TST surgery Pinyin TSTshǒushù
In 1975, Thomsonl first proposed the theory of anal cushion downward movement, that is, the anal cushion is a normal tissue composed of the inner wall of the anal canal mucosa, blood vessels, and fiber support structures. It has an irreplaceable role in maintaining anal self-control function. When pathological changes or abnormalities occur, It can be called hemorrhoids when clinical symptoms appear due to movement. In 1993, Italian scholar Antonio Longo first reported and clarified the mechanism of the application of the stapler (PPH), which opened a new era for the treatment of hemorrhoids. The TST operation is a technique that combines segmented tooth ligation in traditional Chinese medicine with PPH, which is an improvement of PPH technique. Compared with PPH, it has a shorter operation duration, shorter hospital stay, less postoperative anal pain, a lower incidence of anal edema, large and smooth urination after surgery, less damage to anal function, and definite curative effect. It is a safe, effective, minimally invasive, new technology for the treatment of hemorrhoids in accordance with anorectal physiology.
Principle of operation
In TST operation, a stapler is used to selectively remove the mucosa and submucosal tissues on the dentate line, so that the prolapsed anal pad is moved up, thereby eliminating the symptoms of hemorrhoid prolapse. At the same time, the blood of the inferior rectal artery is cut off to reduce the blood supply of the hemorrhoids and shrink the hemorrhoids, thereby reducing the prolapse and bleeding of the hemorrhoids. There are three types of surgical instruments: single-opening, double-opening and triple-opening anoscopes, which can selectively remove the hemorrhoid mucosa according to the situation and reduce the interference and stimulation of the transitional epithelium of the rectal anal canal.
TST operation can preserve the mucosal bridge between the hemorrhoids and the normal mucosa in the asymptomatic hemorrhoid area to avoid ring scars and prevent anal stenosis. It is characterized by simple operation, mild postoperative pain (almost painless), few complications, short recovery time, and good curative effect.
Exclude those who cannot tolerate surgery (such as unstable blood pressure and blood sugar), malignant anorectal local space-occupying lesions, portal hypertension, pregnant women, children, severe mucosal edema, and mucosal thickness less than 0. 75mm or greater than 1.5mm.
Do preoperative examinations and other related examinations to eliminate surgical contraindications, including blood routine, urine routine, liver and kidney function, coagulation function, blood sugar, pre-transfusion examination, electrocardiogram, etc. Prepare the skin before surgery, clean the enema with 500 mL soapy water 2 hours before surgery, eat a semi-liquid diet 1 day before surgery, and pay attention to perineal hygiene. Prepare loose underwear, a bidet that can be used in a bath to clean the anus, soft towels, toilet paper, etc., for use after the operation. Adjust your mental state and eliminate tension.
Use a disposable open-loop minimally invasive anorectal stapler (TST) produced by Tianchen International Medical Technology Co., Ltd. Including TST33-T80 stapler, anal canal dilator, anal mirror suture, hook thread, anal dilator internal catheter, 2-0 silk thread.
After the sacral anesthesia is effective, the patient takes the bladder lithotomy position, routinely disinfects the perianal skin with 0.5% iodophor, spreads sterile hole towels, and then cleans the anal canal and lower rectum with iodophor cotton balls. If there is still a stool that is not exhausted, iodophor gauze can be inserted into the upper rectum to keep the surgical area relatively clean (take it out after surgery). Prepare TST special equipment, including one-time open-loop minimally invasive anorectal stapler, internal catheter for anal expander, hook thread needle, single-opening, double-opening and three-opening circular anal expander. First use your fingers to expand the anus, and then use the anal canal dilator to expand the anus. Observe the distribution, number and size of hemorrhoids, choose a suitable anoscope, put the anoscope coated with paraffin oil into the anus as a whole, fix the anoscope and remove the internal catheter. The anoscope can be appropriately rotated left and right to adjust its position to fully expose the vertical intestinal mucosa. Suture a stitch at 3 and 9 o'clock to fix the anoscope. Use Johnson 2-0 with needle thread to suture within 2.5-3.5 cm of the tooth line. For hemorrhoids with more severe prolapse, the needle can be inserted at a low position within the above range, and the lifting effect is better. If there are 3 or more hemorrhoids, the submucosa in the three-open anoscope window is selected for segmented purse-string sutures. Generally, two stitches at 3 and 9 o'clock are sutured first, and then a string is placed on the suture line and then sutured at the 12 o'clock position. 3 stitches. It is especially important to pay attention to the depth of suture. Only suture the mucosa and submucosa to avoid damage to the sphincter. For female patients, it is best to cooperate with the examination of the vaginal wall and use the index finger to penetrate into the vagina to avoid embedding the back wall of the vagina into it. After carefully inspecting the TST disposable stapler, rotate the tail of the TST disposable stapler, remove the plastic partition, and bring the head of the stapler into the rectum along the axis of the anoscope, and extend the head into the upper end of the suture. If it is a single-open anoscope, it is not necessary to tie the knot, and it is enough to lead the two ends of the line on both sides of the stapler; for the double-open anoscope, it is best to tie the knot and tighten the stapler; It is a segmented purse string suture, so you need to tighten the purse string and tie the hanging thread.To tighten the purse string, attention should be paid, and the purse string should be tightened as much as possible so that as much prolapsed mucosa enters the cutting groove of the stapler. Hook the end of the thread through the side port of the stapler with a crochet needle, draw the purse-string and the end of the string, and clamp it with vascular forceps. The assistant assists in fixing the anoscope. The surgeon keeps the TST disposable stapler and the anoscope on the same axis continuously, pulls the sutures and tightens the tail of the stapler at the same time, and sends the stapler slowly along with the tightening force. Enter the anoscope. The scale 4 on the head of the stapler is kept on the same plane with the edge of the anoscope. The assistant must fix the anoscope to ensure that the surgeon maintains the same axis of the stapler and the anoscope and cuts the hemorrhoids evenly under the force. Pull the ligature appropriately when tightening, so that the prolapsed mucosa enters the cutting groove as much as possible. Pay attention to the scale of the stapler when tightening, and tighten it to the back of the safety scale. When firing, it is necessary to use force and anastomosis to ensure complete resection and anastomosis. When the force is not enough or not altogether, it is easy to cause incomplete resection and anastomosis and subsequent bleeding. After hearing a crisp "click" sound, fix the stapler in the closed state for 30-60 seconds to suppress the bleeding. And pay attention to observe the patient's response, the autonomic reflex is more obvious should be treated. Then turn the tail of the stapler reversely for half a turn and take it out. Take out the stapler and check the number and size of the mucosal tissue removed. Take the triple-opening anoscope as an example. You should cut off the 3 segments of the mucosal bridge first, and then rotate the anoscope left and right to fully expose the 6 ear-shaped mucosal protrusion anastomoses, ligate sequentially or ligate with a figure of eight to stop the bleeding, check repeatedly and check for no activity After sexual bleeding, use oil gauze and gelatin sponge to plug the anus to stop bleeding. The external hemorrhoids will disappear or shrink after the stapling of the rectal mucosa. The larger ones can be removed, or externally stripped and internally ligated. The excised part should be routinely examined by pathology.
On the day after the TST operation and on the first day after the operation, a semi-liquid diet, lotus root flour and corn paste are allowed. Milk is not recommended (lactose intolerance). The purpose is to maintain at least 24 hours of inconvenience to promote wound healing. Intravenous fluids. Usually 750～1000mL per day, with appropriate addition of antibiotics and hemostatic drugs.
Urinary retention may occur due to discomfort or pain around the anus after surgery. Use towels to heat the lower abdomen and use neostigmine 1 mg intramuscular injection or Zusanli acupoint injection. Elderly patients due to decreased bladder muscle contraction and relaxation, and female patients who tend to contaminate the wound due to urine, can consider indwelling a urinary catheter, which is generally removed when the bladder is filled with fluid on the second day after the operation.
Generally, there is no need for an indwelling analgesic pump after surgery. Some patients may have pain and swelling on the night after surgery. Diclofenac sodium can be taken orally, and analgesics (such as pethidine) can be used for severe pain. A small number of patients have long-term post-defecation pain after surgery, which is considered to be caused by the incomplete detachment of the stapler nail. The symptoms can be relieved after removal under an anoscope (compared with PPH, the number of titanium nails implanted in TST surgery is small, and titanium nails cause anus Less discomfort).
In the evening on the first day after surgery, use drugs to help defecation, such as polyethylene glycol 4000 powder, or lactulose. The purpose is to keep the stool unobstructed, so as to avoid the anastomotic edema caused by stool difficulty. The perineum should be kept clean after defecation, which can be washed with clean water or light salt water.
If there are no special circumstances, the patient can be discharged from the hospital 2-3 days after surgery and follow-up at the outpatient clinic 20 days later.