【Abstract】 Objective To explore the coping strategies when accidents occur during the operation of prolapse and hemorrhoids (PPH). Methods A retrospective summary of the treatment measures for 156 cases of prolapsed hemorrhoids in the treatment of prolapsed hemorrhoids with the use of prolapsed hemorrhoids by circumcision and nailing. Results During the operation, there were accidents such as hematoma, broken thread, incomplete nailing, incomplete cutting, mucosal injury, and excessive purse string. Except for large area of incomplete nailing and 1 case of incomplete cutting, there were no major hemorrhage during and after operation. Serious consequences. Conclusion Being in disorder, a calm and calm mental state, and adequate preoperative preparation are powerful guarantees to minimize the adverse consequences of accidents. At the same time, preoperative conversation is to reduce the risk of accidents during the operation. An important precaution against negative effects.
[Keywords] circumcision and nailing of hemorrhoids (PPH) intraoperative accident strategy
The procedure for prolapse and hemorrhoids (PPH) of the stapler prolapse and hemorrhoids (PPH) is performed with the help of supporting instruments, so that the resection and nailing can be completed at one time, which greatly simplifies the operation process and makes the operation simple and convenient , Fast, and because of this, due to the problems of surgical equipment, the characteristics of sewing purses, inconvenient operation, and the individual differences of different patients often cause some accidents during the operation, which directly affects the effect and Cause complications and even endanger the patient's life. Therefore, how to prevent all kinds of accidents and take effective response measures in time after accidents is a powerful guarantee to ensure the success of the operation and minimize the adverse consequences. We have performed a total of 156 PPH operations since December 2001. Although some accidents occurred during the operation, effective measures were taken in time to avoid serious consequences, and anastomosis of huge and severe hemorrhoids was also achieved. The desired effect . Several unexpected situations and countermeasures are summarized, and some discussions are made in conjunction with relevant literature.
1 Clinical data
Among the 156 patients, 155 surgical instruments used the disposable round hemorrhoid stapler PPH01 or 03 produced by Johnson & Johnson in the United States. One case used a domestic reusable stapler. The purse-string was used in addition to the 7th silk thread once. , The rest are made of "2-0" Prolene with needle thread at both ends produced by Johnson & Johnson, the hemostatic thread mainly uses Johnson & Johnson's "3/0" Vicryl absorbable thread. All patients had no obvious abnormalities in blood routine, blood type, prothrombin time and electrocardiogram before operation.
2 Unexpected situation and countermeasures
2.1 Among 156 cases of hematoma, 51 cases of different degrees of hematoma occurred, which was caused by the direct injury of the submucosal blood vessels by the suture needle during the purse-string suture. The assistant quickly pressed the back of the anoscope suture device to the hematoma, and it was loosened when the operation continued to suture. Open and quickly adjust the exposure field. The surgeon and the assistant cooperated with each other to complete the purse-string suture as soon as possible. In 6 cases, the hematoma continued to increase after the purse-string suture was completed. That is, the operation was accelerated while the pressure was pressed, and the operation was completed as soon as possible During the operation, the tissues were cut and the hematoma was stasis purple, and the postoperative anastomosis was not significantly different from those without hematoma. We believe that hematoma during PPH surgery is a relatively common phenomenon, which is consistent with the rich blood vessels in the rectum and internal hemorrhoids. As long as the compression is timely, it will generally not cause great obstacles to the operation. Because the hematoma does not affect the tissue being pulled in The central rod, therefore, does not affect the effect of the operation. After the nail is fired, the hematoma disappears or becomes significantly smaller.
2.2 The purse string was broken 4 times, the only time that the No. 7 silk thread was used once, when the purse string was pulled and the stapler was started to rotate, it was hung up by the side hole of the stapler. After connecting the thread, be careful to avoid the side when pulling again The edge of the hole, the operation was successfully completed without daring to pull it hard; due to the high tension of the Prolene thread, it is generally pulled continuously with bare hands, so you can safely pull it boldly, but it also appears during the operation. 3 times of thread breakage, 2 times occurred when the purse-string was pulled until the indicator line started to move, one of which was because the two threads of the double purse-string were crossed, and the other was because the purse-string was tightened and knotted. Needle holder pliers pinch the thread, because the double purse string is used, and the indicator line has begun to move, indicating that the tissue has been pulled into the staple window, so you don’t need to pay attention to the broken thread and continue to pull another purse string to complete the firing Yes, it is suggested that it is best to use a special purse string during PPH surgery, and be careful not to pinch and avoid crossing during double purse-string suture; there is also one time that the upper purse string was cut after firing, accompanied by anastomotic staples. Incomplete, the indicator line only moved to the posterior 1/3 before firing. After the postoperative observation of the excised tissue specimen, it was found that the widest part was 5.0cm long and thick. It is considered that the tissue drawn into the central rod by the lower purse-string is too thick Too many, and due to the limited capacity in the staple bin, the upper purse string cannot be pulled into the staple bin completely, and a small amount of thread and tissue are exposed. Therefore, the thread is cut off when firing, and the staple is not complete. It is suggested that the two purse-strings should not be too far apart during double purse-string suture, and the needle should not be inserted too deep.
2.3 Incomplete nailing In addition to the above-mentioned 1 exception, 4 cases also occurred. Among them, 1 case of hemorrhage was caused by a reusable domestic stapler, because the hemorrhoids were located on the left side and left back side of the hemorrhoid (about 2-6 points). ), the right anterior side (about 9-11 o’clock) the anastomosis was not nailed, the wound surface cracked and a lot of blood oozing and there were 4 jet-like hemorrhages which led to hemorrhage (about 1000ml), of which the blood jets from 3 and 5 points were The size of the toothpick, due to the large amount of blood oozing and spraying, the visual field is unclear, the clamp can not stop the bleeding, the bleeding was stopped after emergency stitching for about 30 minutes . Since then, before PPH surgery, we routinely prepare one "3/0" Vicryl resorbable thread, and at the same time use a 6×17 round needle to pass the 4th silk thread for use. The second case of imperfect nailing was a patient who had the main complaint of blood. This patient had undergone 6 internal hemorrhoid ligation (1 site each time) and 13 injections of hemorrhoids in the local area in the past 3 years, but he still had blood in the stool. The hospital introduced the PPH operation. Due to the above treatment, some of the mucous membranes in the maternal hemorrhoid area were severely fibrosis, and the 7 and 11 points on the finger examination could be palpable, and the hemorrhoid mucosa was light gray and white under the anal microscope. The most severe part of fibrosis at 11 o'clock was cut off and nailed completely, and the most severe part of fibrosis at 7 o'clock was the nailing site. Because the tissue was too thick and not nailed, 2 nails fell off on the wound surface One nail was exposed, the wound was oozing blood and two pulsating hemorrhages were seen, suggesting that care should be taken to avoid nailing on such severely fibrotic parts during surgery; the other 2 cases of incomplete nailing were because the anastomosis was too low to close The position of the dentate line is in the lower right position. The three patients were first sutured with a needled Vicryl suture to pulsate bleeding, and then used a 6×17 round needle to pass the No. 1 silk thread across the anastomosis and line a figure of 8 suture to draw the seal. On the wound surface, bleeding stops immediately, hemostasis is complete, and the amount of bleeding is small. We believe that with the above adequate preparations, even when the nail cannot be closed completely after firing, it should be possible to tie the pulsating bleeding suture with Vicryl suture first, and then suture the fractured cut surface with silk thread to seal the wound, thereby reducing blood loss to a minimum .
2.4 Incomplete incision occurred in 1 case due to the large difference in the size of the hemorrhoids. The original intention was to cut a small amount of tissue at the 5 o'clock position of the small hemorrhoids and deliberately insert the needle. As a result, the cut tissue was not a complete circle and was interrupted on the left rear. Small hemorrhoids remained at 5 o’clock, only the mucosal surface was cut. Because the hemorrhoids were small and did not affect the retraction, no bleeding was seen at that time, so no treatment was performed, which resulted in hemorrhage during defecation on the night and on the 5th day after the operation. The needles for small hemorrhoids should not be too shallow, and must go to the submucosa, otherwise not only the hemorrhoids cannot be removed, but also the hemorrhoid mucosa will be torn and the hemorrhoidal mucosa will be torn and the hemorrhoid mucosa will be torn. The residual small hemorrhoids should be removed after sutures. If it is a damage to the rectal mucosa It is best to stitch it up just in case .
2.5 There were 3 cases of mucosal injury, two of which were caused by shallow needle insertion during purse string suture, and injury to the mucosa during stretching. The preventive measures are shown in the above "incomplete cutting"; there is 1 case because the tip of the stapler was inserted When using too much force, the head end damaged the rectal mucosa. We think that when inserting the head end of the stapler, first use the index finger to probe the tightness and height of the purse string, so as to know what to do, and then apply lubricant to the head of the stapler. Placement with moderate force can prevent such damage.
2.6 The purse string is too high. We once had a patient. Because the upper purse string was sutured too high (6.3cm from the anal opening), the stapler shaft completely covered the anal opening after the tip of the stapler entered the upper end of the purse string. Seeing the situation inside the anus, we can neither tighten the purse string nor pull the purse string from the side hole under direct vision. We tighten the purse string outside the anus and then tie the stretch knot on the outside first, and then use it The matching retractor was extended into the side hole, and by slowly rotating the stapler, nearly 5 minutes of groping and pulling, finally the two purse strings were successfully pulled out and the operation was successfully completed. This case suggests that the purse-string suture should not be too high, especially when sewing the double purse-string, pay attention to control the height of the upper purse-string, because the length of the center rod of the stapler is only 5.5cm, and the length of the anal dilator is 3.2cm, so if the anal canal is dilated The upper edge of the stapler is used as a reference, and the purse-string suture should not exceed 2.5cm above it. Otherwise, the shaft may completely cover the anal opening after the tip of the stapler is inserted, which will cause difficulty in operation.
In addition to the above-mentioned situations that we encountered, there are reports of accidents in PPH surgery, such as empty firing, failure to pull out the stapler after firing, incomplete recovery, and low purse string suture.
So, how can we take effective response measures in time after an accident to ensure the success of the operation? We believe that being in a state of chaos, a calm and calm mental state, and adequate pre-operative preparation are powerful guarantees to minimize the adverse consequences of accidents, and to be able to "not be surprised" must be proficient PPH operation, and at the same time have rich experience in traditional hemorrhoidectomy.Ren Donglin  had an insightful analysis of this. "PPH seems to be a simple operation, but in order to obtain the ideal therapeutic effect, two points must be paid special attention: 1. Must be a professional anorectal surgeon. In a large number of traditional In terms of his anal surgery experience, he has the theoretical and practical understanding of anorectal diseases, and if an accident occurs during the operation, effective countermeasures can be taken. This is the first condition to ensure the safety and effectiveness of PPH surgery. 2 , Must receive training on PPH theory and practical operation. "We also have personal experience of this. We perform more than 500 traditional hemorrhoid fistula surgeries in outpatient clinics every year. It can be said that we have accumulated a wealth of various accidents in traditional operations. experience. When the various accidents that occurred during the above PPH operation occurred for the first time, we were basically unprepared or insufficiently prepared to deal with it, especially 1 case of massive bleeding with a domestic stapler, we were invited to the grassroots Needless to say, the “3/0” Vicryl absorbable thread with needles was carried out in the hospital. There were no needles of suitable size and curvature. We had to use the remaining half of Prolene purse string with needles to sew first, and then Look for relatively usable needles of size and arc to puncture 2/0 gut suture and #4 silk suture to stop bleeding. For example, for "incomplete recovery" (which we have not encountered), for a surgeon who lacks experience in traditional hemorrhoidectomy surgery, if it is not treated, it can be said that the operation has failed, and if it is treated, it will inevitably be difficult to achieve ideals. effect. In 156 cases, we also performed combined operations on 22 of them, and the results also showed the various advantages of PPH . As for "empty firing", "stapling can not be removed after firing", "purse-string suture is too low", etc., it is mainly due to insufficient proficiency in PPH operation and a manifestation of lack of confidence in the operation.
Careful and detailed preoperative talk is an important preventive measure to reduce the negative impact on patients when unexpected situations occur during the operation. It is a powerful guarantee for improving patient satisfaction and reducing doctor-patient conflicts and disputes. Judging from the principle of PPH, there should be no pain after PPH. According to the promotional materials provided by Johnson & Johnson, the effect is immediate. There is no wound outside the anus, giving the patient the illusion that it will be better and painless immediately after the operation. The patient came to this point, and the patient has high expectations for this, but in fact, the patient will have varying degrees of difficulty in urination, abdominal distension, discomfort or pain, or sensation of swelling or burning in the anus on the day after surgery, and some will Feel very uncomfortable. Therefore, it is very important to explain these conditions to the patient in detail before the operation. For this reason, we specially made a slide show, starting from the principle of PPH surgery, explain the situation to the patient in detail, and tell the patient that this is PPH. Some normal postoperative reactions are inevitable, because PPH operation needs to cut off the sensitive lower rectal mucosa and part of the pathological anal cushion under anesthesia (we use spinal anesthesia) and staple them together. The huge mechanical impact during firing makes the anastomosis inevitably produce a kind of aseptic inflammatory response, with varying degrees of swelling and hotness, and anesthesia often causes difficulty in urination, and some patients will stimulate the sphincter muscle due to surgery Pain caused by cramps, trimming external hemorrhoids, expanding anus, etc. Among the 156 patients we have operated on, 88 were very satisfied, 63 were satisfied, and 5 were basically satisfied. The reason for such a high satisfaction rate is not only related to the satisfactory results of the operation, but also to the preoperative The fine work done after the operation is inseparable.
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-----This paper was written in June 2005 and published in "China Journal of Modern Medicine" 2006, Issue 6, pages 943-945