In recent years, as people's understanding of the nature of hemorrhoids and the mechanism of hemorrhoids continues to deepen, great changes have taken place in the concepts and methods of hemorrhoid treatment. The traditional concept believes that the three mucosal masses located on the right anterior, right posterior, and left center above the tooth line are abnormal structures, namely internal hemorrhoids. Therefore, there is a saying of "ten men with nine hemorrhoids and ten women with ten hemorrhoids". Based on the above-mentioned understanding, the treatment method and treatment concept adopts "every hemorrhoids must be cured", and strives to completely eliminate the "hemorrhoids" (anal cushion) structurally. In 1975, Thomson first proposed the theory of anal cushion based on his research results, that is, the traditional idea that the anal cushion is actually the normal anatomical structure of the anal canal. Its essence is not the pathology of local varicose veins caused by various reasons. Sexual venous mass is a blood vessel mass composed of special arteriovenous communication. Although it is similar in appearance to a vein, there is no muscle layer in the blood vessel wall. Therefore, unlike veins, this blood vessel mass has a vascular cavernous effect. Fine control is of great significance. In 1994, Loder further proposed the hypothesis of the anal cushion in the occurrence of internal hemorrhoids, that is, it occurs because the suspensory ligament Treitz muscle and the Park ligament that fix the anal cushion are damaged or broken, which leads to the prolapse and movement of the anal cushion.
Based on the above understanding, in recent years, more and more scholars in the concept of treatment have given up the concept that every hemorrhoid must be treated, and instead only treat symptomatic internal hemorrhoids. The purpose of treatment is to eliminate hemorrhoids in the past. The purpose is to eliminate the symptoms. In terms of surgical methods, the hemorrhoids were removed anatomically as thoroughly as possible in the past. Instead, the prolapsed anal cushion was reset by surgery, and the structure of the anal cushion was preserved as much as possible during the operation to achieve postoperative failure. Influence or as little as possible the purpose of fine stool control. Surgical treatment of hemorrhoids is mainly based on prolapsed internal hemorrhoids and mixed hemorrhoids with obvious symptoms, especially the circular prolapsed internal hemorrhoids. Commonly used surgical methods mainly include external stripping and internal ligation and hemorrhoid circumcision, the essence of which is to anatomically remove the internal hemorrhoids that increase prolapse. In 1998, Italian scholar Long et al., based on the new theory of internal hemorrhoid formation, reported a new method for the treatment of stage Ⅲ and Ⅳ annular prolapsed internal hemorrhoids by circular resection of the lower rectal mucosa and submucosa tissue-procedure for prolapse and hemorrhoids, PPH). Because this surgical method is in line with physiology, the operation is simple, and the postoperative complications are few, it has been quickly widely promoted and applied at home and abroad.
1 External stripping and internal ligation was first proposed by Miles in 1919. In 1937, Milligan and Morgan of St. Mark’s Hospital in the United Kingdom improved the operation method. It is currently generally called Milligan-Morgan surgery or external stripping and internal ligation. The most commonly used surgical method in clinical practice. The main point of this operation is to make a V-shaped incision with the tip outward at the junction of the skin and mucous membrane of the inferior pole of hemorrhoids, peel it up to the root of the hemorrhoid along the surface of the internal sphincter, and cut the hemorrhoid tissue with local suture and ligation. The advantage is that the operation is simple, and the effect of radical treatment of single or relatively isolated internal hemorrhoids is good. The disadvantage is that only 3 hemorrhoids can be removed at a time, and a certain mucosal bridge needs to be preserved between the 3 female hemorrhoid wounds. Otherwise, it is easy to cause anal stenosis after surgery, and the postoperative recurrence rate can reach about 10%. In addition, postoperative anal edema is often accompanied by obvious pain and long time; wound healing is slow, usually takes 3 to 4 weeks; if too much tissue is removed, postoperative anal incontinence or anal The tube is narrow. In order to reduce postoperative anal pain, many scholars have tried many new methods in recent years, such as hemorrhoidectomy and partial resection of the lateral internal sphincter, using electric knife or laser knife instead of scissors or ordinary scalpel to cut the skin, and during surgery The wound skin was sutured at one stage to shorten the healing time of the wound after surgery, but the effect was not obvious.
2 Circumcision of hemorrhoids was first reported by Whitehead in 1882. It is mainly suitable for internal hemorrhoids with annular prolapse or annular mixed hemorrhoids. It was later improved by Saresola and Klose in the 1940s. It is generally called Saresola-Klose method or Klose method. Also known as the Whitehead method. The basic point of this operation is to separate upward along the surface of the internal sphincter muscle at a position 0.3~1.0cm above the tooth line, circularly excise the lower rectal mucosa, submucosal tissue and all hemorrhoid tissues with a width of about 2~3cm, and combine the rectal mucosa with the anal mucosal skin Stitched. The advantage is that the hemorrhoids are completely removed and the postoperative recurrence rate is low, but the disadvantage is that the operation time is long and the intraoperative bleeding is much. 10%~13% of the patients after the operation are accompanied by more serious complications, such as anal stenosis and extramucosal Sensory fecal incontinence caused by turning, anal canal sensory loss, etc., are currently less used.
3 Stapling hemorrhoidectomy (PPH) Stapling circular hemorrhoidectomy, also known as prolapsed hemorrhoid mucosal ring resection and anal cushion suspension. The essence of stapler surgery for hemorrhoids is to preserve the integrity of the anal cushion. A special stapler is used to circularly remove the mucosa and submucosal tissues of the intestinal wall of the lower rectum above the hemorrhoids (in principle, the hemorrhoids are not removed, but for large hemorrhoids) For severely prolapsed circular hemorrhoids, the upper part of the hemorrhoids can be removed at the same time), and at the same time, the distal and proximal mucosa are anastomosed, so that the prolapsed internal hemorrhoids are suspended and pulled upwards and no longer prolapse. Since the arteries in the submucosal layer that supply hemorrhoids are cut off at the same time, the blood supply of hemorrhoids decreases after surgery, and the hemorrhoids gradually shrink about 2 weeks after surgery.
The operation has been reported abroad since 1998, and has been performed in China since July 2000. The number of surgical cases and complications reported in the literature are still relatively small. According to the author and limited literature reports, the main common complications after surgery are: (1) Urinary retention: The incidence is about 40%~80%. There are more men than women. Patients who use spinal anesthesia are significantly higher than those who use sacral or local anesthesia. Its occurrence may be related to anesthesia and postoperative anal pain and stimulation. (2) Anal pain: Theoretically speaking, there is no wound on the perianal skin during PPH operation, and there should be no pain in the anus after the operation. However, due to the sufficient expansion of the anus during the operation, the skin of the anal canal is often torn. In addition, the intraoperative clamping of the perianal skin may also be the cause of postoperative anal pain, but the pain time and pain level are significantly less than those of external stripping and internal ligation, mainly on the night of the operation, and the next day. For relief, analgesics are generally not required. (3) Lower abdominal pain: Approximately 10% of patients complained of traction in the lower abdomen when the stapler was fired, and some patients even experienced vomiting. About 15% of patients complained of lower abdomen pain on the day after surgery. The exact mechanism is not clear. It may be related to the traction reflex of the intestine during anastomosis. Generally, no special treatment is needed. It can relieve itself the next day after the operation. Some severe cases The patient can be relieved by intramuscular injection of atropine or anisodamine. (4) Bleeding: There are two situations, one is intraoperative bleeding at the anastomotic site. In the author's group of surgical patients, about 30% of patients can see pulsating bleeding at the anastomotic site after anastomosis, most of which are located in 3. The site of female hemorrhoids, especially the right front of the anastomosis is the most common, followed by the right back and left center. The location, quantity, and severity of pulsating bleeding of the anastomotic stoma are related to the distance between the anastomotic stoma and the tooth line. The higher the distance, the less bleeding. On the contrary, if the anastomotic stoma is closer to the tooth line, that is, the anastomosis is located in the middle of the internal hemorrhoids. When internal hemorrhoids are removed), there is more bleeding, which is related to the abundant blood vessels near the dental line. For fluctuating bleeding, authors routinely use local sutures to stop bleeding, but many authors did not pay enough attention to this in the early stage of the method. It is reported that about 10% of patients need to be treated with local hemostasis after surgery, and some patients even have local bleeding. Cause severe hemorrhagic shock. Therefore, the author emphasizes that after intraoperative anastomosis, it is necessary to carefully check whether there is fluctuating bleeding at the anastomosis and perform corresponding treatment. The other is blood in the stool after surgery. Most patients have less bleeding and can last for about 1 week. The amount of bleeding is relatively small and no special treatment is required. (5) Anal sensory disturbance: If the anastomosis is too close to the tooth line, some patients will experience local swelling in the early postoperative period, and even cannot feel the excretion of feces. Mild fecal incontinence occurs, which usually recovers about 2 weeks after the operation. . (6) Infection: Molloy reported 1 case of pelvic infection and death after operation. (7) Rectovaginal fistula: Roos reported 1 case of rectovaginal fistula caused by local infection of the anastomosis.
Several problems should be paid attention to during surgery: (1) The position of the purse-string suture is moderate: generally it should be about 3~4cm above the dentate line, that is, the anastomosis is 1~2cm on the dentate line, and the position of the purse-string suture line is too high. Low level will cause excessive resection of the anal cushion, easy bleeding at the anastomotic site during and after the operation, sensory disturbance of the anal canal in the early postoperative period, and sensory fecal incontinence; and the position of the purse-string suture is too high, which will pull the anal cushion upward. The suspension effect is weakened, and the retraction of the hemorrhoids is not obvious or even ineffective. (2) The depth of the purse-string suture: The depth of the purse-string suture should be in the submucosa. If the suture is too shallow, it will easily cause mucosal tears during traction. It has been reported that the resection circle of some patients is incomplete. The reason may be that the purse-string suture is partially The position is sutured too shallowly, and the local mucosa tears when the purse-string is knotted or pulled, and the mucosa at this site cannot be effectively removed. If the suture is too deep, it is easy to damage the internal anal sphincter and cause postoperative anal incontinence. (3) The suture and ligation should not be too tight, otherwise the intestinal wall will be tightly tied to the center rod of the anastomotic ring, which will affect the downward pull. (4) The number of purse string sutures should be determined according to the degree of prolapse. In Longo and later literature reports, a single purse-string was used, but the author found that most of the specimens removed when a single purse-string was made are uneven, that is, more suture pulling parts are resected, and less tissue is resected on the opposite side.In addition, the narrow width of the removed tissue is not effective for patients with severe prolapse. According to the author’s experience, the upper and lower width of the bowel wall resection is related to the degree of suture pulling downwards, the number of purse-string sutures and the distance between the two purse-string sutures. The greater the degree of pulling downwards, the more it enters the gap in the stapler. The more intestinal wall, the wider the width of the resection. The width of the excision of two purses is wider than that of one purse. Similarly, the wider the distance between the two purses when two purses are made, the wider the upper and lower width of the tissue removed. . Therefore, the width of intestinal wall resection should be determined according to the severity of internal hemorrhoids prolapse. For patients with severe prolapse, the corresponding resection width should be wider. Two purses can be made to draw deeper into the stapler. Conversely, patients with mild prolapse can only have one purse string suture. For patients with asymmetrical prolapse, a half purse-string stretch can be added to the more severe side of the prolapse to make more excisions at this site. (5) Female patients should avoid the retractor on the anterior wall of the rectum. At the same time, check whether the posterior vaginal wall is pulled into the stapler before closing the stapler and before the stapler is fired, to prevent damage to the posterior wall of the vagina and cause rectovaginal fistula.
In short, as people's understanding of the mechanism of hemorrhoids and the anatomy of anal canal and rectum continues to deepen, the methods of hemorrhoid surgery are also continuously improved, and the purpose is to focus on how to be more physiologically, and reduce or eliminate preoperative symptoms while reducing postoperative symptoms. Pain, shorten the postoperative hospital stay, and reduce the possible complications after the operation. As a new method, the stapled hemorrhoidectomy has many advantages compared with traditional surgical methods, but due to the shorter development time , The long-term effect still needs further follow-up observation.