Bleeding after hemorrhoid surgery is a common complication after hemorrhoid surgery, and it is also an unavoidable problem in the career of anorectal surgeons, and sometimes even causes disharmony between doctors and patients. Therefore, it is the basic requirement of an anorectal surgeon to deeply understand, learn to prevent and handle bleeding after hemorrhoid surgery. Today we will talk about the prevention and treatment of bleeding after hemorrhoid surgery.
★ Two situations of bleeding
1. Obvious bleeding
If the bleeding point is outside the anus, if the clothes are soaked, the patient may feel burning and discomfort in the anus, which is easy to find and treat in time.
2. Hidden bleeding
If the bleeding point is in the rectum, due to anal sphincter spasm and postoperative packing and compression until the anus is closed, the bleeding directly flows into the rectum or colon, so the bleeding cannot or is not easy to be found.
When the amount of bleeding is low initially, the patient may not feel anything, but as the amount of bleeding increases, the patient may feel discomfort in the lower abdomen, desire to defecate or feel burning in the anus, and when the bowel movement cannot be controlled, the intestinal cavity will accumulate blood rapidly Excretion, the blood is mostly dark red with blood clots. At this time, due to the rapid discharge of a large amount of blood, the patient may feel palpitation, dizziness, sweating, weakness of limbs, pale complexion, weak pulse, drop in blood pressure, and even shock. This type of bleeding should be closely monitored for changes in the patient's condition, such as whether the bowel is active, whether the pulse is increasing, whether the blood pressure is stable, etc., in order to detect and treat in time.
More colleagues tend to bleed greater than 400ml, which should be paid attention to and intervention measures should be taken actively.
☆ Causes of bleeding
Clinically, it is generally divided into primary bleeding and secondary bleeding.
1. Primary bleeding: bleeding that occurs within 24 hours after surgery.
(1) Intraoperative internal hemorrhoids ligation thread is not tightly ligated, loosening occurs, or because the ligation stump is too small when the hemorrhoids are removed, the ligation thread slips off.
(2) The incision exceeds the tooth line, and the blood vessels under the rectal mucosa are abundant, which leads to bleeding.
(3) The bleeding small blood vessels were not treated in time during the operation, and the wound was not compressed tightly after the operation.
(4) When the internal hemorrhoids are ligated, the ligation technique is rough and the hemorrhoid mucosa is torn off without completely stopping the bleeding. Or active bleeding points have not been stitched.
(5) Defecation on the postoperative day, causing slippage of the ligature or tearing of the wound.
2. Secondary bleeding: bleeding that occurs 24 hours after surgery.
(1) During the shedding of internal hemorrhoids, hemorrhage is caused by the patient's strenuous activity or dry stools and struggling in the toilet.
(2) After hemorrhoid necrosis, secondary infection occurs, the tissue is fragile, and the blood vessel is easy to rupture. This is the main cause of postoperative secondary hemorrhage.
(3) Due to the high concentration of the drug injected into the hemorrhoids, the excessive dose, and the deep part, it damages the blood vessels of the muscle layer and causes bleeding.
(4) Systemic diseases: certain hematological diseases such as blood system diseases, hypertension, arteriosclerosis, portal hypertension, and immune diseases that cause coagulation disorders, etc. are not actively treated before surgery.
★ Prevention of bleeding
1. Before surgery, ask for detailed medical history, perfect necessary auxiliary examinations, especially examinations related to hemostatic function, and exclude surgical contraindications.
2. The operation should be skillful to minimize the damage to the tissue. The external hemorrhoids should not be peeled beyond the tooth line, and the internal hemorrhoids should not be injected too deeply; the basal ligation of the mother hemorrhoidal artery with obvious pulsation should be done, and the pulsating bleeding of the wound should be sutured immediately to stop the bleeding.
3. After the operation, a tampon was placed in the anus, and the wound was compressed by the tower-shaped gauze and fixed with tape. The patient was resting supine to reduce abdominal pressure.
4. Excessive activities should be avoided after operation, especially strenuous activities and weight-bearing should be avoided during the period of internal hemorrhoid shedding (7 to 14 days after surgery). During this period, except for special circumstances, anoscopy and digital examination are generally not performed.
5. Keep the stool unobstructed, and avoid bleeding caused by the dry feces and the damage caused by the toilet.
☆ Treatment of bleeding
1. A small amount of oozing blood can be re-pressurized after changing the dressing, or locally compressed with gelatin sponge, thrombin, adrenaline gauze, etc., while instructing the patient to rest in bed.
2. Severe bleeding or pulsating bleeding: hemostasis should be implemented in time. For patients with massive hemorrhage in the rectum, the operation also needs to establish a fluid channel to avoid the rapid discharge of blood in the intestinal cavity and shock which makes it difficult to rescue.
3. Both of the above two types of bleeding can be locally hemostasis combined with systemic treatment, such as intravenous application of hemostatic drugs, blood volume replacement, shock correction, etc.
➥Skills to stop bleeding in the rectum:
1. Under anesthesia, put a large horn-shaped anoscope after the anus is relaxed, remove the blood first, find the bleeding point, and use the absorbable thread to make a figure-eight stitch on the normal mucosa of the upper edge of the bleeding point.
2. If there is a lot of bleeding, the blood pressure of the patient drops, the blood vessels are retracted, and the bleeding point is not found, in order to prevent re-bleeding, suture the edge of the wound where bleeding may occur. After stitching, take out the anoscope, wait for 10 minutes, and put it in again to observe whether there is continued bleeding.
3. Sometimes the hemorrhoids in the hemorrhoid ligation area is not completely necrotic and shed, it is best to re-sutural treatment. Sometimes the mucous membrane is fragile or erosive, and there will be more and more seams. At this time, you can do a deep suture at the upper end of the bleeding point where the mucosa is slightly intact, and the technique should be gentle. If there is no pulsatile bleeding, local application of hemostatic drugs can be used to compress and observe at the same time.
In short, every anorectal surgeon has his own experience in handling bleeding after hemorrhoid surgery, but it is always the right way to prepare before surgery, be proficient in surgical operations, and actively prevent it.