Anorectal disease is a common clinical disease, with a high population prevalence. The "hemorrhoids" in the old saying "ten people and nine hemorrhoids" is the general term for anorectal diseases. Traditional anorectal surgery has many postoperative complications and sequelae. The severe postoperative pain makes the patient fear of undergoing surgical treatment, and even becomes increasingly serious due to incurable treatment. In recent years of clinical practice, the author has introduced the concept of painlessness into anorectal surgery operations. Through clinical observation and summary, patients with anorectal surgery can basically survive the recovery period of anorectal surgery in a painless or slightly painful state. Stone construction of the Fifth Hospital of Baoding City
The applied local anesthetics generally choose 2% lidocaine 5ml, bupivacaine 37.5mg 5ml, normal saline diluted to 40ml, methylene blue solution 1ml, and epinephrine 0.1～0.2ml. For perianal local anesthesia, the dosage should not be too large. Too large can cause perianal edema, causing postoperative swelling. At the same time, excessive application of anesthetics on the superficial surface can make the loose perianal skin become "external hemorrhoids" or make the original The external hemorrhoids become larger, resulting in an excessively large resection area, prolonging the healing period. Generally, the amount of anesthetic is 5-8ml, which can meet the needs of surgery, such as complicated anal fistula or long fistula or large abscess range can be increased to about 10-12ml. When local anesthesia is performed around the anus, the lithotomy position is generally selected at 3, 6, 9, 12 o'clock. Generally, the lithotomy site is at 6 o'clock, that is, the infiltration of the posterior median coccyx area should be large, so that the drug solution is distributed in a fan shape. This area can seal the perineal branch of the 4th sacral nerve, the anal coccyx nerve and the pudendal nerve branch, which is good for anal relaxation Important role, generally use 2~4ml. The two sides are followed by 1～3ml, and the front dosage is 0.5～2ml. If there is no lesion in the front, it may not be infiltrated. Then infiltrate the diseased or surgical site appropriately.
From clinical observations, the severity of pain after anorectal surgery is certainly related to the type and severity of the disease, mental state, individual differences, etc., but anesthesia, surgical methods and some specific operation details have an important impact on postoperative pain. Through clinical observation, we found that the pain and discomfort after anorectal surgery mainly depend on two aspects: the size of the trauma and the tension of the surgical area. Therefore, in order to be painless after surgery, it is necessary to achieve low trauma and reduction of tension. At the same time, one should also be familiar with the anatomy and nerve distribution of the anorectum.
For general anorectal surgery, local anesthesia can meet the requirements of surgery. First of all, local anesthesia has little effect on the whole body, and its anesthesia risk is small. There is no anesthesia accident in the observed patients. In addition, the proper addition of epinephrine to local anesthetics can not only extend the anesthesia time and reduce the toxicity of the anesthetic, but also reduce intraoperative bleeding. The application of local anesthesia does not affect the patient's activities, while patients with sacral anesthesia and epidural anesthesia need to stay in bed for a period of time.
Familiar with anatomy and nerve distribution
To be familiar with the anal margin, anal canal, dentate line and the anatomical structure of the rectum, the anal canal is innervated by spinal nerves, and the pain response is sensitive; while the mucous membrane above the dentate line is innervated by autonomic nerves, so there is no pain. Therefore, the injection and ligation of internal hemorrhoids should be performed above the dentate line. The external hemorrhoids of mixed hemorrhoids should be peeled above the dentate line and then the internal hemorrhoids should be ligated (usually peeled to about 0.5cm above the dentate line). And for other anorectal diseases, ligation and sutures below the dentate line should be avoided as much as possible, unless necessary for hemostasis. At the same time, the receptors in the wall of the rectum and anal canal ensure local fine discrimination, which helps to control the bowel movement. Therefore, if the skin is absent from the anal canal due to surgery, it can cause defecation reflexes and cause sensory incontinence. Therefore, the skin of the anal canal should be preserved as much as possible during the operation to maintain its physiological function.
Low invasiveness means to minimize the trauma caused by surgery. Low invasiveness can reduce pain and shorten the healing time. To achieve low invasiveness during anorectal surgery, our experience will be as follows:
(1) For thrombotic external hemorrhoids or varicose external hemorrhoids, a small vertical incision should be made from the hemorrhoid body, and the bleeding thrombus or venous plexus should be stripped through the incision to avoid overall resection.
(2) For internal hemorrhoids that are mainly bleeding, if there is no prolapse, sclerotherapy injection is the main method. The internal hemorrhoid sclerotherapy we implemented uses Xiaozhiling injection and Shi Zhaoqi's 4-step injection method.
(3) For internal hemorrhoids who prolapse but can repay on their own, there is no obvious erosion and thrombosis, and the base is wide, use hardening injection.
(4) For mixed hemorrhoids, mainly varicose-type external hemorrhoids, it is not advisable to remove the skin of the anal canal on a large scale. Veins can be removed under the skin of the anal canal at the incision, and the skin of the anal canal should be preserved as much as possible. If the skin of the anal canal is damaged too much during the operation, the postoperative scar may be too large and inelastic, which may affect the defecation function or cause the anal canal to be narrow.
(5) For anal fistula or anal fissure surgery with internal hemorrhoids, sclerotherapy should be used as much as possible. For anal fistula with a long fistula, cut the fistula within about 1.5cm outside the anal margin, and scrape the fistula outside the anal margin for drainage. For complex anal fistulas, the main tube is cut and the branch tube is scratched and drained to reduce the wound area and damage.
(6) For the treatment of anal fissure, the traditional internal sphincterotomy after the traditional anal fissure resection, the surgical incision is large, the healing is slow, and the anus is deformed after the operation, we use lateral internal sphincterotomy plus anal fissure internal hemorrhoidectomy, and hypertrophic anal papilla ligation Resection, the injury is small, the healing is fast, the anus is not deformed after the operation, and there is almost no pain after the operation.
Reduce tension even if the tension in the surgical area is reduced
To reduce anorectal surgery, we experience the following points:
(1) Avoid sewing the anal canal and anal margin below the dentate line.
(2) If postoperative anal canal tension is too high, it is possible to make a longitudinal incision to reduce tension and cut off part of the internal sphincter.
(3) When the mixed hemorrhoids and external hemorrhoids are peeled off, one side should be peeled above the dentate line, and the base of the ligation should be as narrow as possible.
(4) For the ligation and resection of anal papilloma and internal hemorrhoids, a tension-reducing incision should be made at the base of the anal papilloma and the ligation should be properly peeled above the dentate line to make the ligation above the dentate line.
(5) The ligation of internal hemorrhoids should not exceed 4 at most. For smaller internal hemorrhoids and accessory hemorrhoids, injection of sclerosing agent can be used.
(6) After the operation, avoid too much gauze packing in the rectum and anal canal.
Local edema after surgery can also increase local tension, causing pain and swelling. In order to prevent postoperative edema, the following points should be noted:
(1) Excise excess skin on the anal margin to prevent postoperative edema.
(2) The wound at the anal margin or anal canal is "V"-shaped, even if the base of the retained tissue is larger than the top; at the same time, the wound should be "∧"-shaped, even if the wound outside the anal margin is larger than the wound inside the anal canal. In order to make blood and lymph flow back smoothly, to prevent postoperative edema.
(3) Minimize walking 24 hours after operation to prevent swelling due to poor local blood return caused by standing or walking.
(4) Instruct patients to eat cellulose-rich foods 24 hours after the operation, or to apply laxatives appropriately to maintain soft stools, reduce defecation effort and shorten defecation time. Through several years of clinical observation and exploration, the author has explored the above-mentioned painless surgical methods and techniques in anorectal surgery, and indeed achieved painless or slight pain after anorectal surgery.