Hangzhou Third People's Hospital (310009) Yang Guangen
Keywords: anorectal surgery, complications, postoperative hemorrhoid edema, etiology, prevention and treatment
Edema after hemorrhoid surgery is the swelling and swelling of the wound margin or the preserved skin bridge after hemorrhoid surgery. It is the most common complication after anal surgery. Edema after hemorrhoid surgery can cause: ① severe pain in the anus; ② affecting the drainage, cleaning and dressing of the wound, leading to slow wound healing; ③ residual external hemorrhoids after the edema subsides, affecting the efficacy. As anorectal specialists, I want to avoid the occurrence of edema after hemorrhoid surgery, but there are not many articles worth learning from (1)(2). Based on long-term clinical experience, lessons, and literature, the author discusses as follows.
1.1 Inflammation of the anus before hemorrhoid surgery has not completely resolved
It is more common in thrombotic external hemorrhoids (with palpable internal and multiple small indurations, and obvious congestion or bruising on the surface), inflammatory external hemorrhoids and incarcerated hemorrhoids. The inflammation is not completely controlled and the inflammation is rushed. The postoperative inflammation worsens and forms inflammatory edema. .
1.2 surgical incision infection
It is mostly because the anal surgery is not strictly disinfected, the principles of aseptic operation are not observed during the operation, or the postoperative treatment is not appropriate, which may cause wound infection and inflammatory edema.
1.3 surgical reasons
1.3.1 Hemorrhoid tissue, especially varicose vein tissue and thrombus are not completely peeled off
As the veins and lymphatic network in the remaining hemorrhoid tissue are destroyed, the venous and lymphatic drainage are obstructed, causing edema. This situation mostly occurs in the preserved skin bridge, and the external hemorrhoids when the internal hemorrhoids are ligated and the external hemorrhoids are not treated.
1.3.2 Poor incision drainage
Occurs in cases where the incision is too short. The incision was too short due to factors such as the loosening of the anal canal during the anesthesia and the displacement of the anal canal. As a result, the incision was completely shrunk above the anal skin line. Because the anal canal was in a contracted state, the wound was not drained smoothly. Edema (3).
1.3.3 After the operation, the skin tissue (skin bridge) is not reset in time
Because the skin and skin bridge were not reset in time, and the dressing was too tight, the anal skin and skin bridge could not return to their normal position after the anesthesia disappeared, causing the anal canal skin or skin bridge to be incarcerated in the anus, venous and lymphatic drainage obstacles, and edema.
1.3.4 suture tension is greater
If the skin is removed too much, the width of the remaining skin bridge is small, and the incision tension is bound to be greater when sutured, causing the anal skin and subcutaneous tissue to be stretched and compressed, affecting lymph and venous return, and forming edema (4).
1.3.5 Improper anesthesia or injection of drugs
During local anesthesia, there is too much local injection of medicine, and the injection of internal hemorrhoids sclerosing medicine is injected below the tooth line by mistake. In addition, the blood vessels in the anus were accidentally damaged during local anesthesia, resulting in subcutaneous hemorrhage, and edema after the operation.
1.3.6 Causes of internal sphincter spasm
Preoperative internal sphincter spasm or anal canal pressure is high, no treatment during the operation, postoperative internal sphincter spasm or anal canal pressure continues to exist, due to the "button hole" effect, the inferior rectal vein and anal vein reflux disorder, causing edema (5)(6).
1.3.7 The movement of the leather bridge is too large
In order to remove the hemorrhoids under the skin bridge, the hemorrhoid tissue under the skin bridge is subtly removed during the operation, resulting in the suspension of the skin bridge. This skin bridge is susceptible to compression, distortion, abrasion and edema during defecation (7) .
1.3.8 The anal structure was severely damaged
Larger perianal abscesses and anal fistulas can cause relatively large defects in the anal canal due to surgery, and the pressure at the defect is unbalanced. It is easy for surrounding tissues, especially hemorrhoids, to squeeze into the defect, causing edema.
1.3.9 Too long operation time and excessive traction during operation
If the operation time is too long and the local tissue is clamped or stretched too much, the degree of local damage is relatively aggravated, and the chance of infection is relatively increased, so edema is prone to occur after surgery.
1.4 Anatomical reasons
We have found that in some clinical cases, the anal canal tissue or even the entire pelvic floor has moved down, the anal canal epithelium has moved down and out (the structure of the anal sphincter remains unchanged), and the tooth line has moved down to the anal edge. In this case, no matter how it is handled during the operation, the incidence of postoperative edema is extremely high, and even difficult to avoid.
1.5 postoperative constipation
Due to constipation, it is also common clinically to cause blood stagnation in the anus, squeeze and stretch the skin bridge, and cause edema.
2.1 Try to wait until the inflammation subsides before surgery
For incarcerated hemorrhoids, thrombotic external hemorrhoids, inflammatory external hemorrhoids, etc., the inflammation must be controlled before surgery. Generally, the operation should be performed after the inflammation is completely controlled.
2.2 Prevention of infection
The surgical field must be thoroughly disinfected before the operation, and attention must be paid to aseptic operation during the operation. Appropriate use of antibiotics after surgery, take a bath, wash, and change dressing. Oral or external use of traditional Chinese medicine for clearing away heat, cooling blood, removing dampness, detoxifying and reducing swelling can reduce the occurrence of postoperative edema.
2.3 Precautions during surgery
2.3.1 Try to peel off the hemorrhoid tissue thoroughly
Especially the varicose vein tissue should be completely removed, and the hemorrhoid tissue under the skin bridge can be subtly dissected and removed. For those with many small thrombus scattered and scattered, the small thrombus should be removed as much as possible.
2.3.2 Make surgical wound drainage good
Pay attention to repair the wound, make the incision flat, appropriate length, and good drainage. The incision should extend to approximately 2cm outside the original anal margin, generally to the outer edge of the perianal melanin circle. In this way, when the anesthesia disappears and the anal canal epithelium and internal sphincter return to their normal positions, the surgical incision will not appear short. We have realized that the healing of hemorrhoid surgery incision is related to the width of the incision, and has nothing to do with the length of the incision. Therefore, without increasing the incision width, the surgical incision can be extended outward to ensure the smooth drainage of the wound. Will speed up the incision healing.
2.3.3 Do the skin and skin bridge reset
At the end of the operation, the skin of the anal canal and the skin of the skin bridge should be leveled and pushed back into the anal canal. As little as possible, too much gelatin sponge and gauze should be filled in the anal canal. As long as the bleeding is completely stopped, a piece of oil gauze is placed in the anal canal.
2.3.4 low tension suture
Keep enough skin bridges in number and width. If the wound is sutured, the skin on the wound edge should be properly separated to reduce tension.
2.3.5 Local anesthetic injection must be evenly infiltrated
Do not inject large amounts under one skin. The injection of internal hemorrhoids should be injected above the dental line.
2.3.6 Selective release of the internal sphincter head
For patients with internal sphincter spasm or high pressure in the anal canal, attention should be paid to loosen the internal sphincter head during the operation to relieve the "button hole" effect (5).
2.3.7 Fix the leather bridge
For cases with large skin bridge movement, one or two needles can be fixed with needles and threads. If the anal canal skin bridge or mucosal bridge moves down significantly, you can sew it upwards and hang a needle.
2.3.8 Pay attention to keep the anus intact
For those with large anal fistulas and abscesses, pay attention to minimize tissue damage and leave large defects during the operation; and try to remove the accompanying hemorrhoids.
2.3.9 Reduce traction during operation and shorten operation time.
2.4 Prevention and treatment of constipation
Pay attention to correcting constipation before surgery, do an enema before surgery, and use drugs to treat symptoms in time after surgery.
3 Treatment of postoperative edema
3.1 Internal governance
Take clearing away heat and detoxification, removing dampness, promoting blood circulation and removing blood stasis as Dafa. Commonly used to relieve pain Rushen Decoction and Liangxue Dihuang Decoction. Commonly used medicines include cork, scutellaria, atractylodes, knotweed, silver flower, raw rehmannia, paeonol, red peony, citrus aurantium, nepeta and so on.
3.2 External treatment
3.2.1 Chinese Medicine Sit Bath
I often use lychee grass, houttuynia cordata, knotweed, raw rhubarb, glauber's salt, comfrey, safflower, gallnut, cork and other medicinal decoction about 1000ml, first smoked and then washed.
3.2.2 External application of ointment
In this hospital, scutellaria oil ointment and general swelling powder are commonly used to adjust the application. Using borneol to make snail water for external coating is also effective. In addition, external application such as hemorrhoid cream can also be used.
3.2.3 Other therapies
The use of low-power laser, infrared, microwave, etc. irradiation, spectrum therapy, etc., also has a good effect on eliminating edema after hemorrhoids.
3.3 Western medicine anti-infective treatment
Use appropriate antibiotics such as norfloxacin, metronidazole and so on.
The author has realized that as long as the above-mentioned work is done well, the occurrence of edema after hemorrhoid surgery can be greatly reduced. I hope that the above experience and views can be helpful to you all.