1. General information: 63 cases in this group, 41 males and 22 females. The age ranged from 17 to 72 years old, with an average of 41.5 years old. The course of disease was 1 to 38 years, with an average of 12 and a half years. There were 42 cases of circular mixed hemorrhoids, mainly internal hemorrhoids, 21 cases of circular internal hemorrhoids, and the internal hemorrhoids of internal hemorrhoids or mixed hemorrhoids were all grade III or IV, and there were 1 or more of them Huge internal hemorrhoids (2.7cm×2.1cm or more). All 63 cases were treated with drugs, 28 of them had been treated with sclerotherapy, 5 had hemorrhoid band ligation, 8 had a history of hemorrhoidectomy, and 6 had a history of hemorrhoidectomy twice.
2. Equipment: Johnson & Johnson’s disposable hemorrhoids stapler, including 39 PPH01 type and 24 PPH03 type, purse string and hemostatic thread are Johnson & Johnson’s "2-0" Prolene with needle thread on both ends and "3/0" "Victory can absorb the thread.
3. Surgical methods: (1) Preoperative preparation: oral compound mannitol half a day before surgery for bowel preparation, 6h fasting before surgery, 4h water deprivation, bladder lithotomy under spinal anesthesia, routine disinfection and draping; (2 ) Placement and fixation of anal canal dilator: Use 4 non-traumatic forceps to hold the corresponding anal marginal skin of the 4 largest internal hemorrhoids. The clamping distance and the amount of tissue vary with the size of the hemorrhoids, so that the internal hemorrhoids can be pulled just right Note: ①After inserting the anal canal dilator, the exposed length of the hemorrhoids is appropriate to ensure the suspension effect. ②Avoid too much hemorrhoids in the anus to ensure the vision when sewing the purse string. After determining the appropriate distance and the force of the clamping tissue, fix the anal canal dilator with one stitch at 2, 5, 8, and 11 points. (3) Determination of the position of purse-string suture: comprehensively determined by the upper edge of the hemorrhoid, the size of the hemorrhoid or/and the position of the dentate line. The upper edge of the hemorrhoid is the main positioning basis. For the dentate line is fuzzy and visible, refer to the size and dentate of the hemorrhoid For the dentate line that has completely disappeared, the upper edge of the hemorrhoid is the main basis, and the size of the hemorrhoid is determined by reference; for the huge hemorrhoid, in order to ensure the recovery effect, the upper part of the design is designed to be removed. Purse-string suture is generally determined at 0.5cm～1.0cm of the upper edge of the largest hemorrhoid. (4) Purse-string suture: Using a rotary anal mirror suturing device, the needles are sutured evenly along the submucosa of the rectum from the position of the largest hemorrhoids, usually 6-8 stitches. The starting point of the second purse-string is in the first double purse-string suture. The opposite side of the needle starting point of a purse, the position is about 0.5 ~ 1.0cm above the first purse. (5) Push the hemorrhoid tissue: loosen the traction forceps, and use the index finger or non-traumatic forceps to wrap the gauze to push the hemorrhoids and the prolapsed anal canal tissue into the rectum as much as possible. This link cannot be ignored. When sewing the purse, hold it deeply in the submucosa It is equally important and directly related to the width of the cut tissue. (6) Tighten the firing: extend the opened stapler, tighten the purse-string, continue to pull the purse-string, and tighten the stapler until it is fired at the tightest state. This step emphasizes that one must continue to pull the second. The stapler should be fired after it is received the tightest. (7) Check for hemostasis: carefully check the anastomotic stoma with a rotating anal mirror suture ligator. Whether it is active bleeding or bleeding, it is sutured in a figure 8 with 3/0 absorbable Vicryl thread to completely stop bleeding. (8) Postoperative treatment: Observe the integrity and width of the excised tissue, use intravenous antibiotics for 3 days after the operation, and the fluid volume on the same day does not exceed 1000ml. After urination and exhaust, you can enter a semi-liquid diet. The postoperative hospitalization is 1 to 4 days. , An average of 2.5d. Outpatient follow-up.
1. Efficacy: All the hemorrhoids prolapsed from the anus in all patients after the operation are all retracted, and the effect is significant. The resected tissue was intact in 62 cases, incomplete in 1 case, uniform in width in 34 cases, inhomogeneous in 29 cases, width was 2.1-4.6cm, with an average of 3.6cm.
2. Complications and treatment: Difficulty urinating, abdominal distension and discomfort, pain, swelling in the anus, and burning sensation are the main complications after PPH. They often occur at the same time or alternately, and become the main pain of the patient that day. These discomforts are all in Significantly improved after 10 to 36 hours, and gradually disappeared from 1 to 16 days. Take 2 tablets of colotrex 5-8h after operation to relieve the above symptoms. Fifteen patients had blood in the stool from 1 to 12 days after the operation, which was mostly caused by dry stool. One case of hemorrhage was cured by conservative treatment. There was no fecal incontinence, recurrence of hemorrhoids, or anastomotic stricture during the follow-up period of 1 to 41 months.
The appearance of PPH is a good news for patients with prolapsed hemorrhoids, especially for patients with severe circular hemorrhoids. However, it is often difficult to operate and can not achieve the desired results in accordance with the PPH surgical procedures  for huge and severe circular hemorrhoids. The most critical step in PPH surgery is purse-string suture. A clear vision is the basis for a good purse-string. For huge hemorrhoids, it must be done from the beginning of traction. After the anal dilator is inserted, the hemorrhoids should not be exposed too much. So as not to affect the suspension effect, nor to make the hemorrhoids in the anus too much to affect the vision of the purse-string; the determination of the purse-string suture position is the focus of the PPH operation. She determines the position of the anastomosis. It is currently recognized that the dentate line is used as the positioning basis. However, the dentate lines of huge hemorrhoids are fuzzy or have completely disappeared. Of course, it cannot be implemented. Some people use the anal canal as a basis for positioning. Because the distance from the reference object is too far, the operation is difficult to grasp.So, how can positioning be easy to operate and achieve satisfactory results? Hemorrhoid circumcision and nailing operation, its original intention is "hemorrhoids" circumcision and nailing, that is to say, the anastomosis should be directly above the pathological anal cushion, that is, the internal hemorrhoids, so the distance between the purse strings should be based on the internal hemorrhoids The upper edge is determined. In theory, it is ideal to design the anastomosis directly above the hemorrhoids. However, because the size of the hemorrhoids is often different in patients, and such a design is difficult to guarantee the recovery effect of huge hemorrhoids, therefore, we use the hemorrhoids The upper edge, the size of the hemorrhoid or the dentate line are considered and determined, and the upper edge of the hemorrhoid is the main basis, and the size of the hemorrhoid or/and the dentate line is appropriately referred to. For the design of huge hemorrhoids, the upper end is partially removed. A very desirable effect .
Purse-string suture is a key step in PPH surgery, but this key step can only be completed by the operator's hand. The mucosa and submucosa are thin and loose, and closely adhere to the muscle layer. It is often difficult to rely on hand feeling alone. To achieve the ideal effect of sneaking in the submucosa, sometimes too deep or too shallow, too deep will narrow the width due to hanging to the muscle layer, and too shallow will cause bleeding risks due to damage to the mucosa. In addition, there are unpredictable accidents such as broken sutures when pulling sutures. In order to reduce the failure rate, ensure the smooth progress of the operation and achieve satisfactory results, we have switched to double purse-string sutures. As for the distance between the two purse-strings, there is no need to be too far apart. The distance is about 0.5cm～1.0cm, which is mainly to reduce mistakes and double insurance.
Intraoperative and postoperative bleeding is the most dangerous complication of PPH surgery. After the above improved operation, due to the wide tissue cut, the anastomosis was clearly visible, the bleeding was stopped by the "8"-shaped suture under direct vision, and the bleeding was completely stopped. However, there was also a case of postoperative hemorrhage caused by negligence. The size of the patient’s hemorrhoids is very different. The surgeon hopes to cut less tissue in the small hemorrhoids. Therefore, he deliberately inserts the needle in the small hemorrhoids and hangs it gently. As a result, only the hemorrhoid mucosa is injured. It was not a complete circle, and no bleeding was seen at the time, which was not treated, leading to heavy bleeding on the 5th day .
Difficulty in urination, discomfort or pain of abdominal distension or swelling in the anus or burning sensation are the main pain on the day after PPH. We believe that this is some normal reaction after PPH, and it is inevitable, because PPH operation cuts off the sensitive lower rectal mucosa and part of the pathological anal cushion in a circular segment and nails it, due to the huge mechanical impact during firing The effect makes the anastomosis inevitably produce a kind of aseptic inflammatory reaction, with different degrees of swelling and burning sensation, and the pain is caused by sphincter spasm, trimming of external hemorrhoids, and dilatation of the anus. These discomforts were significantly improved 10 to 36 hours after surgery, and gradually disappeared from 1 to 16 days. Difficulty urinating, abdominal distension and discomfort are mainly related to anesthesia.
Anastomotic stenosis and postoperative recurrence are the two major complications considered by Yao Liqing . However, 63 patients who underwent our operation were followed up for 1 to 41 months, and no prolapse recurrence or anastomotic stenosis occurred.
We believe that in the operation, the anal dilator is inserted after moderate traction, and the upper edge of the hemorrhoids is used as the main positioning basis for purse-string suture. In-situ 6-8 stitches are uniform and just right double purse-string suture of the submucosa, and the purse-string is loosened After pulling the forceps, use the index finger or non-traumatic forceps to wrap the gauze to push the hemorrhoids and the prolapsed anal canal tissue into the rectum as much as possible, and continue to traction when tightening the stapler until it is fired at the tightest point to ensure the smooth progress of the PPH operation and The important operation skill of increasing the width of the cutting tissue can also avoid and reduce complications, especially the incidence of intraoperative bleeding and prolapse recurrence.
1 Anorectal Surgery Group of the Chinese Medical Association Surgery Branch. "Circular resection and nailing of hemorrhoids (PP)
H) Revision of Interim Guidelines. Chinese Journal of Gastrointestinal Surgery, 2005, 8: 342.
2 Li Shenglong, Yin Tingbao, Zhang Xi, etc. A report of 38 cases of stapling treatment of huge and severe annular hemorrhoids. Chinese Journal of Basic Surgery and Clinical Medicine, 2004; 11:525～526.
3 Li Shenglong, Zang Ling, Yin Tingbao, et al. 1 case of massive hemorrhage after hemorrhoid mucosal nailing. Chinese Journal of General Surgery, 2004; 13:960.
4 Yao Liqing, Zhong Yunshi. Stapling and hemorrhoid mucosal nailing for severe hemorrhoids. Chinese Journal of Modern Surgery, 2003; 7: 175~179.
------The paper has been published in the "Chinese Journal of General Surgery" 2006, Issue 8, pages 611～612