The technique involves the use of a specially designed instrument, which is a modified proctoscope, housings a Doppler transducer, used to locate the arteries. It also has a light and a window through which the suturing is performed. No anaesthetic is used or required because the suturing is performed in the relatively insensitive part of the anal canal, above the dentate line. A long Needle Holder and a "knot pusher" are used for inserting the suture and tying the knots.

Patients are prepared by having fluids only by mouth from midday before the procedure and by using two "Microlax" enemas (Kabi Pharmacia AB). One the night before, and the other two hours before the procedure. The patient is placed in the left lateral position, the area is prepared by applying Xylocaine ointment generously to the perianal and anal regions. An examination is then performed, including procto-sigmoidoscopy. Having confirmed the diagnosis, the patient is then sedated with intravenous Midazolam (Roche).

The instrument is then gently inserted, having first prepared the area with Betadine solution. The arteries are located by listening to the sound transmitted via the "Echo Sounder", which is connected to the instrument, and are then ligated. We have modified the Morinaga technique, which in our opinion, has a greater potential for improving the results.

Firstly, we do not change the position of the patient when doing the left and right sides. This is superfluous and only adds to the discomfort of the patient and prolongs the time of the procedure. We use a technique of suturing which we believe guarantees securing most of the arterial supply to the hemorrhoidal tissue, thus making the procedure highly effective. This technique will be described later. We were fortunate enough to obtain a Color Ultrasound Duplex machine which we used over a six month period. A laparoscopic probe was used to insert in the anal. This machine enabled us to study the anatomy of the area in detail. We were particularly interested in the relationship between the Prostate and the arteries in the male because that organ is the only one potentially liable to be injured by the sutures. The color Doppler showed that the prostate had little chance of being injured.

We were also able to get "before and after" pictures which demonstrated the success or failure of the arterial ligation. These pictures recorded not only the vascular pattern, but also the arterial wave form; disappearance of the wave indicated successful ligation.

The Color Doppler also demonstrated clearly the number and position of the terminal arteries of the Superior Rectal Artery. Anatomy texts generally describe three terminal branches, one on the left and two on the right. Thomson however did correct this misconception after making a detailed study of the blood supply of the anal canal. He showed that there was a variable number of terminal arteries, with an average number of five. He was not able, however, to demonstrate a regular pattern of the vascular anatomy.

However, using the Color Doppler, we were able to determine that there are a constant six terminal arteries, in a constant position - 1, 3, 5, 7, 9, 11 (as viewed in the anatomical lithotomy position) - in the upper anal canal. We believe that this is the first time that this anatomical arrangement has beet reported.

We ligate the arteries, using 2-0 Vicryl, with a special technique alluded to above. The posterior arteries (3 and 5, and 7 and 9) are ligated together with a "double figure of eight" suture on each side. The anterior arteries ( 11 and 1 ) are ligated separately, also with "figure eight" sutures. At the completion of suturing, the arterial sounds will have disappeared. The hemorrhoidal tissue will be observed to commence shrinking immediately. No packing or dressings of any description are required.

Post operatively, patients return to a normal lifestyle almost immediately, eating a normal diet and using their bowels normally. However, we do advise patients not to undertake any strenuous activities for one week. Minimal post operative analgesia is usually required.

Relatively few complications were encountered in this series, making it a very safe procedure.
They are listed in the following table.