Wang Weitao Cui Wenjuan Han Ruifeng Liu Bing
Abstract In order to solve common complications such as anal stenosis, mucosal ectropion, and residual hemorrhoids after the operation of circular mixed hemorrhoids, in recent years, in clinical practice, circular mixed hemorrhoids have been treated with staggered stripping and anal canal plastic surgery. Patients with ring-shaped mixed hemorrhoids prolapse, pain, blood in the stool and other symptoms, and avoid common complications after traditional surgery. Surgical treatment and clinical observation were performed on 253 cases of circular mixed hemorrhoids. As a result, 249 cases were cured and 4 cases improved. No anal stenosis, mucosal ectropion, residual hemorrhoids, rectovaginal fistula, postoperative bleeding and other serious complications occurred. The curative effect is better than that of the ring-shaped mixed hemorrhoids that were carried out at the same time, such as the preserving dentition, skin bridge, and hemorrhoid stage stripping and ligation, and achieved satisfactory results.
Key words staggered stripping; anal canal plastic surgery; annular mixed hemorrhoids
From January 2004 to September 2007, our department used "staggered stripping and anal canal plastic surgery" to perform surgical treatment and clinical observation on 253 cases of circular mixed hemorrhoids, and received satisfactory results. The summary report is as follows:
Clinical data: There are 161 males and 92 females in this group. Age 22-71 years old, average age 42 years old, medical history 3-30 years. Stages of hemorrhoids: 232 cases of stage Ⅱ and Ⅲ, 21 cases of stage IV. There were 62 cases with varying degrees of anemia, 29 cases with incarceration and thrombosis, and 9 cases with rectal mucosal prolapse.
Treatment method: Exclude patients with serious heart, cerebrovascular, coagulation disorders and other diseases, clean the enema before surgery, use perianal local anesthesia or continuous epidural anesthesia. The patient takes the left side lying position or the bladder lithotomy position, and disinfects the perineum and rectal mucosa with iodophor, and disinfects the vagina if necessary in female patients.
After the anesthesia takes effect, the anus is first fully expanded. According to the shape, size, degree of prolapse, number and distribution of the annular mixed hemorrhoids, they are divided into groups according to the natural boundary between the hemorrhoids, generally 5-6 groups. Clamp the prolapsed hemorrhoids with tissue forceps and pull them out of the anus as much as possible. Starting at 6 o'clock, the skin and mucous membrane are cut longitudinally with an electrosurgical knife up to about 0.5 on the plane of the normal tooth line (equivalent to the middle of the internal sphincter) CM, down to the tip of the tailbone and the midpoint of the anal margin, cut off the lower part of the external sphincter skin and part of the internal sphincter (approximately 1CM wide) along one side, and expand the anus again, and then sew the incision horizontally with 3-5 stitches to fully expand the anus Circumference diameter, and the suture between the hemorrhoids sewn thereafter to complete the anal canal shaping operation. Then use two straight forceps side by side to clamp between 4-6 points and 1-3 points, cut to the surface of the external sphincter and continue to cut both sides to the base of the pre-sutted hemorrhoid to absorb the suture Make a narrow “V”-shaped incision at the base of the mixed hemorrhoids and external hemorrhoids. Cut the skin and peel off the hemorrhoid tissue and varicose veins to about 0.5CM on the corresponding dentinal line. Mucosa at the top of the base 10﹟Silk thread "8" stitching. The other groups of mixed hemorrhoids and hemorrhoids were treated in the same way. During the operation, peel off the varicose veins as much as possible. Note that the tops of the internal hemorrhoids should be stitched staggered and not on the same plane. The stripped hemorrhoids may not be cut off, and they can fall off by themselves. At the end of the operation, a compound long-acting anesthetic is injected around the wound and sealed at the base to relieve postoperative pain. Check the wound again for no active bleeding. The anal canal is built with petroleum jelly gauze wrapped in latex 1 tube. Control the bowel movement for 24-48 hours, and give antibiotics and moisturizing drugs after the operation to keep the stool smooth. After defecation, routine fumigation, bathing, dressing change, observation, regular expansion of the anus until healed.
Therapeutic effect: this group was completely healed in an average of 28-42 days after treatment, and followed up for 4-12 months. Results: 249 cases were cured, 4 cases improved, no anal stenosis, mucosal ectropion, residual hemorrhoids, rectovaginal fistula, postoperative hemorrhage And other serious complications occur. The curative effect is better than that of the ring-shaped mixed hemorrhoids, such as preserving dentition, skin bridge, and hemorrhoids by stages.
Discussion: Annular mixed hemorrhoids are a common clinical disease in the anorectal department. The main symptoms are: (1) Repeated prolapse of the mass can cause edema, erosion and infection. Because of the prolapse of the ring, hemorrhoid incarceration is easy to be complicated. At this time, edema, The pain is severe, and some patients have difficulty urinating. The elderly with the course of the disease are often prone to complication of rectal mucosal prolapse, causing symptoms of difficulty in defecation; (2) Hematochezia, mostly dripping in the stool, part of the jet-like bleeding, severe anemia in the later stage, dizziness, fatigue, etc. Due to the many surgical methods of this disease, anal stenosis, mucosal ectropion, residual hemorrhoids, postoperative bleeding are still common complications, so the treatment of this disease is still a hot topic of clinical exploration. The traditional ring-shaped mixed hemorrhoid surgery was first reported by whitehead in 1882, and later improved by saresola and klose in the 1940s. The cork-shaped ring-shaped hemorrhoidectomy was used. Because of the complexity of the operation and the long operation time, the operation was improved. There is a lot of bleeding and severe complications such as anal canal stenosis, mucosal ectropion, mucus leakage, sensory fecal incontinence, etc. after surgery. It is basically abandoned.In recent years, most of the surgical procedures reported in other places use the preserving of the skin bridge or the tooth line on the basis of external stripping and internal ligation, but most of the retained skin bridge will eventually be left as hemorrhoids due to edema. Foreign body sensation. Another currently popular new surgical procedure "procedure for prolapse and haemorrhoids" (PPH) was first proposed by the Italian scholar Longo in 1998. Although the PPH operation conforms to the anal cushion theory, it avoids The anal canal mucosal tissue is changed to the Whitehead operation above the anal canal mucosa, which preserves the anal canal mucosal tissue and avoids some of the shortcomings of traditional surgical methods. The integrity of the pad and its sensitivity are not essential factors to control. Although the anal pad feel has a certain effect on anal self-control, it is not the main one. Therefore, for some patients with circular mixed hemorrhoids and prolapse of dentate line, whether it has physiological function and the value of retaining dentate line and internal hemorrhoids is worthy of further investigation. PPH can only restore the anatomical position of the pathological anal cushion. Only the rectal mucosa above the internal hemorrhoids is fixed. The treatment of combined external hemorrhoids is still not ideal. There are also clinical postoperative urine retention, hemorrhage, incomplete hemorrhoidectomy, infection, and rectovaginal fistula. And other complications, and its treatment is expensive, not easy for the masses to accept, it is difficult to promote and apply in the grassroots.
This group of circular mixed hemorrhoids adopts staggered stripping and anal canal plastic surgery. The main points of operation are: 1. The longitudinal section and transverse suture of the posterior anal position, the cutting of the lower part of the external sphincter skin and part of the internal sphincter, and the maximum expansion of the anal area To prevent postoperative sphincter spasm, and complete the anal canal reshaping together with the skin and mucous membranes between the hemorrhoids, prevent postoperative anal stenosis, anal edema and postoperative pain; 2. Pull the hemorrhoids out of the anus as much as possible before surgery. The skin of the hemorrhoids and external hemorrhoids are stripped and ligated alternately in the tooth line area, and the blood vessels of the varicose hemorrhoids are stripped as far as possible to eliminate the hidden dangers of hemorrhoids and mucosal ectropion.