterology (for IBS or chronic constipation), nutrition (dietary counseling)

Which Department to Visit?

You can visit our Genel Cerrahi department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.