Department of Anorectal Surgery, Chaoyang Hospital (West District), Capital Medical University Li Hengshuang
Abstract 51 cases of circular mixed hemorrhoids were treated with injection and "W" plastic surgery. After six months to three years of follow-up, the cure rate was 96% and the improvement rate was 4%. No complications such as bleeding, urinary retention, fecal incontinence, and mucosal ectropion were found. The appearance of the anus is flat, the stool is smooth, and the medium-sized anoscope passes smoothly. The article also introduced the surgical methods and follow-up results in detail, and discussed the reasons for the better curative effect and the deficiencies of the surgery.
Key words injection therapy; "W" plastic surgery; circular mixed hemorrhoids; surgery
Annular mixed hemorrhoids are listed as one of the intractable diseases in anorectal surgery due to their wide range of lesions, complicated operations, and many postoperative complications and sequelae. In order to avoid and reduce complications and sequelae, we are looking for a surgical method that can complete the operation at one time without affecting the function of the rectum and anal canal. Based on the treatment of internal hemorrhoids with injection therapy, the "W" plastic surgery of plastic surgery Introduced into the treatment of circular mixed hemorrhoids, the purpose of completing the operation at one time without affecting the function of the rectum and anal canal is achieved. From June 1989 to June 1993, we used this method to treat 51 cases of circular mixed hemorrhoids, with a cure rate of 96%. The report is as follows.
1 clinical data
1.1 General information: 51 cases in this group, 14 males (27.5%), 37 females (72.5%). Male: Female = 1:2.64. Among them, 17 cases were 20-39 years old, 17 cases were 40-49 years old, 15 cases were 50-59 years old, and 2 cases were over 60 years old. There were 21 cases of internal hemorrhoids with degree III. There were 37 cases of external hemorrhoids with partial varicose veins and 14 cases with varicose veins and partial fibrous skin tags. There were 16 cases of papillitis and nipple hypertrophy, 5 cases of rectal polyps, 9 cases of anal fissure, 4 cases of anal stenosis, 28 cases of rectal mucosa laxity or internal prolapse, 11 cases of rectal protrusion, and 1 case of perianal skin itching.
1.2 Diagnostic criteria: There are more than 4 circular mixed hemorrhoids or hemorrhoids, and the mutual fusion involves more than 1/2 of the anal margin. The number of hemorrhoids in this group: 4 in 18 cases, 5 in 14 cases, >6 in 19 cases. Disease scope: >1/2 in 18 cases, >2/3 in 13 cases, >3/4 in 20 cases.
1.3 Operation method
1.3.1 Take the right side decubitus, after the simple sacral anesthesia takes effect, treat the internal hemorrhoids with injection therapy. Prolapse of the rectal mucosa, polyps and other intrarectal lesions and other lesions outside the rectum are treated together.
1.3.2 Treatment of external hemorrhoids: In order to facilitate the operation, the operation is performed in the order of down and up, right and left. The position can be determined according to the habit of the surgeon. We are accustomed to using the right decubitus position to start the operation at 7 o'clock. For example: ①The first incision: Make a radial cut at 7 o'clock in the anal margin, up to the lower edge of the tooth line, and down to 0.5-1cm from the lower edge of the external hemorrhoid, and cut the skin to the subcutaneous. ②Second incision: the upper end is cut obliquely to the lower left from the midpoint of the first incision, and is basically flat with the lower end of the first incision. A triangular flap of about 45-60 degrees is formed between the first and second incisions, which we call the inferior flap. Free the "lower skin flap" from the skin, cut off the excess connective tissue and venous plexus under the skin, lift the flap up, and sew the top corner of the flap to the upper end of the first incision with 3-0 gut or #0 silk thread. ③Third incision: Make a third incision in parallel with the second incision about 0.5cm away from the second incision. Its upper end starts from the lower edge of the tooth line, goes down to the lower edge of the external hemorrhoid 0.5cm, and reaches the subcutaneous depth. And remove the excess skin and subcutaneous tissue between the second and third incisions. ④The fourth incision: the upper end starts at the lower edge of the tooth line, at about 1.0cm away from the third incision, the white upper left obliquely moves to the lower right, and ends at the midpoint of the third incision, so that the upper end is formed between the third and fourth incisions. , The bottom is the top, the triangular flap of about 45-60 degrees, we call it the epithelial flap. Free the "epithelial flap" from the subcutaneous, cut off the excess subcutaneous connective tissue and venous plexus, pull down the top of the flap, and sew on the lower end of the third incision. ⑤ Fifth incision: Make a fifth incision parallel to the fourth incision about 0.5cm away from the fourth incision. The upper end starts at the lower edge of the tooth line, and the lower end is flush with the lower end of the third incision, and the excess between the fourth and fifth incisions is removed. The skin and subcutaneous tissue of the skin, and then follow step ② to redo the second "lower skin flap". Then repeat steps ①-⑤ until all the annular external hemorrhoids are removed. ⑥ 1-2 stitches of reinforcement suture between the edges of adjacent flaps. When suturing, bring the epithelial tissue to increase the tensile strength. Prevent the skin flap from tearing when stool.
1.3.3 Precautions: ①Due to the different sizes of hemorrhoids in various parts, during the operation of suturing skin flaps, they will appear in individual parts.
Now the "cat ears" can be properly trimmed, so that the suture flaps are inserted into each other, flat and smooth. ②After the flap is sutured, perform a digital rectal examination to test the tightness of the anal canal. If there is obvious tension, perform the lysis of the lower edge of the internal sphincter and the underside of the external sphincter at 6 o'clock or 5 or 7 o'clock. To the degree that the anal canal can accommodate the index finger loosely. ③Appropriate local pressure bandaging of the incision to prevent postoperative incision bleeding and swelling. ④ To prevent postoperative wound pain, apply long anesthetics locally.
1.4 Postoperative treatment: ① Intake liquid or semi-liquid food for 2 days. ② Control stool for 48 hours. ③ To prevent dry stools, enema can be used before the first bowel movement after surgery to prevent dry and hard stools and excessive force to tear off the skin flap. ④Sit bath after defecation, Yuhong Shengji Ointment
The dressing was changed until the incision healed. ⑤For silk sutures, the sutures should be removed 5-7 days after the operation, or after the white line falls off, the residual sutures should be removed 10 days later.
2 Efficacy analysis
2.2 Curative effect criteria: ①Cure: flat anal margin: no internal and external hemorrhoids, or found hemorrhoids but diameter <0.5cm; ②Improvement: internal and external hemorrhoids and hemorrhoids diameter
2.3 Results: 51 cases in this group, 49 cases were cured, the cure rate was 96%, 2 cases were improved, and the improvement rate was 4%. 02.4 Postoperative complications and sequelae: 51 cases in this group, no urine retention, bleeding, infection and The skin is necrotic. One case had skin flap avulsion at 12 o'clock due to dry and hard stools and excessive defecation. In 2 cases, the sutures between the flaps were avulsed at the point 11-1. These 3 cases (S.g) had local dressing changes and healed within 21 days. The remaining 48 cases ((94.1) incisions healed at first stage. Followed up for half to 3 years, they reported smooth defecation, no fecal incontinence and wet anus. On digital examination, the anal canal felt normal tightness, the appearance of the anal rim was flat, no mucosal ectropion, and medium anus The mirror passed smoothly.
3.1 Annular mixed hemorrhoids are the most complicated type of hemorrhoids. The internal hemorrhoids and hemorrhoids are numerous and large, while the external hemorrhoids are in the form of annular varicose veins or connective tissue hyperplasia. The operation is complicated and there are many postoperative complications. It has been regarded as a major problem in anorectal surgery. It is listed as one of the intractable diseases in anorectal department. At present, the treatment of mixed hemorrhoids is mostly used in China by external stripping and internal ligation. The operation adopts multiple incisions, small wounds, ligation of the mother hemorrhoid area, and preservation of the anal canal skin bridge to reduce postoperative complications. However, the effect on circular mixed hemorrhoids is not good. Many scholars at home and abroad believe that 3/4 of the skin of the anal canal should be preserved during the operation, and the skin of the anal canal should not exceed 1/4 of the circumference of the anus in one operation, otherwise the operation should be divided into stages. The scope of annular mixed hemorrhoids is more than 1/2' of the circumference of the anus, and they are accompanied by severe internal hemorrhoids. They are resected by external stripping and internal ligation at one time, and anal canal stenosis is usually left after the operation. The use of segmented resection and ligation, due to the number of operations, prolongs the treatment cycle, and increases the patient's pain. Whitehead's modified surgery is mostly used abroad, and there are many complications. Barrios  (1979) 41 cases of modified circumcision, urinary retention 32%, bleeding 5%, stenosis, intestinal mucosal ectropion and anal incontinence 10 %. Wolff  began to do modified skin circumcision in 1963. By 1983, a total of 556 cases of this operation were performed, and 484 follow-up results were reported in 1988. There was no surgical death, no recurrence, and the incidence of early and late complications was 12.2%. From June 1989 to June 1993, based on the application of injection therapy for internal hemorrhoids, we used plastic surgery's "W" plastic surgery for the treatment of circular mixed hemorrhoids. 51 cases of circular mixed hemorrhoids were treated with this surgical method. The cure rate was 96% (49/51), improvement rate 4% (2/51). The operation was completed at one time, shortening the treatment cycle. Except for 3 cases where the flaps or sutures between the flaps were avulsed in the early stage, no complications such as urine retention, bleeding, infection, skin necrosis, and no anus were found. Tube stenosis, mucosal eversion, fecal incontinence and other sequelae. Compared with Barrios and Wolff surgery, the incidence of complications and sequelae is lower (see attached table). "W" plastic surgery sutures wounds in a "Z" shape, so it has the same advantages as continuous "Z" plastic surgery . It is suitable for loosening cord stripe scar contracture, resetting of misplaced tissues, preventing lumen cord stripe ring stenosis and scar contracture formation (3), it can minimize postoperative incision fatigue scar contracture, properly applied, there are Extend the long axis of the flap. Therefore, the application of this operation to treat circular mixed hemorrhoids can smooth the anal margin and avoid postoperative anal stenosis to the greatest extent. We believe that the purpose of the treatment of external hemorrhoids should be to remove the diseased tissue, restore the normal anatomy of the anus, and maintain the normal function of the anus. We introduced "W" plastic surgery into the surgical treatment of circular mixed hemorrhoids. After clinical verification, the expected results have been achieved, which shows that the operation is desirable.
3.2 Treating internal hemorrhoids is a prerequisite for treating external hemorrhoids. At present, due to the improvement of injection methods, the cure rate of third-degree internal hemorrhoids has reached more than 95.5% , making it possible to treat circular mixed hemorrhoids with injection therapy and "W" plastic surgery. In patients with circular mixed hemorrhoids, due to the prolapse of internal hemorrhoids, the connective tissue of the anal margin proliferates, and pathological shortening of the anal canal is common clinically. The loose or prolapsed rectal mucosa is fixed by injection therapy, the internal hemorrhoids are retracted, the slipped anal cushion is reset, the anatomical structure of the lower rectum and anal canal is restored to the approximate normal anatomical position, and the pathologically shortened anal canal The increased length of the dentition allows the operation to be completed under the dentinal line, which overcomes the shortcomings of the traditional hemorrhoid circumcision that removes the dentate line and the skin of the anal canal together. It may be that sensory incontinence and rectal mucosa did not occur in this group of cases. Reasons for eversion.In addition, because the surgical incision is below the dentinal line, compared with Whitehead's modified operation, the internal hemorrhoid vascular plexus which is easy to hemorrhage is not injured, and the incision is appropriately compressed after the operation. This may be the reason why this group of cases did not have bleeding.
3.3 We applied long-acting anesthetics during the operation. For those with anal canal stenosis, we used the lower edge of the internal sphincter muscle and the subcutaneous lysis of the external sphincter. This may be to control the postoperative sphincter spasm pain and prevent postoperative anal pain. Effective measures for marginal edema, this has a certain effect on maintaining the appearance of the anus after the operation, preventing postoperative anal stenosis, and also preventing the early postoperative complications-urinary retention.
3.4 Insufficiency of the operation: The operation is still too complicated, time-consuming, and requires good anesthesia cooperation.
1 Barrios G, Khubchandani M. Whitehead operation revisited. Dis Colon Rectum, 1970,22:330--332
2 Wolff BG, Culp CE. The whitehead hemorrhoidectomy: An unjustly maligned procedure. Dis Colon Rectum, 1988,31:588-589
3 Song Ruyao, etc. Cosmetic Plastic Surgery. Beijing: Beijing Publishing House, 1990.132-137
4 Shi Zhaoqi. The experience of "Xiaozhiling" in the treatment of hemorrhoids in the third stage. Journal of Traditional Chinese Medicine, 1980, 21(7): 24
Journal of Colorectal Surgery, Volume 1, Issue 2, 1995 (Received Date: 1994-10-26)
Address: Department of Anorectal Surgery, Chaoyang Hospital, Capital Medical University, No. 5, Jingyuan Road, Shijingshan District, Beijing