"Hemorrhoidal mucosa suture + multiple segments of mixed hemorrhoid ligation in the outer peel mixed hemorrhoid treatment efficacy of multiple" was published in 2010 in "Advances in General Surgery China", author: tall trees wave, Ling-yu.
Multiple mixed hemorrhoids (including circular mixed hemorrhoids) is one of the refractory diseases in the anorectal department. The clinical treatment is mainly based on surgery, and there are various surgical methods. In the past, surgical treatment, especially simple segmental ligation and open surgery Residual hemorrhoids after treatment are prone to edema and recurrence, and complete removal of the lesion can easily lead to complications such as anal stenosis and varying degrees of incontinence, which makes the surgical effect unsatisfactory. At present, the purpose of removing the lesion and eliminating the symptoms is often used. In order to explore a reasonable surgical method for the treatment of multiple mixed hemorrhoids and reduce the occurrence of postoperative complications. From June 2006 to January 2009, we have used suture ligation of the hemorrhoids + multiple mixed hemorrhoids segmented external stripping and internal ligation to treat multiple mixed hemorrhoids (including circular mixed hemorrhoids). Through clinical observation and postoperative follow-up, we have achieved satisfaction Efficacy. The summary report is as follows:
1 Clinical data
1.2 Treatment methods
1.2.1 Preoperative preparation Check blood and urine routine, blood coagulation routine, liver and kidney function, biochemistry, ECG and chest X-ray before operation, and exclude surgical contraindications. Fasting for 6 hours before surgery, water for 4 hours, clean enema 3 hours before surgery. Antibiotics were given half an hour before surgery to prevent infection. Patients with mental stress can be given phenobarbital sodium 0.1 g intramuscular injection half an hour before surgery.
1.2.2 Surgical method: The patient is placed in a prone position, the anus is fixed with a wide tape, and the surgical field is exposed. 10ml of 2% lidocaine, 5ml of 0.75% levobupivacaine, 5ml of water for injection, anesthetize the sacral canal (Yaoshu acupoint). After the anesthesia is satisfied, the operation area and anal canal are routinely disinfected, sterile towels are laid, and the anal canal is repeated. After disinfection of rectal iodophor, digital rectal examination combined with anoscopy to find out the location, number, size and the relationship between hemorrhoids inside and outside the anal canal, pay attention to whether there are thrombosis, edema and erosion, and according to the size of mixed hemorrhoids and external hemorrhoids. And design incisions, choose 3 female hemorrhoids as the sutures of the hemorrhoid mucosa and external peeling and internal ligation (this is the main direction). For some major hemorrhoids that are not in the female hemorrhoid area, choose the primary hemorrhoid area as the peeling point. First select a female hemorrhoid area, sew the hemorrhoidal artery with No. 7 silk thread at the upper pole of the hemorrhoid about 1.0cm (relaxed uplift of rectal mucosa), and suture 3 stitches upwards, about 2-3cm, tighten the ligation and lift the rectal mucosa (Pay attention to the depth of the suture, do not suture too deep, the pain after suture to the sphincter is severe, and the suture of superficial hemorrhoidal artery is incomplete, and hematoma is prone to appear). Then select the more obvious hemorrhoids as the center of a segment, generally divided into three to five segments, between segments as far as possible with the natural depression of the skin on both sides of the hemorrhoid as the boundary, retain the anal canal skin bridge and rectal mucosal bridge, cut the external hemorrhoids Base skin, peel the external hemorrhoid venous plexus from the subcutaneous surface of the external sphincter and the superficial surface of the internal sphincter to 0.5cm above the tooth line, try to keep the Treitz muscle intact. The large curved vascular clamp clamps the base of the internal hemorrhoid along the incision direction. The silk thread is ligated under the forceps of the large curved blood vessel, the peeled off external hemorrhoids and 2/3 of the internal hemorrhoids are cut off together, and the wound edge is trimmed to make the incision "V"-shaped to facilitate drainage. Treat the hemorrhoids in other maternal hemorrhoids in the same way (note the mucosal suture Try not to be on the same level when ligating the hemorrhoid stump. Stagger the ligation up and down to make it stagger into a tooth shape. Keep a skin bridge of no less than 0.3 cm between the adjacent hemorrhoids, and strive to cover the anal canal with a smooth and beautiful skin). Make a minimally invasive incision to remove the extra external hemorrhoids between the two points, and pay attention to removing the sinusoids and varicose veins under the incision. After the operation, use the index finger to extend the human anus to reset the hemorrhoid stump and its descending tissue into the anal canal and rectum, inject the methylene blue and levobupivacaine mixture on the wound edge, and fill the wound with Jingwan red gauze. Covered with a shaped dressing, bandaged with T-band, and fixed with wide tape.
1.2.3 Postoperative treatment: On the same day after the operation, go to the pillow to lie down for 4 hours, enter a semi-liquid diet on the first postoperative day, and a normal diet on the second postoperative day. Among them, 176 cases had defecation on the second day after surgery, 304 cases had a bowel movement on the 3rd day after surgery, and 27 cases had no defecation on the 4th day or more after surgery, and received an enema with 600ml soapy water. Routine anorectal dressing is changed after defecation, and antibiotics are routinely used for 3-5 days to prevent infection.
2.1 Observation indicators: (1) Operation time. (2) Postoperative hospital stay. (3) Postoperative anal pain: refer to the WHO pain level classification standard : 0 grade, no pain or slight falling discomfort; I grade, slight pain tolerable, no need to use analgesics, and does not affect sleep; II grade, If the pain is severe or there is a feeling of falling from the anus, oral analgesics are relieved, which slightly affects sleep; Grade III, the pain is severe, unbearable, seriously affecting sleep, oral analgesics have poor effect, and intramuscular injections of analgesics are needed to relieve them.(4) Secondary bleeding after operation. (5) Urinary retention: refers to the need for catheterization and indwelling catheter on the day after surgery. (6) Edema of wound edge. (7) Postoperative anorectal stenosis. (8) The curative effect judgment standard refers to the "Criteria for Diagnosis and Treatment of Hemorrhoids" . Cure: the symptoms disappear, the prolapsed hemorrhoids are eliminated, and the anal function is normal; improvement: the symptoms are relieved, and the prolapsed hemorrhoids are reduced; unhealed: there is no change in symptoms and signs. (9) The evaluation standard of anal function is according to Hiltunen standard. Normal: the anus controls stool, intestinal fluid, and intestinal gas normally; partial anal incontinence: the anus cannot control loose stool, intestinal juice, intestinal gas, or contaminates underwear; complete anal incontinence: the anus cannot control the formed stool.
2.2 Efficacy All 507 cases in this group were cured with normal anal function. The average operation time was 26.3 minutes. There were no postoperative bleeding, perianal infection, anal stenosis or anal incontinence. Some patients have temporary poor recovery of urinary function, wound-edge edema, etc., which are all relieved after psychological intervention, physical therapy, and bathing. The average hospital stay was 9.1 days. All patients were followed up for 1 to 3 years without recurrence and no long-term sequelae such as anorectal mucosal ectropion, anal stenosis, sensory anal incontinence, etc.
External stripping and internal ligation was first proposed by Miles in 1919. In 1937, Milligan and Morgan at St. Mark’s Hospital in the United Kingdom  improved the operation method, generally called Milligan-Morgan operation, which is currently the most commonly used clinically. One of the surgical methods, their paper "Anatomy of Anal Canal Surgery and Operation of Hemorrhoids" was translated into a classic of the 20th century. In 1975, Thomson  put forward the "theory of shifting down the anal cushion", thinking that hemorrhoids are not only caused by venous stasis caused by varicose veins under the anal mucosa, but also pathological hypertrophy and displacement of the anal cushion. This doctrine is increasingly recognized by everyone, but due to the inconsistency of the doctrine, the diversity of clinical operations has resulted. According to the theory of anal cushion, in 1998, Italian surgeon Antonio Longo  proposed a new method for the treatment of Ⅲ and Ⅳ degree prolapsed internal hemorrhoids by circular resection of the lower rectal mucosa and submucosa tissue, and designed PPH based on this mechanism, but its main The treatment mechanism is not to treat the hemorrhoids itself, but to remove the rectal mucosa above the hemorrhoid area, and pull the prolapsed hemorrhoids back into the anus through traction to achieve the purpose of treatment.
The important principle of modern treatment of hemorrhoids is to protect the anal cushion and restore the pathologically enlarged and displaced anal cushion . It emphasizes that the hypertrophy and lowering of the anal cushion is the pathological basis of symptomatic hemorrhoids. Unrestricted removal of the anal cushion will inevitably lead to the loss of normal anorectal physiological functions, but it does not explicitly deny the traditional multiple mixed hemorrhoids by segmental external peeling. Tie technique. Read et al.  believe that the integrity and sensitivity of the anal cushion are not indispensable factors for control. Although the feeling of the anal cushion plays a certain role in anal self-control, it is not the main one. Therefore, restrictive resection will not affect the anus's bowel control function.
Based on this principle, we modified the traditional surgical procedure, using multiple mixed hemorrhoids external peeling and internal ligation + hemorrhoid mucosal suture, and the hemorrhoid mucosa suture was selected at different points, which effectively avoided postoperative anorectal stenosis. Complications are significantly better than PPH surgery. In addition, it has the following advantages: (1) Suture the hemorrhoid mucosa, which not only ligates the hemorrhoid artery, but also blocks the dilated blood vessels of the hemorrhoid, and makes it shrink and disappear, and the sutured rectum is used The mucosa is used as a suspension fulcrum to restore the prolapsed anal mucosa and skin to the normal anatomical position, which can eliminate the sensory dysfunction caused by the rectal mucosa entering the anal cushion area, and it is also conducive to judge and only deal with the pathological hyperplasia The tissues retain normal anal mucosa, anal skin and anal marginal skin, which protects the fine bowel control ability of the anus to the greatest extent, thereby effectively avoiding the occurrence of anorectal mucosal ectropion, anal stenosis, and sensory anal incontinence. . (2) The scar tissue formed after the external stripping and internal ligation of the pathological tissue can re-fix the anal canal tissue that has returned to the normal anatomical position, and reconnect the Treitz muscle and the anal mucosa through the scar tissue to restore the physiological function of the Treitz muscle. Conducive to the fixation of the anal canal mucosa. (3) Keep a certain amount of skin bridge and mucosal bridge between the hemorrhoids. The subcutaneous varicose vein mass is peeled between the incisions of the external hemorrhoids, which significantly reduces the postoperative perianal skin tags and wound edge edema, and improves the cure of multiple mixed hemorrhoids. It reduces the recurrence rate after surgery.
The following points should be noted during the operation: (1) According to the location, number, shape and space of multiple mixed hemorrhoids, design the hemorrhoid segmentation and the position and distance of the anal canal skin bridge mucosal bridge. (2) Keep a skin bridge of no less than 0.3 cm between two adjacent hemorrhoids, and a mucosal bridge greater than 0.5 cm. At the same time, the internal ligation surface should be on a different plane to avoid postoperative anal stenosis. (3) The "V"-shaped incision for external hemorrhoids should reduce tension to facilitate drainage and avoid edema. (4) When multiple mixed hemorrhoids are cut and ligated in segments, the extra external hemorrhoids between the two points are removed by a minimally invasive incision, and attention should be paid to clear the sinus and varicose veins under the incision. (5) After the operation, the index finger must be used to extend the anus to reset the hemorrhoid stump and its descending tissue into the anorectal canal.
Some patients had no obvious complications or sequelae except temporary poor recovery of urine and bowel function after operation. In short, we use suture ligation of the hemorrhoids + multiple mixed hemorrhoids by segmented external stripping and internal ligation to treat multiple mixed hemorrhoids. Based on the theory of anal cushion, we have improved the traditional external stripping and internal ligation to effectively reduce postoperative bleeding. , The probability of wound edge edema, avoid long-term sequelae such as mucosal ectropion, anal stenosis, sensory anal incontinence, improve the cure rate of multiple mixed hemorrhoids, reduce the recurrence rate after surgery, and it is reasonable and effective to treat multiple mixed hemorrhoids The technique is promoted.
Note: The above patients have been followed up until now. Under normal life and work conditions, they no longer have symptoms of pain, bleeding and prolapse, unpleasant irritation such as spicy food, fatigue, dry stool, etc., mild symptoms in the anus, life improvement or drug treatment for 2-3 days to relieve disappear.