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Doppler-guided haemorrhoidal artery ligation is a minimally invasive technique for the treatment of symptomatic haemorrhoids, but is not effective in fourth degree haemorrhoids. Aproctoscope was designed to allow combined haemorrhoidal artery ligation and transanal recto-anal repair. We report our experience with thisprocedure.Theprocedure was performed on 100 consecutive patients with fourth degree haemorrhoids from 2006 to 2008. Other symptoms were bleeding in 80 cases and pain in 71 cases. Nineteen patients hadpreviously been treated for haemorrhoids. All patients were evaluated at 2, 6, and 12 months, and then annually.The mean operative time was 32 min. On average, nine ligatures per patient were placed. Eighty four patients were discharged on the day of operation. Nine patients developed early postoperative complications: pain in six, bleeding in four, dyschezia in one and thrombosis in three. Late complications occurred in four patients, and were managed conservatively. Recurrence was observed in nine patients after a mean follow-up of 34 months.Doppler-guided haemorrhoidal artery ligation and recto-anal repair is easy to perform and safe. Theprocedure should be considered as an effective alternative for the treatment of fourth degree haemorrhoids.