Shenyang Anorectal Hospital (110002) Liu Bin
Keywords: mixed hemorrhoids; surgical treatment; clinical and basic research
1 Modern concept of hemorrhoids
In September 2002, the Anorectal Surgery Group of the Chinese Medical Association Surgery Branch clearly pointed out that internal hemorrhoids are pathological changes and abnormal displacements of the supporting structure of the anal cushion, vascular plexus, and arteriovenous anastomotic branches. External hemorrhoids are pathological expansion and thrombosis of the subcutaneous venous plexus far from the dentate line, the branch of the inferior rectal vein. Mixed hemorrhoids are the fusion of internal hemorrhoids with the venous plexus of external hemorrhoids in the corresponding part through the anastomotic branches of the abundant venous plexus.
2 Causes of hemorrhoids
In recent years, with the continuous in-depth research on the anatomy, physiology, pathology, and histology of hemorrhoids, the etiology of hemorrhoids generally includes three theories: ① the theory of varicose veins; ② the theory of vascular hyperplasia; ③ the theory of downward anal cushion.
3 New concepts of modern surgery
① Asymptomatic hemorrhoids do not need to be treated, only if they are accompanied by bleeding, prolapse, incarceration or thrombosis, they need treatment;
② Symptomatic hemorrhoids do not need radical treatment. The purpose of treatment is not to eliminate the hemorrhoids itself, but to eliminate symptoms. Even if the hemorrhoids without symptoms are large, it is not necessarily an indication for treatment. On the contrary, when the hemorrhoids are small but have serious complications, Must also be treated;
③ Only when non-surgical treatment is ineffective or the tissue around hemorrhoids is extensively destroyed in stage III and IV, surgical treatment is considered.
4 The development of surgical treatment of mixed hemorrhoids
As the understanding of hemorrhoids continues to change, the surgical procedures for mixed hemorrhoids are constantly being improved. The traditional classic external stripping and internal ligation, especially Milligan-Morgan (1937), is still accepted by most scholars. In recent years, influenced by the theory of the etiology of hemorrhoids and the concept of modern minimally invasive surgery, there are reports in the literature that the operation of mixed hemorrhoids has been slightly improved, thereby greatly reducing the occurrence of postoperative complications and sequelae. It has a certain positive effect on protecting the function of anal surgery and improving the quality of life of patients after surgery. External hemorrhoids, mainly varicose veins, mixed hemorrhoids or stage II and III hemorrhoids, have been treated with sclerosing agent injection for decades in China. Representative sclerosing agents such as Xiaozhiling injection and Shaobei injection , Fanteng hemorrhoid injection, their usage, dosage, precautions, postoperative curative effect, and complications have different opinions. At present, Xiaozhiling injection is widely used in Takano Hospital in Japan. In 1997, the Italian scholar Longo first reported the use of a stapler for the treatment of severe prolapsed hemorrhoids. In the following years, PPH surgery became popular in China, and there were disputes about the indications of PPH surgery. With the continuous emergence of new concepts in modern surgery, the recovery of postoperative anal function and fine control of the stool have attracted more and more attention from most scholars and patients. Minimally invasive surgery and plastic and cosmetic surgery have been integrated into anal surgery.
4.1 Several details of external dissection and internal ligation of mixed hemorrhoids
4.1.1 The level of ligation of internal hemorrhoids
Low-position ligation ---- There are more hemorrhoid tissues to be ligated. The thread knot becomes loose during postoperative hemorrhoid tissue necrosis and the blood supply is not completely blocked. If there is an infection at the same time, it is easy to cause massive bleeding during the denucleation period.
High-position ligation method-the internal hemorrhoids are fully peeled from the surrounding tissues, especially from the internal sphincter, until they are peeled to the top of the hemorrhoids, and ligated at the roots, effectively preventing hemorrhage during the denucleation period. In the past 2 years, we have clinically observed 200 patients with high ligation of hemorrhoids during stage III and IV, and the incidence of postoperative hemorrhage during denuclearization was 0%.
4.1.2 Indwelling of internal hemorrhoid ligature
In the past, the end of the internal hemorrhoid ligation thread was cut off. If you want to determine whether the ligated internal hemorrhoids have fallen off, you need to do a digital examination or anoscopy early after the operation, which will cause pain, bleeding and other adverse reactions.
Now, we keep the thread end of the internal hemorrhoid ligation thread, and tie a knot mark outside the anus to distinguish the wound hemostatic thread, to determine whether the hemorrhoids fall off. At the same time, the indwelling ligature also has a partial drainage effect. It should be noted that the knot should be tied on the top of the hemorrhoid as much as possible to prevent the ligation thread from being embedded in the incision and affecting the hemorrhoid from falling off.
4.1.3 Retention of dentate line
The tooth line area is extremely important to the physiology of defecation. Too much damage to the tooth line area during the operation will weaken or disappear the defecation reflex, resulting in constipation or sensory incontinence. In mixed hemorrhoids external stripping and internal ligation, while removing the hemorrhoid tissue as much as possible, as much as possible to preserve the dentate area tissue to maintain normal physiological functions, prevent postoperative complications, prevent anal sensory function decline, and reduce postoperative anus Dryness and discomfort have a certain meaning.
4.1.4 Preservation of the anal canal transition zone
The epithelium of the anal cushion area is the transitional epithelium between the single-layer columnar epithelium and the stratified squamous epithelium. This area contains extremely rich nerve endings. It is an extremely important sensory center for defecation reflex and the structural basis for fine bowel control. Preserving sufficient mucosal and skin bridges during the operation can avoid complications and sequelae such as postoperative anal stenosis and difficulty in defecation. At the same time, it is of great significance to the recovery of defecation reflex and fine bowel control after anal surgery.
4.1.5 Retention of anal cushion
In 1975, Thomson found that there was a thickened submucosal area above the tooth line, histologically composed of blood vessels, Treitz muscle, elastic fibers and connective tissue. Masahiro Takano believes that relying solely on the function of the sphincter in the mechanism of closing the anus is not sufficient, and the soft tissue existing on the inner surface of the sphincter is indispensable. Excessive damage to the anal cushion tissue during the operation can lead to complications such as anal sclerosis, stenosis, sensory dysfunction, incomplete expansion or incomplete closure.
4.1.6 Design of external hemorrhoid incision
The difficulty in the treatment of annular external hemorrhoids lies in how to preserve enough anal epithelium without residual hemorrhoid tissue, so as to prevent the occurrence of anal stenosis. Masahiro Takano advocates dumbbell-shaped incisions. Minimally invasive surgery requires that the external hemorrhoid surgery can achieve a long and narrow spindle-shaped small incision, and the varicose vein tissue is stripped subcutaneously through the wound edge. The width and number of skin bridges are retained as much as possible.
4.1.7 Is the internal sphincter cut off?
In recent years, many literatures reported that the internal sphincter was partially cut to loosen the anal canal during mixed hemorrhoid surgery, which has a certain effect on preventing and reducing postoperative edema, pain, urinary retention, and anal stenosis.
The author believes that if the preoperative anal canal is tight, or incarcerated mixed hemorrhoids, or the anal canal epithelial resection is more, the internal sphincter should be partially cut and released. For segmental ligation of circular mixed hemorrhoids, not only part of the internal sphincter is cut off, but also the subcutaneous part of the external sphincter is cut off. Through many years of observation, it has not been found that the anal dampness or even incontinence caused by cutting part of the internal sphincter or the subcutaneous part of the external sphincter has not been found.
4.2 Several details of internal hemorrhoid injection
Drug injection therapy has long been accepted by anorectologists, and it is becoming a mainstream treatment of hemorrhoids in the future, and is concerned by everyone. In view of the different symptoms of mixed hemorrhoids, which medicine to choose for internal hemorrhoid injection treatment, the concentration, dosage, and usage of each medicine may be different from each family.
The author believes that no matter what kind of drug injection treatment is adopted, only a proficient operation technique can avoid postoperative complications. The following discusses the precautions of the operation through the common complications after internal hemorrhoid injection.
4.2.1 Induration formation
The formation of induration in the injection area of internal hemorrhoids may be related to the following four factors: a. the type of drug; b. the concentration of the drug; c. the depth of the injection; d. pressing after the injection.
Table 1 Observation on the complications of 200 cases of internal hemorrhoids and varicose mixed hemorrhoids treated with Xiaozhiling, Fantengzhi and Shaobei injection
Alum (potassium aluminum sulfate)
Superior rectal artery area
Submucosa in the hemorrhoid area
Lamina propria of hemorrhoid
1:1 total amount of injection
Induration formation (60%)
Tissue necrosis (6.7%)
Rectal stenosis (13.2%)
Red stone fat
Submucosa in the hemorrhoid area
1:1 total amount of injection
Feeling of falling (16.4%)
Feeling of stool (8.2%)
Citrate (black plum)
Gallic acid (gall)
Submucosa in the hemorrhoid area
1:1 total amount of injection
Falling feeling (12.5%)
4.2.2 Tissue necrosis
Tissue necrosis in the injection area of internal hemorrhoids may be related to the following four factors: a. Not strict disinfection; b. Concentration is too high and dose is too large; c. Injection is too shallow or too deep; d. Repeated injection.
4.2.3 Anal and rectal stenosis
Anorectal stenosis after injection is mainly related to scar formation: a. Aseptic inflammation → tissue hyperplasia → scar formation; b. tissue necrosis → tissue repair → scar formation; c. injection at the same level → tissue hardening → ring stenosis; d. The injection volume is too large, the position is too deep → the scar is too large.
4.2.4 Tissue damage
a. Prostate injury-infection and necrosis spread to the prostate, if the injection is too deep to stab the prostate; b. Vaginal wall injury-the injection is too deep, the dose is too large, the infection and necrosis cause injury to the posterior vagina of the vagina, and even the formation of rectovaginal fistula ; C. Sexual dysfunction-related to the destruction of the perineal nerve by drugs.
We observed the histopathological changes at different times after Xiaozhiling, Fantengzhi, and Shaobei injections were injected into the rectal submucosa of rabbits, and summarized the different pharmacological effects of different sclerosing agents.
Table 2 Pathological changes at different times after injection of Xiaozhiling, Fantengzhi and Shaobei injection into the submucous layer of the rectum of rabbits
10 minutes after injection
10 hours after injection
10 days after injection
24 days after injection
The mucosal layer is thinned, the tissue is edema, a few neutrophils are seen, the glands are clear, the submucosal stroma is dense, the collagen fibers are sparsely scattered, and the degree of bleeding can be seen.
Both the mucosa and submucosa have obvious inflammatory reactions, with more neutrophil infiltration, gland atrophy, and slight necrosis and ulcer formation in some mucosa.
Mucosal layer degeneration, edema reduced, lymphocytes and neutrophils are dominant in the interstitium, and more fibroblasts and new capillaries are seen, accompanied by increased local collagen.
The mucosal layer becomes thinner, and the submucosal fibrous tissue increases. The muscle layer is separated by fibrous scars, during which the collagen fibers are dense and scar tissue is formed.
The mucosal layer becomes thin, and the shadow fossa structure left by glandular necrosis can be seen. The submucosal stroma is rich in inflammatory cells and the blood vessel structure is not obvious.
The mucosal layer becomes thin, local degeneration is seen, and the submucosal inflammation is obvious, with more neutrophils and a small amount of lymphocyte infiltration.
Local degeneration of the mucosal layer, the presence of glandular shadow sockets, the structure of each layer is clear, there is a small amount of inflammatory cell infiltration, and the fibrous septum is widened and degenerated.
The mucosal layer is obviously thinning, and a small amount of inflammatory cell infiltration is still seen, fibroblasts are more common, and the muscular layer shows inflammation after necrosis.
The mucosal epithelium and subepithelial tissues have no significant changes, the glands are clear, the connective tissue in the submucosal hemorrhoid area is homogenized, and the blood vessels are mostly in a contracted state without obvious inflammation.
There is no change in the mucosal layer, the submucosal protein is coagulated, denatured, and homogenized, the tissue is dense, the blood vessels are closed, fibroblasts and a few macrophages appear, and the inflammatory response is not obvious.
The homogenized submucosal tissues were further dense, with more fibroblasts and obvious proliferation of capillaries, but contracted large blood vessels were still visible, and there was no obvious inflammation.
The homogenized tissue is reduced, more fibroblasts are seen, capillary proliferation is obvious, no constricted large blood vessels are seen, and no obvious granulation tissue is formed.
According to histopathological observations in animal experiments, it was found that obvious edema and bleeding occurred 10 minutes after the injection of Xiaozhiling injection, which resulted in inflammation. In the following 10 hours, inflammation increased, accompanied by slight mucosal necrosis and ulcer formation. There are mild to moderate inflammation, fibroblasts and capillaries in the interstitium are proliferated actively, accompanied by increased local collagen tissue, and the formation of submucosal scar tissue can be seen after 24 days. After injection of Shaobei injection, non-inflammatory protein coagulation occurs in the submucosal tissue. With the repair of degenerated tissue, the blood vessel wall becomes fibrosis, the lumen becomes smaller and occluded, and the new capillary proliferates. After injection, it does not cause bleeding and inflammation. , There is no obvious scar formation during the repair process, and the mucosal layer is less damaged.
4.3 About PPH surgery
PPH (procedure for prolapse and hemorrhoids) is the procedure for prolapse and hemorrhoids, which was first reported by the Italian scholar Longo in 1997. PPH reduces the blood supply of the hemorrhoid area by raising the anal pad and partially cutting off the hemorrhoidal artery, thereby eliminating the symptoms of hemorrhoids such as blood in the stool and prolapse. It has the characteristics of short operation time, less pain, quick recovery and low recurrence rate.
4.3.1 Indications for PPH surgery: Professor Yao Liqing believes that severe prolapsed hemorrhoids are an absolute indication for PPH surgery, but the main symptoms of second-degree internal hemorrhoids are repeated bleeding and prolapse, which is also a good indication for PPH surgery. The 2005 Zhuhai meeting of the Anorectal Surgery Group of the Chinese Medical Association Surgery Branch clearly pointed out: ring-shaped prolapsed grade III and IV internal hemorrhoids, recurrent bleeding of grade II internal hemorrhoids, and prerectal bulge and intrarectal constipation that cause functional outlet obstruction. Prolapse is an indication for PPH.
4.3.2 Relevant studies have found that compared with traditional surgery, PPH surgery has obvious advantages in short-term efficacy, and there is little difference in long-term efficacy. Simple PPH surgery for the treatment of hemorrhoids has a clear overall effect, conforms to the principle of minimally invasive surgery, and has obvious advantages.
4.3.3 Modified PPH surgery, which not only takes advantage of PPH but also treats the disease comprehensively. Mainly include: a, PPH + sclerosing agent injection; b, PPH + partial ligation of internal hemorrhoids; c, PPH + external hemorrhoid resection; d, PPH + external peeling and internal ligation; e, PPP + PPH, which is used for patients with mixed hemorrhoids and rectal mucosal relaxation Double stapler surgery.
New concepts of modern surgery are constantly emerging, such as minimally invasive surgery, evidence-based medicine, and rapid rehabilitation. These new ideas should penetrate into the field of anorectal surgery as soon as possible and effectively. Foreign countries attach great importance to complications that affect anal function. In terms of maintaining anal function, we should learn from the strengths of each family and carry forward comprehensive treatment, especially in the aspect of minimally invasive treatment and the evaluation and prediction of anal function before and after surgery.
At present, there are still many problems to be done in the standardization and standardization of the treatment of mixed hemorrhoids in China. With the continuous development of theory and practice, various diagnosis and treatment standards based on evidence-based medicine need to be further standardized.
In addition, both traditional medicine and modern medicine emphasize the importance of enhanced nutrition for wound recovery. It is also worth mentioning that integrated traditional Chinese and Western medicine also plays an important role in promoting rapid recovery.