Rubber band ligation of internal hemorrhoids has been a mainstay of surgical practice for over 50 years. A number of published trials have concluded that ligation is more effective than other non-surgical methods of hemorrhoidal obliteration, such as infrared coagulation or injection. Surgery is reserved for patients with significant external hemorrhoidal components. Rubber band ligation is easily performed in the office, is cost effective, requires no anesthetic, and causes little discomfort for the patient.

Two significant innovations have combined to make hemorrhoidal ligation technically simpler, less uncomfortable for the patient, and more convenient for all concerned – the Saeed ShortShot Multi-Band Hemorrhoidal Ligator and the TriView anoscope.

In 2002, Cook Endoscopy (Winston-Salem, NC) released the Saeed ShortShot Multi-Band Hemorrhoidal Ligator, which is a disposable multiple-fire suction ligator. The ShortShot contains four pre-mounted rubber bands that are individually released.

This technique avoids the need to reload the conventional McGiveney ligator between each firing, which saves time and avoids frustration. It also avoids the need for an assistant to reload the ligator.

At the same time as the ShortShot ligator was released, I designed and developed a unique anoscope, allowing all three internal hemorrhoids to be ligated at the same time. The new anoscope avoids the need to remove and reinsert the instrument multiple times, as in a conventional single-slot anoscope. The TriView anoscope contains three lateral apertures in the left lateral, right anterior, and right posterior quadrants, the normal anatomic location of internal hemorrhoids. Once the anoscope is inserted, each of the three internal hemorrhoidal complexes is exposed in its normal anatomic location, making “synchronous” ligation of all three complexes quicker, easier and more accurate.

In a prospective randomized trial, I demonstrated that “synchronous ligation” using the new anoscope resulted in less discomfort for the patient and decreased narcotic requirements, compared to multiple conventional ligation. The improved outcomes are a result of avoiding repeated anoscope insertions, and by permitting optimal placement of the rubber bands, away from the sensitive anoderm. Symptomatic relief using the new technique was similar to conventional three-quadrant hemorrhoidal ligation, resulting in complete symptomatic resolution in over 85% of patients.

Optimally, multiple hemorrhoidal ligation is performed immediately after a colonoscopy, when more serious pathology in the proximal colon and rectum has been excluded. With the patient already sedated, lying in the left lateral position and with a full bowel prep, this is the ideal time to ligate symptomatic internal hemorrhoids. This technique is very popular with patients, who appreciate the convenience of combining colonoscopy with a therapeutic “mini-hemorrhoidectomy,” at the same visit. By avoiding surgery and minimizing discomfort and time off work, the technique is simple, safe and cost-effective.

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