The minimally invasive concept and minimally invasive technology are one of the most important contents of modern surgery. It requires "as little or as little trauma as possible" to enable patients to achieve and maintain the best internal environment and stability, and "patients pay as little price as possible". Achieve the same good results. How to apply the concept of minimally invasive and minimally invasive techniques to anorectal surgery is currently an issue that is actively explored by professional doctors in anorectal surgery, and is also the direction and goal of the future development of anorectal surgery. The "Guidelines for Clinical Diagnosis and Treatment of Hemorrhoids (2006 Edition)" pointed out that asymptomatic hemorrhoids do not need treatment; the purpose of treatment is to eliminate and relieve symptoms; it is more meaningful to relieve symptoms than to change the size of hemorrhoids. Under the guidance of this principle, the traditional concept of "treatment of hemorrhoids at sight" should be discarded, and basic treatments such as dietary adjustments, sitz baths, and conservative treatments such as drugs should be emphasized, and minimally invasive treatment concepts and methods for hemorrhoids should be implemented when surgery is necessary. (Minimally Invasive Procedure for Hemorrhoids.MIPH).
At present, the treatment methods of hemorrhoids in clinical application still have many names, and each method has its advantages and disadvantages. Anorectal medical staff also make improvements to various methods in combination with clinical practice. At the same time, the introduction of minimally invasive technology and the application of modern high technology It also enables the treatment of hemorrhoids to fully reflect the concept of minimally invasive.
1 Injection therapy
Injection therapy has long been the first choice for the treatment of grade I to II internal hemorrhoids. From the necrotic agent Kuzhiye used at the beginning to the most widely used sclerosing agent Xiaozhiling, and then to the improvement of the corresponding sclerosing agent, the improvement of the drug reduces the harm of the drug itself to the human body, and also reduces the operation Later pain and corresponding complications occurred.
2 Bandage therapy
The ligation therapy evolved from the ligation method of internal hemorrhoids. At first, silk thread or catgut was used, and then gradually evolved into rubber band ligation (RBL).
Hemorrhoid ligation (RPH), which uses a special ligation instrument to ligate the apron to the base of the hemorrhoid. Through the elastic contraction of the apron, the blood supply of the hemorrhoid is partially blocked, so that the hemorrhoid body shrinks and falls off to achieve the therapeutic purpose. . Band ligation therapy is a safe, effective, cheap and convenient method for treating internal hemorrhoids of degree II and III, and was once called Minimally Invasive Technique for the treatment of internal hemorrhoids by European and American scholars.
3 Copper ion electrochemical therapy
The copper ions are input into internal hemorrhoids through electrodes, and combine with the substances in the blood to form a copper complex. The complex slows down and coagulates the blood flow of the capillaries in the tissues, edemas the epithelial cells of the vessel wall, and produces aseptic inflammation, necrosis, and Organized, the number of capillaries in the hemorrhoids is reduced, the amount of congestion is reduced, and the hemorrhoids atrophy and become smaller, achieving the purpose of treatment. The method is a safe, effective, minimally invasive and convenient method for treating second-degree internal hemorrhoid bleeding and prolapse.
4 Hemorrhoid artery ligation (HAL)
By blocking the blood supply of hemorrhoids, HAL reduces the pressure in the venous plexus of the hemorrhoids and shrinks the hemorrhoids. At the same time, the ligation effect can make the rectal mucosa and submucosal tissue adhesion and fixation, prevent the anal cushion from moving down, so as to achieve the purpose of eliminating the symptoms of hemorrhoidal prolapse . Doppler-guided hemorrhoid artery ligation (DG-HAL) uses a Doppler special probe to detect the artery above the hemorrhoid at 2 to 3 cm on the tooth line for direct ligation, which makes the clinical operation more accurate and simple. A large number of clinical applications by domestic and foreign scholars have also confirmed that it is a minimally invasive method for the treatment of Ⅱ and Ⅲ degree internal hemorrhoids.
5 Stapling prolapse and hemorrhoids circular resection and nailing (PPH)
This technique is an emerging technique developed by Italian scholar Longo to treat prolapsed internal hemorrhoids based on the theory of downward shifting of the anal cushion. It uses a special stapler to circularly remove the mucosa and submucosa of the intestinal wall of the lower rectum above the prolapsed internal hemorrhoids, and anastomose the distal and proximal mucosa at the same time, so as to achieve the lifting, reduction, and devascularization of the prolapsed internal hemorrhoids. The purpose of body reduction . Since its application, it has been rapidly and widely used in clinics at home and abroad. The treatment of internal hemorrhoids of degree III and IV, especially circular prolapsed internal hemorrhoids, has the advantages of simple operation, less injury, less pain, and quick recovery.
6 Minimally invasive techniques in external stripping and internal ligation
External stripping and internal ligation (Milligan-Morgan operation) is still the mainstream operation for anorectal doctors to treat mixed hemorrhoids, especially severe hemorrhoids. Since its application in 1937, clinicians have made a lot of improvements to this procedure in pursuit of minimally invasive beauty, which can be summarized in three aspects.
6.1 Preservation of the anal cushion In 1975, Thomson put forward the theory of hemorrhoids' anal cushion shifting down, and believed that hemorrhoids are pathological hypertrophy and displacement of the anal cushion and the formation of congestion of the perianal subcutaneous vascular plexus. People have gradually realized that the primary site of hemorrhoids is the ATZ (anal transitional zone) epithelium of functional normal tissue in the anal cushion area, that is, the rectal anal canal transitional epithelium. It has a certain endocrine and immune function, is distributed with highly specialized sensory nerve tissue, and has a fine sense of discrimination, which can induce anal reflex to maintain normal stool self-control function. Under the guidance of this theory, many domestic and foreign scholars updated their concepts and improved surgical methods in time, kept normal anal cushions as much as possible, reduced injuries, and achieved satisfactory clinical results.
6.2 Preservation of the tooth line The tooth line area is a highly specialized sensory nerve terminal tissue zone, which is the induction zone for defecation movement. Too much damage to the dentition during the operation will weaken or disappear the defecation reflex, and cause constipation or sensory fecal incontinence. The clinically derived surgical method of completely preserving the dentition or reducing the damage of the dentition as much as possible has proved that the operation method, Keeping the tooth line can effectively protect the anal function and reduce the occurrence of postoperative complications.
6.3 Preservation of the skin bridge and plastic surgery
For circular mixed hemorrhoid surgery, excessive skin damage can lead to perianal skin defects and increased scars, which will affect anal function and prolong healing time to a certain extent. In severe cases, it can lead to anal stenosis. Therefore, clinically, microscopic The invasive technique achieves the purpose of skin preservation. The treatment of external hemorrhoids has gradually evolved from the initial resection to stripping. Minimally invasive incisions are designed along the perianal skin pattern and the shape of the external hemorrhoids, and strive to preserve the perianal skin and the skin between the incisions. Bridges, such as wing-shaped incisions or auxiliary incisions are also used to ensure the overall appearance of the anus is as smooth as possible, and even achieve a cosmetic effect.
There are many treatment methods for hemorrhoids. At present, no one treatment method is a perfect method for hemorrhoids. The choice of various methods in clinical practice should follow the principle of individualized treatment under the guidance of minimally invasive concept, and also consider health economics. And other factors. Any method or even any cutting-edge instruments and instruments cannot be called minimally invasive in the true sense. Minimal invasiveness must be reflected in the entire diagnosis and treatment process of hemorrhoids and in every detail of facing patients with hemorrhoids. The in-depth basic research on the pathogenesis of hemorrhoids will also affect the progress of hemorrhoid treatment concepts and minimally invasive treatment.