Zhi Jianwen 1, Ni Guowei 2, Ai Meng 3, Guidance: Kou Yuming 1, Jiang Zaiyang 4
(1. Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053; 2. Beijing University of Chinese Medicine, Beijing 100029;
Keywords: circular mixed hemorrhoids; external hemorrhoids resection and suture; internal hemorrhoids ligation and injection; Kou Yuming
Annular mixed hemorrhoids have a high incidence in hemorrhoids and are one of the 16 refractory diseases in the anorectal department announced by the State Administration of Traditional Chinese Medicine . In addition to the prolapse of objects from the anus during defecation, this disease is also accompanied by frequent stools with blood; if the prolapsed mass cannot be returned in time, it will cause incarceration and necrosis, which will seriously affect the patient's physical and mental health and quality of life.
The external hemorrhoids of this disease are distributed in 360°, and normal skin is often not separated between hemorrhoids and hemorrhoids. The pathological form is characterized by connective tissue hyperplasia and varicose veins; internal hemorrhoids are generally above Ⅱ degree , and clinical treatment is more difficult. Teacher Kou Yuming has been engaged in the diagnosis and treatment of anorectal diseases for more than 30 years. As one of the first batch of well-known veteran Chinese medicine practitioners in the Ministry of Health, he has won the true biography of the famous anorectal disease expert Zhou Jimin and veteran Chinese doctor. The surgical method of ligation and injection of internal hemorrhoids has achieved satisfactory results. Because of its thorough treatment, less pain for patients, ideal long-term curative effect, and will not cause sequelae such as anal stenosis, anal canal skin defect, etc., it is very popular with patients. The author is fortunate to learn from the teacher and has benefited a lot. Now I will introduce his experience in the treatment of circular mixed hemorrhoids.
1. Preoperative preparation
Master Kou made detailed surgical plans for patients of different ages, genders, and physical conditions, including bowel preparation, anesthesia methods, surgical incisions, etc., so that he knew well. Particular attention is paid to the conversation with the patient before the operation, to eliminate the doubts of the patient, and to reduce the influence of the patient's psychological factors on the operation and the operation.
2. Surgical method
The patient was placed in a lateral position, routinely disinfected the skin of the operation area with iodophor, and after spreading sterile towels, 0.5% lidocaine underwent infiltration anesthesia at 3, 6, 9, 12 points, and 0.5% lidocaine plus a little adrenaline for local external hemorrhoid infiltration anesthesia. Routinely disinfect the anal canal and lower rectum, expand the anus with the index finger or trumpet anoscope, and then touch the arterial pulse above the maternal hemorrhoid area with the index finger, and mix with 0.5% lidocaine and Xiaozhiling injection into a 1:1 concentration injection Liquid (1ml 0.5% lidocaine plus 1ml Xiaozhiling injection), according to four-step injection (the first step is injected into the superior rectal artery area; the second step is injected into the submucosa; the third step is injected into the lamina propria ; The fourth step is to inject in the cavernous vein area), and determine the injection dose according to the size of the hemorrhoids and the relaxation of the rectal mucosa. After the injection is completed, the index finger is gently inserted into the internal hemorrhoid area to make the liquid medicine evenly distributed in the injection area. Then underwent external hemorrhoid dissection. First select the external hemorrhoids in the mother hemorrhoid area for peeling. Use hemostatic forceps to lift the external hemorrhoids into a "V" shape, make a radial incision, and extend it to 0.5cm on the tooth line. Clamp the base of the peeled external hemorrhoids with curved forceps and clamp it together with the internal hemorrhoids above it, and then ligate the base of the internal hemorrhoids with clamp with "7" silk thread, except for the hemorrhoid flap and part of the ligated internal hemorrhoids . Other external hemorrhoids are treated in the same way. The skin bridge of the anal canal between the external anal incision and the incision is often wrinkled and protruding, so the skin bridge is cut transversely, the external hemorrhoidal venous plexus or hyperplastic tissue is peeled off under the skin, and the excess skin is removed, and a small triangular needle "1" is used. Silk thread sutures the skin. After the operation, the indomethacin suppository is placed in the anus, and it is pressure-wrapped with petroleum jelly gauze, gelatin sponge or collagen sponge.
3. Surgery features
This procedure requires maintaining the natural expansion of the anus, so local infiltration anesthesia is extremely important. Master Kou generally uses infiltration anesthesia at 3, 6, 9, and 12 o'clock. To avoid damage to male prostate or female vagina, special attention should be paid to infiltration anesthesia at 12 o'clock. It is forbidden to insert the needle too deeply, and the anesthetic solution should be appropriate. During infiltration anesthesia, the needle of the syringe should not go straight in. The needle tip should deviate from the anal canal and be at a 45° angle with the longitudinal axis of the anal canal to avoid direct injection of the anesthetic liquid into the internal hemorrhoids and artificially cause the internal hemorrhoids to enlarge.
3.2 The use of Xiaozhiling
For internal hemorrhoids injection of Xiaozhiling, the injection dose should be determined according to the size of the hemorrhoids and the laxity of the rectal mucosa. Each hemorrhoid should be injected in sufficient amount, otherwise the treatment effect will not be achieved. When injecting each hemorrhoid, it should be divided into different levels to avoid injection into a ring at the same level, which may cause anal stenosis. Need to take out the needle slowly to prevent excessive bleeding of the hemorrhoids. After the injection, the injection liquid must be rubbed evenly to prevent local necrosis due to uneven injection.
The choice of surgical incision for external hemorrhoids during operation is particularly important. Excessive resection of the anal canal skin should be avoided, and attention should be paid to the aesthetics of the incision after healing. Master Kou usually sets 4 to 6 surgical areas according to the different shapes and sizes of hemorrhoids; he emphasizes that it is better to make more incisions than to remove or damage the skin and mucosal bridges in a large area at a time to avoid postoperative Skin defect of the anal canal.Incision selection includes the following principles: ① Lift the external hemorrhoids in a "V" shape, and the incision is radial fusiform, 0.5 cm from the upper end to the tooth line, and 0.5 to 0.8 cm from the lower end to the outer edge of the external hemorrhoid; ②The incision should be trimmed in parallel, try not to Resection is too deep, so as not to damage the superficial layer of the external sphincter, trim it smoothly to facilitate drainage; ③The incision should not be too wide to prevent damage to the perianal and anal skin; ④The incision should be long enough to facilitate decompression and drainage, and prevent Postoperative edema and pain; ⑤The width of the anal canal skin bridge between the incision and the incision should be kept at more than 0.5cm, and the skin bridge outside the anal margin often appears wrinkle-like protrusions. Master Kou advocates making a transverse incision to cut off the skin bridge and cut off the part. The skin of the anal canal should be preserved at the inner and outer side of the anal margin as much as possible, the external hemorrhoid venous plexus or hyperplastic tissue should be stripped under the skin, the excess skin should be removed, and the skin should be sutured with a small triangular needle "1" silk thread.
When the curved vessel clamp is used to peel off the base of the external hemorrhoids, the position should be appropriate, and the direction of the clamp should be parallel to the longitudinal axis of the anal canal. The clamping site should be at the base of the peeled external hemorrhoids and 0.5cm on the tooth line, and the mucosal should be moderately tight. Appropriate. The internal hemorrhoids should be clamped as little as possible to prevent excessive damage to the mucosa and cause rectal stricture. Care must be taken when clamping, not to damage normal tissues. The remaining hemorrhoids are ligated with "7" silk thread. Because the ligation position is higher (on the tooth line), the wound pain is greatly reduced.
After the operation, Master Kou paid special attention to the compression bandaging of the incision, requiring that the tape should be attached to the inner thigh as much as possible, and the compression bandage should be firm. Although this will cause a significant foreign body sensation in the anus after the operation, it can greatly reduce the possibility of postoperative bleeding.
In addition, the operation during the whole operation should be gentle and meticulous. Whether in ligating internal hemorrhoids or peeling external hemorrhoids, the hemorrhoids should not be forced to be pulled, and should be in a natural tension-free state. Avoid excessive clamping of the anal canal tissue, and the incision must be trimmed neatly to avoid postoperative pain in the anus and induce dysuria or urinary retention.
4. Postoperative treatment
After surgery, broad-spectrum antibiotics are generally taken for 3 days, stool control is 48 hours, no fasting is required. Take a bath with warm water before the first bowel movement to facilitate defecation and prevent edema of the incision caused by hard work. After defecation, use the Chinese medicine "Qu Du Tang" for clearing heat and detoxification, promoting blood circulation and reducing swelling. Routinely use chlorhexidine to clean and disinfect locally, change the dressing with gauze strips of Shengjiyuhong ointment, and remove the stitches on the 3rd or 4th day depending on the incision.
Paying attention to postoperative dressing change is an important part of reducing postoperative infection and edema. When changing the dressing, chlorhexidine must be thoroughly cleaned and disinfected locally. As the anal sphincter contraction after defecation, the stool is likely to remain in the incision, so special attention should be paid to the cleaning of the incision. Because the local appearance of the anus was "sag", Master Kou suggested that the gauze should be folded and placed in the "sag" when changing the dressing, and clean gauze should be applied to the outside and tape to fix it. This can play a role in pressure, thereby reducing the possibility of edema.
At present, the clinical treatment of circular mixed hemorrhoids mostly uses circumcision and ligation. The former is likely to cause severe mucosal ectropion, mucus flow and pain in the anal canal due to the removal of too much skin of the anal canal; at the same time, the removal of the low rectal mucosa and anal canal destroys the normal bowel reflex and causes sensory anal incontinence; some patients Rectal stricture occurs due to scarring. Although the latter uses internal hemorrhoids suture and external hemorrhoids peeling open method, it cannot completely avoid complications and sequelae such as postoperative hemorrhage, anal stenosis, etc.; domestic and foreign peeling and internal ligation are mostly due to skin bridge folds, incisions and The skin bridge is very easy to swell, and there are still uneven external hemorrhoids in the anus after the operation. Therefore, it is still not an ideal method .
In the surgical treatment of circular mixed hemorrhoids, reducing the damage to the perianal and anal canal skin and rectal mucosa is the direction of surgery to improve . Kou believes that the aesthetics of the anal margin after surgery is also an ideal requirement for surgery. Surgical methods for external hemorrhoids resection and ligation and injection of internal hemorrhoids. Because a certain amount of anal canal skin bridges are reserved, the suturing is uneven, the ligation area is small and the painless area on the tooth line, so there is generally no anal epithelial defect or mucosal ectropion After sequelae, the postoperative pain is also mild, and the pain usually disappears within 24 hours. The injection of sclerosing agent into the hemorrhoid artery area and hemorrhoids reduces the chance of postoperative hemorrhage. After the operation, the Chinese medicine "Qu Du Tang" for clearing away heat and detoxifying and promoting blood circulation and swelling is used to bathe. Generally, there is no edema, and the incision is accelerated. Heals and shortens the treatment time.
2. Kou Yuming. Clinical study of 120 cases of circular mixed hemorrhoids treated by external hemorrhoids resection and suture and internal hemorrhoid injection [J]. Armed Police Medicine, 1997, 8 (1): 23
3. Chen Weiwei. Liang Linjiang's experience in treating circular mixed hemorrhoids [J]. Sichuan Traditional Chinese Medicine, 2003, 21 (3):