Six steps of pain management in anorectal surgery
One step before surgery
Method A: Determine the type of disease and the patient's mental state before surgery; diet, sleep and bowel control; advance medication + psychological intervention.
B Commonly used drugs: Deanxit, Alprazolam + Citalopram.
C Objective: To relieve the doctor-patient confrontational mood, reduce the patient's anxiety, fear and sensitivity, and improve the tolerance to pain.
Two steps. Intraoperative
A Method of anesthesia: basic + sacral canal, basic + epidural, basic + epidural, basic + spinal anesthesia, basic + local anesthesia.
Local anesthesia: three methods: preoperative, intraoperative, and postoperative.
B Commonly used drugs: Liyuexi, propofol, sevoflurane; lidocaine, bupivacaine, ropivacaine: methylene blue, compound lidocaine, morphine suppository.
C Objective: No pain in the anorectum, perineum and sacrococcygeal area; muscles are fully relaxed; the patient is sleeping during the operation, and there is no memory (amnesia) after waking up during the operation; local long-acting anesthesia for 5-7 days.
Three steps. Postoperative
Method A: continuous analgesia, medication + attention shift; analgesic pump, anti-infection.
B drugs: morphine, dolantin, dezocine, tramadol, paracetamol, tramadol, naproxen sodium; antibiotics.
C Objective: To transfer patients' excessive fear of anal wounds (distraction); to prevent and relieve pain caused by muscle spasm, wound edema and infection after anal canal surgery.
Four steps. Urinate
Method A: control, induction (sound of running water), medication, catheterization.
Drug B: Chinese patent medicine, naftopidil.
C Objective: To relieve the urination and defecation caused by postoperative anal trauma; after the bladder is full, relax the urethral sphincter.
Five steps. Stool
Method A: control diet, clean enema, dredge + medicine.
B drugs: Taining suppository, Taining ointment, Fusong, Maren pills, Kaisailu, paraffin oil.
C Objective: Defecation 3 days after operation, to keep the stool soft and smooth, and to reduce the stimulation of the anal wound.
Six steps. Dressing change
Method A: Anesthesia, Chinese medicine fumigation and washing, physical therapy (red light, microwave), delicate and gentle techniques, the dressing changer observes the operation process and grasps the dressing process during the operation. (No need because there is no condition, no need to do well because there is no ability)
B drugs: dicaine, iodophor, hemorrhoids fumigation powder, Taining ointment, Jingwanhong ointment, Kangtai ointment, chitosan ointment.
C Objective: To check the condition of the incision wound; clean and disinfect to prevent infection; organize and guide the wound to heal well, reduce scar formation; reduce pain.
Pain in anorectal surgery
According to the classification of diseases, the degree of pain from small to large:
Rectal polyps (including adenomas)-simple internal hemorrhoids (including PPH)-thrombotic external hemorrhoids-mixed hemorrhoid incarceration (especially in women)-simple anal fissures-perianal abscesses-anal fistulas-sacral hairs Sinus-rectal prolapse-complex anal fistula-simple mixed hemorrhoids-circular mixed hemorrhoids.
Classified by age and mental state, the degree of pain from small to large:
Infants-children (3-5 years old)-elderly (including the elderly over 60 years old, Alzheimer's disease)-female-male (big boss is smaller than small boss).
The radical cure concept of hemorrhoids
Conditions for radical cure: obvious bleeding, prolapse, pain and other clinical symptoms of hemorrhoids. After conservative treatment, they still often occur, causing pain and complications, affecting life and work. The diagnosis of hemorrhoids by anorectal professional doctors confirms the need for surgery. treatment.
Radical treatment: three-level treatment, A suture of the mucosa of the hemorrhoids (the upper end of the hemorrhoids should also be sutured, especially in young people) or PPH; B internal hemorrhoids, mixed hemorrhoids, external hemorrhoids and connective tissue resection (mainly in the mother hemorrhoid area) ; Partial loosening of the internal sphincter (changing the structure and tension of the anal canal).
Achieve the goal: A. The symptoms and signs of anal discomfort completely disappear; B. Under normal life and work conditions, no pain, bleeding and prolapse symptoms, bad irritation such as spicy food, fatigue, dry stool, etc., mild symptoms in the anus, life improvement or The relief disappeared after 2-3 days after drug treatment; C. Although I sometimes feel uncomfortable (eczema, anorectitis), it is not a manifestation of hemorrhoids and does not require additional surgical treatment.
Cystogenic anal fistula
Currently in the scope of refractory and recurrent anal fistula
We believe that its onset is different from the formation of general anal fistulas. Because of the cystic lesions around the anorectum (dermoid cysts, epidermoid cysts, etc.), affected by the constant changes in internal and external pressure, they continue to follow the interstitial space (mainly muscle space). Extending to the submucosa of the anorectal canal (especially in the posterior midline position of the anal canal) infection and ulceration to form a fistula.
Diagnosis and treatment methods
Essentials of surgery
A Find the inner opening or the part close to the cyst cavity, cut the inner opening and fistula tube, fully cut the scar and muscle tissue below the fistula, generally need to cut the anal canal and anal straight ring (we generally use electricity along the inner opening and fistula Cut directly into the cyst cavity); B try to remove the wall of the cyst, especially within 3 cm of the inner orifice of the rectum near the anal canal, the upper end cannot be removed, the inner wall can be scraped off, 99.7% anhydrous alcohol infusion for 2-5 minutes, incision The cysts are separated and fully drained.
Rectal prolapse - should be called primary anal incontinence
It is a congenital cause of dysplasia of the internal sphincter in the anal canal (anal straight ring), causing anal incontinence and rectal prolapse. Patients can have other dysplasias: mental retardation, organ displacement and deformation, and multiple rectal polyps.
Prolapse can be controlled by artificially forming the internal anal sphincter. It may be the only disease that requires reduction of the anal canal in anorectal diseases. We generally adopt three levels of treatment: A: three-column suture of the rectal mucosa; B: internal spiral suture at the straight anal ring; C: external anal sphincter ring contraction. The lateral femoral fascia ring can be used to shrink, and the effect is good.
Early radical treatment of anal fistula and abscess in infants
Constipation-should belong to the treatment of anorectal diseases
The diagnosis of constipation is qualitatively different from intestinal mechanical obstruction.
Various surgical treatments at home and abroad have poor results.
Often accompanied by symptoms and signs of mental, neurological, and endocrine disorders, it should be reversed, that constipation is a mental, neurological, and endocrine disease, manifested in the digestive system (especially the lower digestive tract and anus), normal gastro-colon reflex, sigmoid colon, rectum , The coordinated bowel reflex of the anus, the function is obviously reduced.
Clinical manifestations of intrarectal mucosal prolapse, feeling of falling anus, feeling of blockage, thinning and deforming of stool (the anorectal is not narrowed during digital examination, caused by insufficient relaxation of the internal anal sphincter during defecation), feeling of incomplete defecation, accompanied by mental symptoms Hair, light and heavy. After counseling by a psychologist, patients with anxiety and depression can get better or disappear with anti-anxiety and anti-depressive treatment. We believe that the clinical signs and imaging examination of rectal mucosal prolapse are artifacts. Through the treatment of a large number of patients with external rectal prolapse and severe internal hemorrhoids prolapse, it was found that after more prolapsed rectal mucosa was included in the anus, the patient did not have a significant sense of falling, blockage, or incomplete defecation, which fully shows that there is no rectal mucosal prolapse This independent disease.
The occurrence factors are similar to the formation of anal fistula. Sinus tracts occur and form mostly in adolescents (males), and females (rarely) can sometimes be older, which may be related to the wide screens on the waist and hips and the unique physiological structure of the gluteal cleft tract. The bioionization of the sacrococcyx and the sharp change of local positive and negative pressures, the shed hair or other ionized fragments impact the upper end of the gluteal cleft with the pressure changes, forming needle-tip-sized concave holes and sinuses (more than 1-6), penetrating the skin, The subcutaneous tissue and superficial fascia reach the presacral fascia on the surface of the sacrum and terminate. Due to the presence of foreign bodies and local infection, the sinus tract can spread up and down, left and right, and deep on both sides of the tailbone. The ulceration and discharge of pus can be improved or the inflammation subsided by anti-inflammatory needles. The sinus tract is temporarily closed and the symptoms disappear. It is more common in people with wide body buttocks and more body hair. The incidence is more common in European and American countries than in Asian countries, which is called jeep disease.
Generally, the sinus is single, rarely multiple (there may be two or more upper and lower), sometimes it can be connected to the coccyx synovial sac, but it should be distinguished from the sinus formed by the infection and rupture of the sacrococcygeal cyst. Magnetic resonance can confirm the diagnosis And differential diagnosis.