The Anorectal Surgery Group of the Chinese Medical Association Surgery Branch specially formulated the "Interim Specifications for Hemorrhoid Mucosal Circular Resection and Stapling (PPH)", which elaborated on the clinical indications of PPH. We should strictly grasp the surgical indications in clinical practice and not blindly The expansion of the scope of surgery can only cause a huge economic burden on patients.
Revision of "Interim Specifications for Circular Resection and Stapling of Hemorrhoids (PPH)"
Anorectal Surgery Group, Chinese Medical Association Surgery Branch
1. PPH indications 1. Internal hemorrhoids of degree III and IV with annular prolapse, and degree II internal hemorrhoids with repeated bleeding.
2. The anterior rectal bulge and intrarectal prolapse leading to obstructive constipation at the functional outlet.
2. Preparation before PPH operation
1. Routine blood tests, coagulation function, and ECG if necessary.
2. Oral medicine to clean the enema on the evening before surgery, or enema on the morning of surgery. (One bottle (20ml) was injected into the anus in the evening before the operation and in the morning of the operation).
3. Those who use intraspinal anesthesia or general anesthesia are forbidden to eat or drink every morning.
3. PPH intraoperative operation
1. Use local anesthesia, intraspinal anesthesia or general anesthesia. Take the folding knife position, the stone cutting position or the side lying position.
2. Use a circular anal tube expander to expand the anus, and place a transparent anal mirror under the guidance of the anal expander and fix it. If the prolapsed hemorrhoid tissue is too much, it is advisable to use non-invasive forceps to pull outside the anal canal to facilitate insertion, and then reset the pulled tissue after fixation. The mucosa of the hemorrhoids should be fully exposed.
3. According to the condition of the disease, make a purse string suture 2.5~4.5cm on the dentate line under the exposure of the anal mirror suturing device. Single purse-string suture or double purse-string suture is feasible. If double purse-string suture is performed, the spacing should be about 1.0 to 1.5 cm. Purse-string sutures should all sneak into the submucosa and remain at the same level. Purse-string sutures should be inserted as far as possible from the point of needle exit, generally 3-7 stitches are appropriate.
4. Unscrew the circular stapler to the maximum position, introduce the nail bit and place it on the purse string, tighten the purse string and tie it up. Pull the end of the purse string from the side hole of the stapler with a wire tie.
5. Pull the purse string moderately and tighten the stapler at the same time, and send the circular stapler into the anus to the 4cm mark. Female patients should take care to prevent accidental injury to the back wall of the vagina.
6. Fire the stapler, loosen the handle, and wait for 30s. Unscrew the stapler 1/2 to 3/4 turn and remove it to check the integrity of the excised mucosa.
7. Carefully check the anastomosis. In case of active bleeding, it must be sutured with absorbable thread to stop the bleeding.
Four, PPH postoperative treatment
1. Observe for bleeding (including early and delayed bleeding).
2. A protective agent for the rectal mucosa can be inserted to facilitate wound healing and defecation.
3. Treat urinary retention and pain accordingly.
4. Prophylactic antibacterial drugs should be given appropriately.
5. Eat after recovery from anesthesia, and avoid irritating food.