Rubber band ligation (RBL) is a simple and less invasive procedure for treating grade 1 to 3 hemorrhoids. The procedure entails using small elastic bands to restrict the blood supply to the hemorrhoids, causing them to shrink and eventually fall off.

The concept of ligation as a treatment option for hemorrhoids dates to the time of Hippocrates. Hippocrates, Celsus, and Galen all suggested ligation using a tight thread to treat hemorrhoids [3–5]. However, modern techniques for effective hemorrhoidal ligation (without resection) were not introduced until the middle of the 20th century. In 1963, James Barron described RBL as an office-based procedure for the treatment of stage I to III hemorrhoids [6]. He was inspired by Paul C. Blaisdell, who described the application of rubber bands for hemorrhoids using an umbilical cord ligator in 1958 [7]. Barron introduced the homonymous ligator (Barron ligator) and described technical steps that remain valid today. This procedure can be applied using an endoscope with a forward view or retroflexion, or without an endoscope and using a suction elastic band ligator or a forceps ligator. However, surprisingly, for half a century, the core component of this procedure has been used without major modification from that of the initial device.

RBL is not a perfect procedure, and common adverse effects include pain and bleeding. Studies have reported the frequency of postoperative pain after RBL as 8% to 80%. Because sensitivity to pain changes along the dentate line, the degree of pain varies depending on the level of ligation, which can be affected by the surgeon’s proficiency and technique. Delayed bleeding after RBL normally occurs after 10 to 14 days and is probably related to the sloughing of ligated hemorrhoids before the completion of the healing process [8, 9]. Delayed bleeding is not common, but can be critical in rare cases because it can become a massive lifethreatening hemorrhage.

Kang et al. [10] compared treatments using RBL and the BANANA- Clip (Endovision), a newly designed nonabsorbable polymer ligating clip with a rectangular-shaped applicator. The ligation of hemorrhoidal piles using the BANANA-Clip works on the same principle as RBL—namely, it cuts the blood supply to hemorrhoids, which causes them to shrink and eventually fall off. The BANANA-Clip is a slightly modified version that uses a similar material and applicator as those used in RBL. However, these small modifications can produce better results by improving the convenience and efficiency of the procedure. The shape of the BANANA-Clip and the applicator are thought to be better than RBL for visualizing the pile and ligation at the exact location indicated by the surgeon. The BANANA-Clip holds the pile more firmly, which facilitates vascular endothelial injury and subsequent spontaneous healing, and reduces the frequency of premature sloughing.

Although the study design was retrospective, Kang et al. [10] reported promising results for the BANANA-Clip, such as a significantly lower incidence of delayed bleeding and similar postoperative pain. More large-scale follow-up studies are expected to confirm these results, as the BANANA-Clip becomes accepted as an innovative solution for hemorrhoidal pile ligation.