Stapling prolapse and hemorrhoids combined with external dissection and internal ligation of rhomboid incision in the treatment of 80 cases of circular mixed hemorrhoids
Zheng Jinjian Tan Hong Zheng Junying
Department of Anorectal Chinese Medicine, Liuzhou People's Hospital 545006
[Abstract] Objective To investigate the clinical effect of prolapse and hemorrhoids circumcision combined with diamond-shaped incision external stripping and internal ligation in the treatment of 80 cases of circular mixed hemorrhoids. Methods To retrospectively analyze the clinical data of 80 cases of circular mixed hemorrhoids undergoing prolapse and hemorrhoid circumcision combined with diamond-shaped incision external dissection and internal ligation. Results The postoperative anal morphology of all cases recovered well, the anus was flat after the operation, there was no edema, no anal incontinence, no anal stenosis, no infection and other complications. Conclusion Circumcision of prolapse and hemorrhoids combined with external stripping and internal ligation of rhomboid incision is a safe and effective method to treat circular mixed hemorrhoids. It can reduce postoperative complications while maintaining a good appearance of the anus. The clinical effect is good.
[Key words] Stapling prolapse and hemorrhoids circumcision; diamond-shaped incision external stripping and internal ligation; circular mixed hemorrhoids
Hemorrhoids are common and frequently-occurring diseases, and in the cases of hemorrhoids and fistulas, hemorrhoids account for about 68%. Any treatment method has its indications. The clinical choice of treatment method should be based on the staging of hemorrhoids and the nature of pathological changes to choose surgical treatment . At present, traditional surgical external stripping and internal ligation are mostly used for ring-shaped mixed hemorrhoids. Its curative effect is accurate, the treatment is thorough, and the recurrence rate is small. However, it is often accompanied by anal edema, severe wound pain, and slow wound healing. Excessive skin, postoperative anal canal stenosis, etc. may be accompanied by different degrees; but the simple use of stapled prolapse hemorrhoids circumcision can not be completely removed part of the external hemorrhoids or part of the hemorrhoids still have more residuals. From March 2008 to July 2013, 80 cases of circular mixed hemorrhoids were treated by our department with prolapse and hemorrhoids circumcision combined with diamond-shaped incision external stripping and internal ligation, and the clinical observation was satisfactory. The report is as follows.
1 Materials and methods
1.1 For general information, refer to the "Diagnostic Criteria for Diseases and Syndrome in Anorectal Medicine of Traditional Chinese Medicine", and select 80 patients with annular mixed hemorrhoids who meet the diagnostic criteria and have surgical indications, including 52 males and 28 females, aged 20-72 years, average age 45.5 years old, the course of disease was 1 to 32 years, with an average of 12.5 years. There were 45 cases of connective tissue external hemorrhoids, 21 cases of varicose external hemorrhoids, and 14 cases of external hemorrhoid edema.
1.2 Treatment methods: Clean enema before operation, combined lumbar-dural anesthesia, left decubitus position, routine perianal local skin disinfection drape, female patients at the same time vaginal disinfection, concurrent fingering to expand the anus, understand the size, distribution, and prolapse of hemorrhoids Happening.
1.2.1 Stapler prolapse and hemorrhoid mucosal circumcision The transparent circular anal canal dilator is inserted into the anal canal and fixed on the anus. The plug is removed and the lower rectal mucosa is disinfected to fully expose the 4 cm mucosa on the dentinal line. Insert an anal mirror semi-circular suture device into the anal canal dilator to reposition the prolapsed hemorrhoids or anal canal mucosal part. Use a large round needle on the dentate line to place 3～4 CM mucosa through the semicircular suture device. Perform a horizontal purse-string suture at the submucosal layer clockwise at 12 o'clock at the lithotomy position. The purse-string suture can be sutured with a single purse-string or double purse-string depending on the severity of hemorrhoid prolapse, and a traction thread is used at 6 o'clock. For women, the purse-string sutures the bladder stone-cut At 12 o'clock, place your index finger into the vagina as an instruction to avoid vaginal damage. After the purse string is made, unscrew the hemorrhoid stapler, extend the head of the stapler mushroom to the upper end of the purse string suture ring, and tighten the suture And tie the knot, pull out the suture through the side hole of the stapler with the matching stringer, and pull the ligature appropriately to make the rectal mucosa and part of the submucosal tissue enter the sleeve of the stapler, rotate and tighten the stapler to the safety threshold indication Thread, open the insurance and fire, hold for 30 seconds, then partially open the stapler, gently pull out, check whether there is pulsating bleeding in the anastomotic ring part, if there is bleeding, add a "8" stitch to stop the bleeding, and the anastomosis breaks Where there is poor end-to-end anastomosis, an "8" suture should also be performed to prevent hemostasis at the anastomosis. Vaseline gauze is placed in the anal canal for drainage.
1.2.2 External dissection and internal ligation of rhomboid incision and ring-shaped mixed hemorrhoids. After prolapse and hemorrhoid circumcision, the normal anal cushion is restored. For the incomplete external hemorrhoids, a small radial diamond incision is made to peel off the external hemorrhoids to At 0.5cm on the dentate line, peel off the subcutaneous venous plexus, and the outer mouth can reach 0.5cm from the outer edge of the external hemorrhoid. The incision outside the anal edge is slightly larger, which is convenient for wound drainage. Pay attention to the reduction of the incision in the anal margin, and it is better to make the incision in the anal margin well aligned. Large curved forceps were used to clamp the internal hemorrhoids longitudinally, and the internal hemorrhoids were ligated with No. 7 silk thread and the stump was removed, paying attention to hemostasis. Treat the remaining hemorrhoids in the same way. Put petroleum jelly gauze on the wound, and the square gauze pressure bandage is completed.
1.2.3 Postoperative treatment Antibiotics were applied postoperatively, a half-flow diet was taken 6 hours after the operation, and general diet was changed 2 days later. Postoperative anorectal department dressing change and anal care were performed twice a day, and the postoperative hospital stay was 7-9 days.
2.1 Efficacy standards Refer to "Therapeutic Efficacy Standards of Anorectal Diseases in Traditional Chinese Medicine" . Cure: The symptoms and signs disappear, and the wound heals. Improvement: symptoms and signs improved, wounds healed. Unhealed: No change in symptoms and signs.
2.2 Curative effect All 80 patients were cured, the anal margin was smooth after the operation, and there was no edema of the anal margin; there were no sequelae of anal incontinence, anal stenosis and vaginal fistula after the operation; follow-up for more than 6 months after the operation, no hemorrhoid tissue was found in anal specialist examination Fine stool control function is good, and patient satisfaction is high.
Annular mixed hemorrhoids are considered one of the more complicated diseases by the anorectal department, and the current treatment is mostly based on surgery. The traditional surgical method, external stripping and internal ligation, has been widely used because of its better effect. The surgical method of external stripping and internal ligation is simple and effective, but its shortcomings are obvious. It has obvious postoperative pain, more bleeding, slower healing, longer recovery time, relatively more complications, and often cannot achieve one-time cure.
Stapling prolapse and hemorrhoidal mucosal circumcision (PPH) is a new surgical procedure based on the theory of anal cushion downward movement by Anlom Longo. The theory of anal cushion has changed people’s traditional views on hemorrhoids, giving almost a brand new concept to hemorrhoids. International academic conferences highly appraised this new view and formed a basic consensus: "Anal cushion is a layer of vascular lining at the junction of the anorectal Cushion is an anatomical entity that exists in the viviparous period and cannot be regarded as a disease; hemorrhoids are not varicose veins. Hemorrhoids are called hemorrhoids when the anal cushion tissue is abnormal and symptoms appear." The procedure of prolapse and hemorrhoid circumcision (PPH) was first used by Italian doctor Anlom Longo in 1998 . Stapling prolapse and hemorrhoid circumcision (PPH) circular resection of the hemorrhoid mucosa, completely or partially restore the anatomical position of the anatomical anal canal, so that the anal cushion is lifted and retracted, which solves the problem of preserving the skin bridge, Difficulty in mucosal bridges, as well as anal stenosis caused by excessive removal and ligation of the tooth line, large damage to the fine structure of the anal cushion and anal canal, and mild postoperative pain. Clinical practice has proved that the prolapse and hemorrhoids circumcision and nailing (PPH) for the treatment of grade III to IV hemorrhoids, mixed hemorrhoids, and circular hemorrhoids have satisfactory results . But clinical observation found. For circular mixed hemorrhoids, a considerable number of patients undergoing simple PPH surgery still have obvious external hemorrhoid insufficiency, re-hemorrhoid prolapse, anal edema, and external hemorrhoid thrombosis are also unsatisfactory . Therefore, we used the prolapse and hemorrhoids circumcision (PPH) for the treatment of circular mixed hemorrhoids and combined the rhomboid incision and external dissection and internal ligation. While restoring the pad, only the external hemorrhoids are processed, the venous plexus is stripped, and the hemorrhoids that are not fully recovered by ligation, so that the advantages of the two complement each other, and the postoperative adverse reactions are correspondingly compared with the pure PPH operation or the simple external stripping and internal ligation Less surgery is needed, resulting in better surgical results. Practice has proved that the combined application of the two procedures not only solves the symptoms of anal pad prolapse, but also solves the problem of pathological signs of residual external hemorrhoids, making the treatment effect better.
 Gong Xiang, Sun Xianqian, Qiu Chunlin, Guan Chunlin, He Zhong. The application experience of Hercules anorectal therapy instrument in the treatment of circular mixed hemorrhoids. Medical Information: Mid-term. 2010. (5): 1164-1164.
 State Administration of Traditional Chinese Medicine. Criteria for diagnosis and efficacy of TCM disease and syndrome [M]. Nanjing: Nanjing University Press, 1994:137.
 Lu Chongliang. The new concept of modern diagnosis and treatment of hemorrhoids. Chinese Journal of Minimally Invasive Surgery. 2003. 3(5).
 Yang Xiangdong, Wei Yu, Yan Jingying. Progress in the prevention and treatment of common complications of hemorrhoids in PPH. Colorectal and Anal Surgery. 2008.