Abstract: In the operation of circular mixed hemorrhoids, the skin bridge was used to cut the longitudinal suture and lateral incision to expand the anus. 53 cases were clinically treated with satisfactory results. This method better solves the problem of skin bridge treatment during ring mixed hemorrhoid surgery, reduces postoperative anal pain and edema as much as possible, and more effectively prevents postoperative anal stenosis and anal fissure formation. The necessity and feasibility of transverse cutting and longitudinal suture and lateral cutting to expand the anus, as well as the synergistic relationship between the two and related matters for attention were discussed.
Key words: circular mixed hemorrhoids, transverse and longitudinal suture + lateral incision to expand the anus, surgery
Circumferential mixed hemorrhoids is a difficult disease in anorectal diseases. Circumcision and segmented external stripping and internal ligation are inadequate. Especially the external hemorrhoids of ring mixed hemorrhoids are connective tissue type, which is like a "bottle cap". How to deal with it Skin bridge, flatten the anus, relieve pain, and prevent postoperative anal stenosis. From 1998 to 2003, the author used segmented external stripping, internal ligation, internal injection plus skin bridge transverse cut and longitudinal suture and lateral resection to expand the anus to treat annular mixed hemorrhoids53 Cases, satisfactory results have been achieved, the report is as follows:
1. Clinical data
There were 53 cases of circular mixed hemorrhoids, of which 35 cases were of connective tissue type. There were 33 males and 20 females, aged 26-68 years old, with an average of 38 years old. The main clinical symptoms are: something coming out of the anus during stool, anal pain or foreign body sensation, bleeding during stool, etc. The course of the disease is 5-30 years. Some patients have anal fissures, anorectal polyps, anal papilla hypertrophy, and constipation. Patients with anal fistula and a small number of elderly patients with anal relaxation are not among the 53 cases. Clean the enema 2 hours before surgery.
2. Treatment methods
1. Take the left or right lateral position, apply local anesthesia or sacral anesthesia, spread towels, disinfect the surgical field, expand the anus, and disinfect the inside of the anus under an anal mirror. According to the shape, number and size of ring mixed hemorrhoids, the natural dividing line of the hemorrhoids is divided into 4-6 segments. Routine external peeling and internal ligation, leaving no less than 0.3cm mucosal bridge between two adjacent hemorrhoids. Keep no less than 0.5cm skin bridge, unligated part of hemorrhoids and mucosal bridge injected with 1:1 Xiaozhiling diluent. Combined with anorectal polyps and anal papilla hypertrophy, combined suture resection or laser treatment.
2. According to the degree and location of the preserved skin bridge, completely or selectively remove the part of the skin bridge, trim the subcutaneous tissue of the skin bridge to make the skin bridge flat, and then suture the opposite ends with two longitudinal stitches. Sew a stitch on each side of the skin bridge to fit the subcutaneous tissue.
3. Choose no skin bridge on both sides of the anal margin or cross-cut skin bridge or a wider skin bridge to make a small radial incision with a length of about 0.8-1cm and an anus, deep to the skin, use small mosquito forceps to pick up the head of the internal sphincter After cutting, expand the anus with four fingers, and the anal canal contains two fingers. The anal incision is analgesic with long-acting analgesics.
3. Therapeutic effect
After treatment, the clinical symptoms of 53 patients in this group were eliminated, postoperative pain was less, anal edema was less, no anal stenosis and anal incontinence, no obvious discomfort in the anus, no obvious residual skin tags on the anus, and smooth, all cured.
1. Circular mixed hemorrhoids, especially the external hemorrhoids are of connective tissue type. After traditional segmented external stripping and internal ligation, the skin bridges on both sides of the incision are lengthy and prominent. If the skin bridges are not treated, the postoperative edema and pain will be obvious. The patient has the suspicion of "not cleaned", the anus has a foreign body sensation, and inflammatory external hemorrhoids are easily formed in the later stage. If the operation is performed again, it will bring a certain physical and mental impact and economic burden to the patient. During the operation, the anal canal and 3/5 of the anal margin were preserved as much as possible, and the skin bridge was used to cut the longitudinal seam. The treatment was performed properly, the patient had fewer postoperative complications and the anus was smooth. Pay attention to the tension of the skin bridge when cutting the longitudinal seam of the skin bridge. If it is too tight, the suture of the skin bridge may be broken. If necessary, cut the decompression mouth to decompress; if it is too loose, it is easy to edema, and there are still skin tags after treatment. .
2. Release of part of the internal sphincter is an important part of the operation of circular mixed hemorrhoids. If you do not perform a lateral incision to expand the anus to loosen part of the internal sphincter during the operation, there will be many anal incisions. When the wound is healed, there will be difficulty in defecation when the scar contractures, resulting in anal stenosis, and even causing "incisional anus" at 6 or 12 o'clock in the lithotomy position. "Crack" and even the operation failed. Preliminary lateral resection and expansion of the anus can prevent postoperative anal stenosis and fissure formation, and the success of the operation can be guaranteed.
3. Lateral incision and expansion of the anus is of great significance to the success of the skin bridge transverse and longitudinal suture. If part of the internal sphincter is not loosened, due to large anal trauma, postoperative anal sphincter spasm, anal pain, difficulty in defecation, anal incision and skin bridge edema will be obvious. Preliminary lateral incision and expansion of the anus to loosen part of the internal sphincter can reduce intra-anal pressure, improve local blood circulation, and effectively solve the problems of postoperative anal sphincter spasm, anal pain and edema, and the transverse and vertical skin bridge can be healed. Of course, how much to loosen the internal sphincter should be flexibly controlled according to the size of the removed hemorrhoids, the number of hemorrhoids removed, the amount of skin remaining in the anal canal, and the size and number of incisions on the anal margin.
4. For patients with anal fistula resection and part of the elderly with loose anus, it is not advisable to cut the anus laterally and use it with caution.