Since 1998, the Italian scholar Longo first reported the application of prolapsed prolapse and hemorrhoids (PPH) to treat prolapsed hemorrhoids. Because of its operation method conforms to the anatomy and physiology of the anal area, the operation is simple and the postoperative recovery is fast. Can be widely used. It has been more than ten years since the introduction of PPH surgery in China in 2000. With the gradual promotion of PPH technology, experts and scholars have also developed some new understandings of PPH technology, and have made improvements and innovations in its technology. The short-term curative effects produced by different operation methods are different. There are also differences in the way of purse-string suture for different patients. The following reports on our department's experience in the use of single-purse-string suture and double-purse-string suture as well as minimally invasive external stripping and internal ligation for the treatment of severe mixed hemorrhoids are as follows.
1 Clinical data
Example 1: A case of severe circular mixed hemorrhoids treated with PPH double purse method (Patient Yang Mouen, male, 43 years old, with anal bulging and prolapse for more than a year, and the recent aggravation cannot be repaid by himself. Date of admission and discharge: 2012, 2, 28- -2012, 3, 6, hospitalization number: 1210458, with pictures)
Example 2: PPH single purse-string surgery + small incision minimally invasive external stripping and internal ligation for the treatment of severe circular mixed hemorrhoids. (Patient Huang Chenghua, female, 57 years old, date of admission and discharge: 2012, 2, 13--2012, 2, 24. Hospitalization number: 1207712. The anal mass prolapsed for several years with blood in the stool, and the anal prolapsed after the stool cannot be returned The patient was admitted to the emergency department for 4 days, and manual reset was performed after admission. At the same time, Taining suppository + indomethacin suppository was used to take the anus, supplemented by conservative treatment such as dehydration, swelling and anti-inflammatory for two days)
Example 3: PPH single purse-string + external stripping and internal ligation for the treatment of severe circular mixed hemorrhoids with partial mucosal prolapse (patient Qiao Zongying, female, 58 years old, hospitalization number: 1206310, admission and discharge date: 2012, 2, 6--2012 , 2, 21, history of hemorrhoids for many years, this time he was admitted to the emergency department for two days due to hemorrhoids prolapsed after defecation. After admission, he received treatments such as repayment, dehydration, swelling, and anti-inflammatory treatment. After local inflammation was slightly controlled, surgical treatment was performed. image)
Example 4: A case of PPH single purse-bag treatment of annular mixed hemorrhoids (patient Wang Yumei, female, 29 years old, hospitalization number: 1213207 admission and discharge date: 2012, 03, 13-2012, 03, 20, anal mass prolapsed 6 years, symptoms worsened , Recent pain and discomfort, cannot be returned to the hospital.)
2 Inclusion criteria
In accordance with the "Interim Standards for Diagnosis and Treatment of Hemorrhoids" formulated by the Anorectal Division of the Chinese Medical Association in April 2000: I degree: hemorrhoids are small, do not protrude, and the hand tissue is bloody or dripping; II degree: hemorrhoids are mostly larger than 1 cm2 , The prolapse can be repaid by itself, dripping or ejecting blood, the amount is large; Ⅲ degree: hemorrhoids are large, the boundaries are not clear, easy to prolapse, need to be repaid, there is little blood or no bleeding in the stool; Ⅳ degree: hemorrhoids prolapse often appear in a ring shape, Prolapse or incarceration, low blood in the stool or blood in the stool. Mixed hemorrhoids are usually formed when internal hemorrhoids develop to degree Ⅲ or higher. Mixed hemorrhoids gradually worsen and protrude out of the anus in a circular shape. When the prolapsed hemorrhoids are plum-shaped around the anus, they are called circular mixed hemorrhoids. This group of cases was included in the scope of the study based on this standard.
3 Surgical methods
The disposable anorectal stapler produced by Changzhou Rexos Medical Device Company, model: XXG-34 (with label). Clean the enema in the morning to remove watery stool. Use spinal or epidural anesthesia. The patient takes the left side lying position, exposes the anus, disinfects the surgical field with conventional iodophor, and drapes. After the inner core of the anal expander slowly expands the anus, the anal expander is inserted and fixed to the skin of the anal margin. Single purse-string suture group: With the upper edge of the hemorrhoid as the boundary, a purse-string suture is made clockwise from the largest hemorrhoid along the submucosa; the double purse-string suture group: 4 cm on the tooth line, 6 o'clock from the left side (chest and knee) Start at 9 o'clock) in the rectal submucosa to make the first purse-string suture clockwise, and then make the second purse-string suture 1~2 cm below the first purse-string from the left side at 12 o'clock clockwise to prevent prolapse In severe cases, the second purse-string position can be properly downwards to include the upper part of the hemorrhoids with severe prolapse. Insert the tip end of the PPH stapler that has been expanded to the maximum extent over the purse-string suture, tighten the suture and tie the knot, and hook the knotted suture at the corresponding side hole of the stapler with the hook threader Tie the knot, pull the knotted thread to the handle, so that the sutured and ligated mucosa and submucosal tissues enter the stapler sleeve, tighten the stapler to the safety compartment, open the safety device and fire, press for 30 s, and the anastomosis will be Open the device counterclockwise and take it out. Carefully check the anastomotic site. The bleeding site is sutured with absorbable thread to stop bleeding. In the operation, the external hemorrhoids that are not significantly retracted are selected to make a fusiform incision in time, and the external hemorrhoid venous plexus is peeled off. If the external hemorrhoids are large, they are peeled off to both sides. Each time, 3 to 5 places are cut and the tooth line is retained to fully stop the bleeding. Appropriate use of anti-infection and hemostatic drugs after surgery. The liquid diet was given from the next day.
All patients recovered smoothly after the operation. The operation effect was good (photo attached). There was no bleeding after the operation. After eating and drinking the next day, the stools were unblocked without blood in the stool, and the postoperative perianal appearance was good.
The treatment of prolapsed hemorrhoids by PPH is based on the theory of "anal cushion". The "anal cushion theory" believes that there is a 1.5-2.0 cm wide annular tissue band above the tooth line of the human anal canal. This tissue band is thick and soft. Think its
It is a highly specialized vascular cushion composed of smooth muscle fibers, connective tissue and vascular plexus. The anal subcutaneous smooth muscle and the combined longitudinal muscle play an important role in the anal cushion. The joint longitudinal muscle is composed of three layers, inner
The layer is the extension of the longitudinal rectal muscle, the middle layer is the levator ani sling, and the outer layer is the extension of the top ring of the external sphincter. The three layers form a central tendon below the inner sphincter, and many fibrous septa are separated from the tendon. The fibers emitted from the central tendon partially pass through the internal sphincter, and are mixed with the internal sphincter fibers and elastic tissue fibers, as well as the striated muscle fibers of the adjacent external sphincter, forming a fiber complex, and finally continuous with the anal subcutaneous smooth muscle. Up to
The role of suspending anal mucosa. This fiber composite is densest at the tooth line, and in the entire circumference of the anal canal, there is one place on the left side and two places on the right side, which are equivalent to the 3, 7, and 11 points of the lithotomy.
The advantage of PPH is to avoid the removal of hemorrhoids to the greatest extent, and to retain the normal anal cushion. By circularly removing the rectal mucosa and submucosal tissues that are close to the anal cushion above the dental line, the anal cushion and anal canal are completely upward. Suspension, at the same time, cut off the blood vessels that supply the anal cushion in the mucosa and submucosa, reduce the blood supply of the anal cushion after the operation, and the hemorrhoids gradually atrophy, on the one hand, it relieves the symptoms, on the other hand, it effectively retains the fine bowel control ability of the anal cushion. Therefore, the key to PPH surgery is to remove part of the rectal mucosa and submucosal tissue.
Purse-string treatment in PPH surgery is related to the width, depth, and integrity of partial rectal mucosal resection, as well as the suspension, fixation, and devascularization of hemorrhoids. It is closely related to the success or failure of the operation. The processing of the purse string is embodied in the processing of many links such as the height and depth of stitching and the type of purse string stitching.
1) The height of the purse string: The height of the purse string suture is directly related to the suspension and fixation of hemorrhoids and the relief of hemorrhoids. It is also related to the protection of the anal cushion, postoperative anal pain, swelling feeling and rectal stenosis, and is related to postoperative hemorrhoids. Whether it relapses also has a crucial impact. If the position of the purse string suture is too high, the upward pulling and sling effect of the anal cushion caused by the operation will be weakened, and the operation effect will be poor. If the position of the purse-string suture is too low, part of the anal cushion is often removed together. Although the effect of hanging the anal cushion upward is obvious, there is more bleeding at the anastomotic site during the operation. In addition, if the anal cushion is removed too much, the patient will have an anus after surgery. Department of discomfort, increased stool frequency. Regarding the height of the purse string suture, there are large differences reported by scholars at home and abroad. Some foreign scholars reported that it should be 4~6 cm on the tooth line. Liao Jiannan et al.  believed that the purse string suture should be about 3~4 cm on the tooth line. After anastomosis, the anastomosis is 1~2 cm on the tooth line, which can achieve the ideal anal cushion lifting and reduce intraoperative bleeding and anal discomfort. Most surgeons use the dentate thread as the basis for the positioning of the purse-string or the operating specification. However, many surgeons raise objections to the dentate thread alone to determine the height of the purse-string suture. The upper part of the dentate line is the internal hemorrhoids, and the lower end of the rectum above the internal hemorrhoids is where the purse-string suture is to be performed. The dentate line as a reference is too far away from the purse-string suture, and it is difficult to accurately locate it. Hou Wenying et al.  believe that a considerable number of patients with prolapsed hemorrhoids have blurred or even completely disappeared dentate lines, and they cannot be identified even after the anus is enlarged and a transparent sleeve is placed. At the same time, the size of hemorrhoids in some patients is very different. Large and asymmetrical, the dentate line is not on the same plane, so it is difficult for the dentate line to play a good role in positioning. Li Shenglong et al.  proposed to use the upper edge of the hemorrhoid as the main basis, while referring to the position of the dentate line and the size of the hemorrhoid for the location of the purse-string suture. For smaller hemorrhoids, the anastomosis is designed directly above the hemorrhoid, and the purse-string suture is generally determined in it. The upper edge of the larger hemorrhoid is 1.5~2.0 cm. For larger and huge hemorrhoids, the upper end is considered to be partially removed. The purse-string suture is generally determined at 0.5~1.5 cm of the upper edge of the largest hemorrhoid, and the anastomosis is designed in the hemorrhoid. The top half.
2) The depth of the purse string: The depth of the suture is mainly related to the width and completeness of the tissue resection, which affects the suspension and cut-off effect.If the suture is too deep, it is easy to pull the muscle tissue into the cutting groove, injure the muscular layer or the entire layer of the rectum, cause uneven cutting, or cause postoperative rectal stenosis, or even anastomotic leakage. For female patients, it may also accidentally injure the back wall of the vagina and cause a recto-vaginal fistula. If the suture is too shallow, less tissue will enter the staple cartridge after traction, which will result in less tissue removed, and the width of the resection is not enough. In addition, if the suture is too shallow, mucosal tears and hematomas are prone to occur, and the anastomosis is not easy to adhere to the muscle layer, which affects the suspension effect. The appropriate suture depth should be controlled in the submucosal layer to prevent penetration into the muscle layer. Liao Jiannan et al.  believe that under this premise, the depth of the suture should be as deep as possible. There are two advantages: First, when the volume of the anastomosis chamber is certain, Deeper sutures will bring in more tissues, and the mucosal suspending effect will be better; secondly, more tissues will be drawn into the tissues, the anastomotic tissue will be thicker, the pressure will be uniform, and the hemostatic effect will be better. The specific operation requires the surgeon to have a good feel. The judgment method is that the needle is inserted smoothly when the needle is sutured, and the needle can slide horizontally when the needle is not discharged, and there is room for movement.
3) Selection of needle entry point: The choice of needle entry point also has a non-negligible impact on the overall efficacy of PPH. Most surgeons choose the starting point for needle insertion at 3 and 9 o'clock in the thoracic and knee positions, which is less effective for hemorrhoids with large prolapses such as 6 and 12 o'clock. The starting and ending point of the purse string is the place where the force of the traction line is the greatest, and the mucosa that is drawn into the cutting groove is the most. Therefore, Zhang Zhenyong et al.  selected the prominent part of the hemorrhoids to start the needle insertion, and the needle was taken out from the same point after 1 week of suture. The effect of moving up the prolapsed hemorrhoids is more obvious. I still choose to insert the needle from the left side lying position at 6, 12 o'clock (equivalent to the chest and knee positions at 3, 9 o'clock), so as to prevent female patients from pulling the anterior wall of the rectum too much, causing vaginal damage and causing rectum Vaginal fistula.
4) Types of purse-string suture: There are indeed many disputes about which purse-string suture method is used for PPH. The usual single purse-string suture refers to the continuous suture under the anorectal mucosa. The operation is simple.
The operation time is short and there are few intraoperative complications, but because of only a little traction, the resection of the hemorrhoid mucosa is not wide enough, or incomplete and uneven, which increases the incidence of postoperative complications such as anal edema and hemorrhoid recurrence and prolapse. During the operation, I preset or sew a traction thread on the opposite side of the needle entry point, so as to avoid the above shortcomings. Fu Chuangang et al.  reported that the average width of the rectal mucosal ring of single purse-string resection was about 1.5 cm, which was less than the theoretical width, and the lifting effect on the anal cushion was limited. For severe hemorrhoids of stage III and IV, double purse-string sutures can be used, and the resection width of the mucosa can be controlled by the distance between the two purses, which can achieve effective resection width and postoperative anal margin retraction, and has a therapeutic effect on severe prolapsed hemorrhoids good. Therefore, most people think that the method of suture should be determined according to the degree of hemorrhoid prolapse. For prolapse length <3.0 cm, a single purse-string suture can achieve the therapeutic effect, and for those with a length of> 3.0 cm, double purse-string suture is appropriate. When double purse-string suturing is performed, the distance between the two purse-strings should not exceed 1.5 cm. If the distance is too long, due to the limited capacity between the staple cartridges of the stapler, part of the double purse-string mucosa will be stuck in the anastomosis, resulting in poor healing of the anastomosis, or The nailing mucosa is too thick, resulting in poor rebate of the titanium nail and bleeding in the anastomosis. Ke Changqing et al.  reported that the double purse-string suture was too wide,> 1.5 cm, which caused uneven traction of the tissue into the staple cartridge, resulting in anastomotic tear or incomplete staples, and 11 cases of staple loosening. Therefore, Yan Jiang et al.  performed a secondary stapling prolapse and hemorrhoid mucosal circumcision. After the first PPH operation, if there is still part of the mucosal prolapse, it is then 0.5 to 1.0 cm below the original anastomosis. Then carry out a full-week purse string suture.
The success or failure of every link in PPH surgery will affect the final result of the operation, especially the choice of purse string, the suture height and depth of the purse string, which have a direct impact on the integrity of the resected tissue and the width of the resected tissue.
The relationship between the hemorrhoids is related to the clinical effect of hemorrhoid suspension and fixation. The author believes that for different conditions and prolapse of hemorrhoids, different surgical methods should be adopted, instead of blindly using single or double purse strings, emphasizing personalized purse-string suture is more beneficial to the development of PPH surgery.
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