2021年2月23日星期二

hemorrhoids external causes,Clinical experience of incomplete external stripping and internal ligation for treatment of circular mixed hemorrhoids

    1. Definition

    l Circular mixed hemorrhoids are not clearly defined in textbooks. Because of its relatively difficult treatment, clinical practice treats them as special or severe hemorrhoids. The disease is one of 16 refractory diseases in the anorectal department announced by the State Administration of Traditional Chinese Medicine.

    l "Circular" does not refer to the internal hemorrhoids, but the mixed external hemorrhoids. "Ring" has relative and absolute. Relative refers to the number of external hemorrhoids, generally more than three, which are connected as a whole or basically as a whole, but there is a natural groove between the two hemorrhoids. The external hemorrhoids are definitely connected together into a lip-like protrusion, and the boundary between the two hemorrhoids cannot be distinguished.

    l Therefore, ring-shaped mixed hemorrhoids refer to a type of hemorrhoids that have more than 3 external hemorrhoids or are completely connected to form a lip-like protrusion.

    2. Classification and reasons

    l According to the pathological classification of the external hemorrhoids of mixed hemorrhoids, ring-shaped mixed hemorrhoids can be divided into varicose-type ring-shaped mixed hemorrhoids and hoof-type ring-shaped mixed hemorrhoids.

    l Through the pathological observation of a large number of hemorrhoid specimens, we found that the pathological changes of hemorrhoids are mainly high venous dilation, tissue inflammation and edema, and even intravascular thrombosis. The modern "anal cushion theory" classifies the onset of hemorrhoids as "hole-shaped blood vessel" varicose or adjustment disorder, and Ttritz muscle aging or rupture.

    We believe that the abnormality of the anal sphincter, especially the internal sphincter, is an important reason for the formation of circular mixed hemorrhoids, and the normal resting pressure of the anal canal is an important sign of anal health. The ring-shaped mixed hemorrhoids formed by different abnormal states of the internal anal sphincter are also different. Internal anal sphincter spasm, contracture, high resting pressure of the anal canal to form knotted circular mixed hemorrhoids, internal anal sphincter relaxation, low resting pressure of the anal canal to form varicose-shaped circular mixed hemorrhoids.

    l Hoof knot tissue in mixed hemorrhoids is the product of tissue regeneration and repair after local inflammation and edema of the anal margin. Due to the stimulation of chronic inflammation, the anal sphincter continues to spasm and thicken, resulting in tightness and poor elasticity of the anal canal, and compression of stool during defecation, resulting in increased pressure of the anal marginal capillaries, lymphatic drainage disorder, and local edema. On the one hand, it causes the proliferation of interstitial fibroblasts and the formation of collagen fibers;

    l On the other hand, because lymph fluid is a good culture medium for bacteria and fungi, it causes repeated regenerative inflammation. With the continuous production and subsidence of edema and inflammation, the local hoof tissue is also continuously regenerated, resulting in the formation of mixed hemorrhoids with hoof tissue. Varicose-type mixed hemorrhoids are the product of local compensatory reactions. Due to congenital anal sphincter hypoplasia and long-term acquired constipation, excessive defecation time leads to excessive fatigue of the anal sphincter, resulting in relaxation of the anal canal, lower resting pressure, locally compensatory varicose veins, and eventually varicose mixed hemorrhoids.

    3. History and current situation

    l The classic procedure for the early treatment of annular mixed hemorrhoids in foreign countries is the “circumcision of hemorrhoids” created by Whitehead in 1882. Due to its well-known reasons, the three major complications of anal stenosis, mucosal ectropion, and moist anus are relatively high. It has long been rejected by most scholars. Half a century later, in 1937, the "hemorrhoid ligation resection" founded by Milligan-Mougan of St. Mark's Hospital in the United Kingdom was named after the surgical method of removing the hemorrhoids by ligating the root vessels connecting the roots of the internal hemorrhoids. Ligation&Exision method, referred to as LE technique. This operation was the most standard surgical method in the world at that time and opened a new era of mixed hemorrhoid surgery, so far it still has important clinical value.

    l In 1979, Mr. Takano of Japan published the "Ligation and Resection Method for Preserving the Anal Epithelium as much as possible". After that, he based on the medical theory of anal padding and after 10 years of painstaking research, in 1989 he published "Preserving the anal epithelium and Radical hemorrhoidectomy with pads", the main points of this procedure are: ① Make a dumbbell-shaped incision; ② Peel the internal and external hemorrhoids and internal hemorrhoid tissue from the incision to the area of ​​the suprahemorrhoidal artery for ligation; ③ Peel off the internal hemorrhoid tissue and varicose veins from the incision and retain Anal pad tissue and Ttreitz muscle; ④ Purse-string suture the wound within 0.5 cm below the tooth line and fix it to the ligation point of the suprahemorrhoidal artery area; ⑤ Suture the skin incision to close the incision.

    The surgical treatment of annular mixed hemorrhoids has the following advantages: ①The hemorrhoid skin incision is dumbbell-shaped, which fully preserves the anal skin and mucous membrane; ②It not only removes the varicose veins in the liner, but also retains the important support of the anal liner The structure is like Ttreitz muscle; ③The purse-string suture restores the descending anal canal skin, tooth line, and mucous membrane to the normal position, thereby solving the problem of hemorrhoid prolapse; ④Fix the purse-string on the internal hemorrhoid area and hang it on the rectal wall The curative effect is more reliable; ⑤The suprahemorrhoidal artery is sutured first during the operation, which can reduce the possibility of bleeding during and after the operation; ⑥When the incision skin is sutured, the retained skin and mucous membrane bridges close to the wound surface and heal with the wound granulation adhesion. Shorten the course of treatment; ⑦There is no exposed wound in the anal canal, which reduces postoperative anal pain. The main disadvantage is: improper operation may produce anal edema, skin tags, incision dehiscence, necrosis, and even anal stenosis.

    In 1995, Morinaga and others in Japan reported using Doppler and a specially designed proctoscope to find and ligate the hemorrhoid artery to treat 105 hemorrhoid patients, which was considered a successful operation without pain and low complications. In 2003, Shelygin reported that this method was used to ligate the terminal branches of the superior rectal artery. It was believed that it could reduce the blood supply to the hemorrhoid mass, fix the hemorrhoid mass and the muscle wall, thereby eliminating the symptoms of prolapse. The effective effect was 82.6% in 102 patients. In 2005, Ramirez reported using the same method to treat 32 patients with stage III and IV hemorrhoids. During the operation, an average of 5 arteries were ligated, 19 cases disappeared, 6 cases improved, and 7 cases failed. Postoperative complications such as anal discomfort, tenesmus, and lower rectal bleeding occurred. The clinical effect of this method needs to be further verified. At the same time, the method requires corresponding equipment and mastering certain related operation techniques, which is currently difficult to promote in China.

    In 1998, Italian scholars proposed a new method for the treatment of annular prolapsed hemorrhoids by circular resection of the lower rectal mucosa and submucosal tissue. This method can reset the prolapsed anal cushion and block the blood supply of the suprahemorrhoidal artery to the hemorrhoid area. Atrophy of hemorrhoids. In 2002, Trentin reported using this method to treat 100 cases of hemorrhoids and 6 cases of rectal mucosal prolapse. 42% of patients did not take analgesics and could return to work alone in 9.9 days. In 2003, Dixon reported that 62 patients with severe hemorrhoids who used this method were followed up. As a result, 6 people had complications, including 1 case of urinary retention, 1 case of death, 2 cases of pain, and 2 cases of bleeding.

    Hemorrhoid stapling surgery well protects the anal function, and can reset the prolapsed anal cushion, which is easy to operate and less painful after surgery. However, disposable staplers are expensive, single or semilateral hemorrhoids prolapse and other non-circular hemorrhoids are not suitable for use, and the scope of control of the mucosal resection is not ideal. The amount of mucosal resection depends on experience, and the reduction of severe hemorrhoids is insufficient. It is good, and different degrees of bleeding can still occur after anastomosis. According to literature reports, about 7% of patients need to undergo other surgical treatments after surgery. The long-term effects, especially stenosis and hemorrhoid recurrence, need further clinical observation.

    l The early treatment of hemorrhoids in China is the method of dry hemorrhoids, the Song "Tai Ping Sheng Hui Fang" from 982 to 992 AD. The earliest recorded ligation therapy in "Treatment of Hemorrhoids and Anal Side of Rat Milk", such as "Use spider silk on the right side to tie the hemorrhoids nipple, unconsciously fall".

    l Most of the current domestic treatments for annular mixed hemorrhoids are modified LE procedures. Aiming at the "anal cushion theory", some new procedures for preserving the tooth line and protecting the anal cushion are used, for example:

    1. Segmented tooth stripping and internal ligation to prevent postoperative anal stenosis

    l Based on the traditional external stripping and internal ligation, reasonable segmentation is adopted, and the ligation point near the tooth line is dislocated up and down to avoid the same plane to prevent postoperative anal stenosis.

    2. Treatment of internal and external hemorrhoids separately

    l Ligation of internal hemorrhoids: Clamp the base of internal hemorrhoids with a vascular clamp, pull it outwards moderately, and double ligate the suprahemorrhoidal artery area with silk thread. The ligation point is about 0.5cm away from the tooth line without damaging the tooth line.

    l Treatment of external hemorrhoids: Clamp the skin of the external hemorrhoids outside the anal margin with vascular forceps, and make a radial incision with surgical scissors. The upper edge of the incision extends to about 0.5cm below the tooth line. The skin margins on both sides are retracted, and the external hemorrhoid tissue is peeled off sneakily. , And to be removed, try to preserve the anal skin, trim the skin edge, suture the incision, and leave no dead space.

    l Dental floss is an important sensor in the anal canal. Less damage to the dental floss during the operation is also a protection for anal function. However, the scope of this operation is limited. If the dental floss prolapses with internal hemorrhoids, this method is not suitable.

    3. External stripping and internal ligation and broken bridge suture

    l After segmentation, make a radial "V" incision in the external hemorrhoids to peel off the subcutaneous hemorrhoids to 0.5cm on the tooth line. Use large curved forceps to clamp the base of the hemorrhoids completely. A round needle No. 7 silk thread penetrates the lower "8" of the forceps Sew the hemorrhoids and peel off the tissue, cut off one-half of the ligated stump and return it to the anus. If there are many hemorrhoids and the connecting ring is unclear, it is difficult to leave the skin and mucous membrane bridges. Choose relatively flat hemorrhoids as the skin and mucosal bridges. The lengthy and completely detached hemorrhoid skin bridge ascends the bridge.

    l Use small curved forceps to lift the lower edge of the skin bridge to fully peel off the skin and mucous membrane subbridge venous mass and hemorrhoid tissue. At this time, the skin bridge is in a free shape, avoiding the dentition and cutting off the excess bridge, and then carefully trim the skin and mucosa The bridge is smoothly covered on the sub-bridge tissue, and the skin bridge is carefully aligned and sutured with No. 0 silk thread. The needle thread passes through the muscle under the suture to fix the skin bridge on the subbridge sphincter, and strive to make the new anal canal skin bridge and mucosal bridge smooth.

    4. Suspension of hemorrhoids with internal anal cushion

    lEach external hemorrhoid is incised longitudinally along the natural depressions on both sides of the hemorrhoid, and the hemorrhoids and the cutaneous venous plexus on both sides are stripped to the muscle layer, and the upper end is 0.5cm below the tooth line. The hemorrhoids are removed in the same way as other external hemorrhoids, used between skin bridges 420 microbuckwheat thread sutures to eliminate wounds. The suprahemorrhoidal artery at the top of the hemorrhoid is punctured through the suture, and the suture is used to continue to penetrate the upper 1/3 of the hemorrhoid, tighten the knot and form a point suspension. The principle of this method is ligation of the hemorrhoid artery and suspension of the anal cushion, which reduces the blood supply of the hemorrhoid, breaks the disorder of blood vessel regulation in the hemorrhoid area, reduces the pressure in the anal cushion, and reduces recurrence. At the same time, the anal cushion is suspended and lifted to restore the normal position of the anal cushion.

    5. Multi-point high suspension of anal cushion

    l Applicable to those who have annular mixed hemorrhoids protruding out of the unbounded groove. During the operation, use the anal retractor to pull open the anal canal and rectum, clamp the external hemorrhoids with tissue clamps, pull the internal hemorrhoids without closure with the larger curved vascular clamp, expose the rectal mucosa of the hemorrhoids, and close the rectal mucosa with the larger curved vascular clamp to form a Long spindle-shaped strip, the top cut is 4-5cm away from the dentate line. Use a large round needle to hang a 7-gauge silk thread and insert the needle from the foremost end of the vascular clamp. Deeply perform single thread ligation in the submucosal layer, and insert the needle from the lower end of the vascular clamp and the upper end of the internal hemorrhoid. Then, the lower end of the vascular clamp is wound back to the upper end of the internal hemorrhoids and the needle is inserted again, and the ligation is carried out. No matter whether the internal hemorrhoids are corroded or not, they are not treated.

    l Treat the rectal mucosa of other hemorrhoids in the same way. The rectal mucosal ligation area that is ligated more than 3 points, that is, the upper end width should be small, and the distance from the dentate line can be reduced appropriately, but do not damage the anal cushion tissue. After the suspension ligation is completed, the external hemorrhoids can be seen to move up significantly and the anal canal skin Move up completely. External hemorrhoids are cut and peeled in an arc shape and sutured.

    6. Anal cushion injection and stripping

    l Injection of sclerosing agent into the loose rectal mucosa above the 3 anal pads and the upper 1/3 of the 3 female hemorrhoids and larger internal hemorrhoids. Set the stripping incision, stripping the inside out according to the usual method.

    7. External resection and internal ligation and external stripping and internal ligation

    l According to the different types of circular mixed hemorrhoids, external resection and internal ligation are used for hoof knot type circular mixed hemorrhoids, and external dissection and internal ligation are used for varicose vein type circular mixed hemorrhoids.

    l External resection and internal ligation (hoof knot type circular mixed hemorrhoids): According to the natural depressions on both sides of the hemorrhoid, 4-6 surgical areas are generally selected. First, a vascular forceps are clamped on each side of the cut line. , Cut longitudinally between the two forceps to make it an independent hemorrhoid tissue. Use a large curved full-tooth vascular forceps to clamp the base of the hemorrhoid along the longitudinal axis of the rectum, and place the surgical scissors close to the bottom of the vascular forceps. Cut to the tooth line, and then ligate it with silk thread, leaving part of the internal hemorrhoid stump to prevent the ligation line from slipping off and causing hemorrhage and bringing it into the anus. Treat internal hemorrhoids in other parts with the same method.

    l External stripping and internal ligation (varicose-shaped ring-shaped mixed hemorrhoids): Because the hemorrhoids are not obvious, the 3 and 9 o'clock positions of the lithotomy are selected as the stripping incision, radial incision, free anal flap, blunt stripping resection After peeling off the subcutaneous venous plexus on both sides of the incision for the varicose vein clusters and thrombus under the skin flap, trim the excess skin flaps and align them neatly, so that the skin flaps on both sides are flat and integrated.

    8. Multiple incision drainage

    l Adopt multiple small incisions for drainage of annular mixed hemorrhoids without resecting or damaging skin bridges and mucosal bridges in a large area at one time, which not only shortens the path of the surrounding skin to the incision hyperplasia, shortens the treatment course, and prevents the operation Anal edema, pain and scar contracture to avoid sequelae such as anal stenosis. It is not difficult to see from the above-listed treatment methods that while treating diseases, more consideration is given to reducing the damage to anal function, especially the protection of anal cushions and dental lines has become a current trend. Traditional circumcision has been basically give up.

    Four, problems and causes

    l Huang Jiasi Surgery clearly pointed out that the treatment of the disease is difficult to relapse, and improper surgery can easily cause sequelae such as anal stenosis, anal canal defect, mucosal ectropion, and leakage of secretions. We believe that the difficulty of ring-shaped mixed hemorrhoids is the contradiction between "going" and "staying". If we consider the thoroughness of the treatment, if we go for more and keep less, it is very likely that complications and sequelae such as skin defects and anal stenosis will occur after surgery. ; If considering safety, go less and stay more, thoroughness is not enough. It is a big clinical problem to be able to balance the efficacy and safety, and to master the degree and skills of "going" and "staying" well. Although many useful attempts have been made in clinical practice, problems still exist, which are summarized as follows:

    1. Anal canal stenosis: Excessive stripping and removal of the anal canal, anal marginal skin and subcutaneous soft tissue, resulting in a large area of ​​skin defects, scar contracture after healing, resulting in anal canal stenosis.

    l2. Rectal stenosis: ligation of excessive internal hemorrhoids or circular resection, or injection of sclerosing agent.

    l3. Rectal mucosal ectropion: excessive damage to the skin of the anal canal, large-scale defect, and compensatory outgrowth and coverage of the mucosa.

    l4. Secondary anal fissure: excessive skin damage, unreasonable incision, and excessive tension of the anal canal cause the surgical wound to not heal for a long time.

    l5. Sensory anal incontinence: It usually occurs after circumcision, when the tooth line and the skin of the anal canal are all removed, causing local sensory disturbances in the anus.

    l6. Anal incontinence: mainly fluid incontinence, mostly caused by internal hemorrhoids and excessive dental floss injuries.

    l7. Skin bridge edema: the incision is unreasonable, the skin bridge is too narrow, the subcutaneous vein mass is not damaged, and the anal canal is too tight.

    8. Residual external hemorrhoids: Skin bridges are treated reasonably, and external hemorrhoids are aggravated after skin bridge edema.

    Five, incomplete external stripping, internal tie and internal injection

    l Surgery is a double-edged sword. It can also cause local trauma while removing hemorrhoids. How to cause the least local invasion while ensuring the curative effect is the most difficult degree to master. In 1939 Calman pointed out that the principles of hemorrhoid surgery are: 1. Restore the anus, anal canal and rectum to the closest normal state without causing stenosis; 2. The operation is simple and the wound is small and can be completed in a short time; 3. The operation can be done. After the pain, the amount of bleeding is minimized. It is easy for us to do this for simple mixed hemorrhoids, but it is very difficult for circular mixed hemorrhoids.

    l We believe that the method of avoiding the hemorrhoids at the source of hemorrhoids can only be used in a limited range, and the treatment of circular mixed hemorrhoids is not a fundamental solution. In our clinical practice, we improved the traditional Milligan-Morgan technique and took advantage of the injection method, combined the two organically to maximize the strengths and avoid weaknesses, and basically fulfilled Calman's treatment requirements.

    1. Operation

    l Anesthesia and disinfection: The patient is placed in a lateral position, sacral canal block anesthesia is performed, and local infiltration anesthesia is performed for sacral hiatus deformities. Iodine and alcohol disinfect the perianal skin, and iodine disinfects the hemorrhoid area on the anal canal and dental line 3 times, and then fill the rectal cavity with 2 dry cotton balls.

    l Stripping point positioning method: follow the principle of "large first, then small, cross, outer hemorrhoids first, inner hemorrhoids second" principle, choose 3-5 external hemorrhoids with the most obvious bulge as the peeling point. Choose the external hemorrhoids corresponding to the larger internal hemorrhoids as the peeling point. The tissue between the two peeling points is the skin bridge and the mucosal bridge to be retained.

    l External hemorrhoids peeling method: Use tissue forceps to clamp the top of the external hemorrhoids and lift gently, cut the skin at 0.5cm from the base of the hemorrhoids on both sides of the hemorrhoids raised from the outer edge of the anal margin, and peel off the subcutaneous knot tissue and venous plexus. The tissue is freed into the anus to the tooth line or 0.2cm above the ligation. The incision should be gradually adducted when free. Pay attention to the ligation of the hemostatic point while peeling.

    l Ligation of internal hemorrhoids: use large curved hemostatic forceps to clamp the base of the external hemorrhoids from free to the dentate line together with the upper 2/3 part of the internal hemorrhoids on the dentate line, and perform simple ligation or "8" penetrating suture at the lower end of the hemostatic forceps Tie, keep the 0.5cm long stump, cut off the rest, and then push it back into the anus, keeping the two adjacent ligation points up and down.

    l Internal hemorrhoid injection method: (1) Medicine Shaobei injection, the concentration is 1:1, that is, 1 part of Shaobei injection plus 1 part of 0.5% lidocaine. (2) Location ①Unligated internal hemorrhoids; ②Under the rectal mucosa at the upper end of the skin bridge; ③Under the loose mucosa at the lower rectum. (3) The injection method follows the sixteen-character injection principle of "seeing hemorrhoids into the needle, first up and down, withdrawing the needle for administration, and fullness". When the injection needle pierces the hemorrhoid mucosa, the speed should be fast, and the needle should be withdrawn slowly to make the medicine fill the hemorrhoid evenly. After the injection, take out the dry cotton ball that filled the rectal cavity before the operation.

    l Renovation of small incisions at the anal margin: trim the skin margins on both sides of the incision, peel off subcutaneously swollen veins and thrombi, and appropriately extend the incision outside the anal margin so that the external hemorrhoid incision is a fusiform radial outward. If the anal margin is still uneven, use a small incision to strip and trim the raised area.

    l After the operation, the wound is filled with hemostatic sponge, and the tower-shaped gauze is compressed and fixed with a bandage.

    2. Description

    l (1) Incomplete external stripping and internal ligation is a simple and effective method for ring-shaped mixed hemorrhoids to fully preserve the skin and mucosal bridges. The preservation of skin bridge and mucosal bridge is an important indicator to measure the effect of mixed hemorrhoid surgery, and is the key to avoid postoperative complications and sequelae. The surgical procedures we have seen in the past have emphasized the importance of the preservation of the skin bridge and the width of the skin bridge should be preserved, but there are no specific measures for how to operate it. Milligan-Morgan's "external stripping and internal ligation" is a classic and effective method for the treatment of mixed hemorrhoids. So far, it can be said that no surgical procedure can completely replace it.

    l But this technique has obvious shortcomings in the treatment of circular mixed hemorrhoids, and only improvements can be made to adapt to the requirements of the new situation. Some circular mixed hemorrhoids have natural dividing grooves, and some do not. If it is considered that the anal margin or the lower end of the rectum can only be kept flat, many operations may be difficult to perform. By retaining the 0.5cm skin under the external hemorrhoids and the 1/3 mucosa under the internal hemorrhoids, the skin bridge and the mucosal bridge can be fully preserved regardless of whether there is a boundary between the hemorrhoids.

    l (2) Incomplete external stripping and internal ligation must be combined with internal hemorrhoid injection to ensure the completeness of the treatment. Retaining part of the "internal hemorrhoid" tissue during ligation is not only the need to retain the mucosal bridge, but also the need to retain the "anal cushion", but also the need for safety. The tension of the ligation point is small, which can effectively avoid the bleeding of the ligature after the operation. But to keep it, one must master the degree, and in addition, it is necessary to simultaneously inject drugs into the tissues outside the ligation point. "Shaobei injection" has strong atrophic hemorrhoids and local fixation, and at the same time does not form induration and has a higher safety. After injection, residual hemorrhoids can be eliminated, skin bridges adducted, and incomplete external stripping and internal ligation can be used to complement each other.

    l (3) Incomplete external stripping and internal ligation must be combined with stripping pruning to ensure the smoothness of the anal margin. If the base of external hemorrhoids does not retain tissue to prevent it from becoming residual hemorrhoids, subcutaneous tissue dissection must be carried out carefully. In principle, the swelling can be eliminated. It is not necessary to peel all the soft tissues from subcutaneous to muscular layer. Just destroy the varicose veins under the skin bridge. Don't become a "hanging bridge". The wide and raised skin bridge can be trimmed with small incisions.

    l (5) Dislocation of the ligation point up and down. This method has reached a consensus in China, and many methods have been adopted. The adjacent ligation points are slightly misaligned up and down, forming a tooth shape, so that the ligation points are not on the same level, so that the postoperative scar contracture is not on the same level, which can effectively prevent sequelae such as anal stenosis.

    l (6) The wound in this operation is not sutured and the internal sphincter is not cut to release the anal canal.

    l (7) This method can also be applied to mixed hemorrhoids or circular mixed hemorrhoids incarceration.

    l (4) Do not hurt "false hemorrhoids". In many cases, the raised tissues of the anal margin are not all hemorrhoids, especially those with heavier internal hemorrhoids. When the larger hemorrhoids prolapse, the normal skin of the anal margin connected to it will also be brought out to form false hemorrhoids. In order to prevent false hemorrhoids from accidentally being injured, we propose a surgical sequence of "large first, then small, crossover". The big goes first, the small is still an inch, you can go, the small is normal, you can keep it. Crossing and very sequentially is also an effective means to avoid accidental injury to false hemorrhoids.

    (8) Preservation and treatment of skin bridge:

    l In 2000, the “Chinese Journal of Anorectal Diseases” reported in the 25302 cases of hemorrhoids in the whole year that 9077 cases of hemorrhoids were surgically operated. In these cases, it seems that it has become a consensus to minimize the damage to the anal canal anatomy and protect the physiological function of the anal canal. , Hemorrhoidectomy with different names unanimously proposes that when hemorrhoids are removed, a fairly wide "skin bridge" or "mucosal bridge" must be kept between the two hemorrhoids.

    l But in clinical practice, the remaining skin bridges often become residual external hemorrhoids. Some skin bridges even appear edema and necrosis and have to be surgically removed again. We use the following methods to solve these two problems through years of summary.

    l①The width of the leather bridge should be greater than 0.5cm. The narrow skin bridge is the main reason for reservation failure. At present, when external hemorrhoids dissection and excision in China, a "V" mouth with a small bottom and a large mouth is used. The reason is to make the wound drainage smooth, which is difficult to ensure the width of the skin bridge. External hemorrhoid incisions are different from abscesses and anal fistulas, and there is no need to consider whether drainage is unobstructed. We use a "V"-shaped fusiform incision. During the operation, the incisions on both sides of the external hemorrhoids are lifted from the base by about 0.5cm, leaving this part of the hemorrhoid tissue, retaining the skin, and peeling the subcutaneous tissue, so that the width of the skin bridge between the two incisions Fully guaranteed.

    l ②The venous mass and thrombus were removed subcutaneously. In order to prevent the remaining skin bridge from becoming residual hemorrhoids, the underlying tissue and pathological products of the skin bridge should be properly treated. Use sharp scissors to peel off the thrombus and destroy the venous plexus that is not stretched, but the subcutaneous tissue cannot be completely removed and the skin bridge can be suspended.

    l ③Drug injection under the rectal mucosa near the heart of the skin bridge. Shaobei injection has astringent and atrophic effects. Injecting into the rectal mucosa at the medial end of the skin bridge can cause the skin bridge to be raised and adducted, and at the same time, it can block the venous return path of the skin bridge and maintain local levelness.

    (9) Causes and prevention of anal edema:

    l The formation of edema is because the operation destroys the local venous return, the venous intravascular pressure at the edema site is too large, the permeability of the vessel wall is improved, the lymphatic fluid is concentrated in the local area, and even the extravasation of blood in the blood vessel causes local thrombosis . Edema can cause unbearable pain in the anus after surgery, or even necrosis of the skin bridge. Therefore, avoiding postoperative anal edema is an important content to be considered in surgical operations and postoperative care. We mainly use the following methods to solve.

    l①The skin bridge cannot be the "bottleneck" of venous return. As mentioned earlier, the width of the skin bridge must be maintained, but it is not enough. It must also be maintained at a suitable length. If it is too short, the local blood will become a "bottleneck" effect, blood flow will be blocked, and it will inevitably cause local tissue edema. Therefore, it is necessary to extend the leather bridge and establish a "buffer" at both ends. The surgical operation is to extend the incisions on both sides of the skin bridge outwards, and try to keep the incisions parallel to the skin bridge.

    l②Reduce the burden on the leather bridge. The tissue under the skin bridge does not need to be completely stripped and resected, and the subcutaneous venous mass can be properly destroyed and the thrombus can be stripped off, blocking the venous access to reduce the burden of the skin bridge. The above-mentioned injection of Shaobei injection at the upper end of the skin bridge can also play this role.

    l③ Avoid excessive resection and ligation of the anal margin during the operation, and avoid excessive exposure of the internal sphincter, which may cause postoperative spasm and affect the blood return of the anal canal.

    l④After the operation, the tower-shaped gauze pad compresses the anus to keep the pressure evenly around the anus.

    l⑤ After dressing change, the anal gauze should not be too much, and the anal canal should not be compressed into a mass.

    l⑥ After the first defecation after the operation, to prevent the toilet and the long defecation time, Kaisailu enema can be used to assist defecation.

    (10) Causes and prevention of anorectal stenosis

    l Because there are more than 2 wounds in the external dissection and internal ligation of circular mixed hemorrhoids, the skin and anal margin tissues removed during the operation make the anal canal tighter than before the operation, and the elasticity is poor, which is likely to cause anal canal stenosis. Some scholars believe that if too much tissue is removed during circular mixed hemorrhoid surgery, there may be a certain degree of anal incontinence or anal stenosis after the operation. Excessive ligation of internal hemorrhoids can also cause rectal stenosis.

    l The most commonly used method to prevent postoperative anorectal stenosis is to cut off the internal anal sphincter during the operation to loosen the anal canal.

    l In clinical practice, we do not cut off the internal anal sphincter to loosen the anal canal to prevent stenosis. Instead, we design a more scientific and reasonable surgical plan to minimize trauma to avoid postoperative stenosis, which is a more active method.

    l①Increase the width of the leather bridge (above)

    l②Small incisions replace large incisions with multiple incisions. The number of leather bridges can be increased.

    l③ The incision is a long and narrow fusiform mouth. Reduce the tension of the incision.

    l④ The subcutaneous tissue of the anal canal at the anal margin is properly retained. The complete stripping of the venous plexus leads to heavier scars after healing, and anal fissures may also occur. During the operation, a small amount of vascular plexus and hoof tissue are retained on the surface of the muscle, which is conducive to wound healing and can reduce scars after healing.

    l⑤ The tissues under the tooth line should be ligated as little as possible.

    We take the following measures to prevent rectal stenosis:

    l ① 2/3 of the internal hemorrhoids are ligated, and the base 1/3 remains. This will not only retain sufficient mucosal bridges, but also protect the anal cushion tissue. The anal cushion is a dynamic component of closing the anus, it participates in assisting the normal closure of the anus and helps control the stool. If the anal cushion is excessively damaged or defective, complications such as anal sclerosis, stenosis, low sensory function, and incomplete closure can occur.

    l② The ligation points of internal hemorrhoids are slightly misaligned. Avoid ligation points on the same level.

    l③ Try to use "8" ligation. Reduce the tension at the ligation point.

    l④ Cooperate with ligation and drug injection. Shaobei injection is used for mucosal bridges, unligated internal hemorrhoids and loose rectal mucosa to ensure local atrophy and ensure the effect. At the same time, the drug does not damage the surface mucosa, does not produce induration and non-scarring repair, and can also prevent stenosis The role of.

    Six, discussion

    1. Preoperative design?

    The first step of circular mixed hemorrhoid surgery is to segment to determine where to remove and where to remain. How to segment? At present, there is no clear principle and unified standard in China. Junichi Iwataru of Japan pointed out that the design question of where and where to leave the whole hemorrhoids is very important. Domestic scholars have grouped the prolapsed anal pads naturally, and selected the peeling and cutting points in the traditional three female hemorrhoid areas. This classification method is relatively blind. In clinical practice, the main lesions of many circular mixed hemorrhoids are not in these three positions.

    l Although the same ring, but specific to each individual, its performance is very different. It is impractical to develop a unified segmentation model. Our principle is: ①"Large first, then small, external hemorrhoids first, internal hemorrhoids second", first remove the larger external hemorrhoids. If the external hemorrhoids are equal in size, the external hemorrhoids corresponding to the larger internal hemorrhoids are used as the incision. . ②3-5 points are appropriate. ③At the same time, it is necessary to consider the balance of the 12 points of the front, back, left, and right anus. Not all incisions should be concentrated on one side, otherwise it will affect the function and long-term effect of the anus after the operation.

    2. Loosen the anal canal?

    l   At present, when circular mixed hemorrhoids are performed in China, more than 90% of them are cut off the sphincter to loosen the anal canal. The reason is that cutting the internal sphincter head can prevent postoperative complications. According to the "button hole", the main cause of hemorrhoids is that internal sphincter spasm or abnormal activities lead to obstruction of the hemorrhoidal venous return, and a large amount of blood in the hemorrhoids blood vessels form hemorrhoids. Cutting or dilating the internal sphincter can reduce the intraanal pressure and improve the hemorrhoids. Clinical symptoms. At the same time, it can reduce postoperative pain, urine retention and anal stenosis caused by internal sphincter spasm.

    l We have found in long-term clinical practice that cutting off the anal sphincter is not a theoretical advantage. We believe that it does more harm than good for the following reasons:

    l (1) Reasonable surgical methods can avoid postoperative anal sphincter spasm. We believe that there are three reasons for postoperative sphincter spasm: ①The wound is too large and the skin bridge and mucosal bridge are insufficiently retained; ②The soft tissue in the wound is stripped too much and the sphincter is exposed; ③The skin bridge edema and thrombosis under the skin bridge occur after the operation. If these reasons can be overcome without cutting the sphincter, postoperative cramps can be avoided.

    l (2) Cut off the sphincter muscle, leading to local mechanical imbalance, which is very easy to cause hemorrhoids on both sides of the incision to increase or skin bridge edema.

    l (3) Blind relaxation leads to more relaxation of the anal sphincter, which affects long-term efficacy. Some domestic scholars have found through research that decreased anal sphincter function is an important cause of hemorrhoids. Some scholars have reported that cutting off the main anal nerve of rabbits and giving anoscope to continue to over-expand the anus can form pathological changes similar to human hemorrhoids in the anus. Yishan et al. [4] also reported that relaxation of the anal sphincter can reduce the function of anal static pump and form hemorrhoids. The author also observed in the clinic that some patients with anal sphincter damage and congenital anal sphincter relaxation are mostly accompanied by severe internal hemorrhoids. In fact, this is a compensatory response.

    l3. Stitching?

    There are sutures in the lM-M operation, and in Takano's anal preservation operation, sutures are also used in some current domestic methods. From the early suture of internal hemorrhoids, to the current suture of external hemorrhoid incisions and transverse seams of skin bridges.

    l We believe that the wound should not be sutured if it is not fasting or confinement. The first is internal hemorrhoids, ligation is better than suture. Long-term clinical practice has confirmed that ligation is a safer and effective treatment for internal hemorrhoids. Mucosal suture is very difficult, especially multiple sutures, especially multiple sutures. Even if it can be sutured smoothly, postoperative safety is a big problem. The second is external hemorrhoids, open is better than closed. If multiple incisions at the anal margin are sutured, the anal opening will be reduced, stool will be difficult, and stool pain will be severe. At the same time, the suture opening is prone to infection, and the healing time is not shorter than the opening. The third is that skin bridges are best not to be sutured with broken bridges, because there are not many skin bridges that really need to do this in clinic, and the quality of sutured skin bridges is not high after survival.

    4. Vein mass peeling?

    l In the past, external peeling was done to completely peel the vein mass and knot tissue from subcutaneous to muscle layer. Some scholars believe that complete stripping of the venous plexus can avoid anal edema. We believe that the thorough stripping of the venous plexus and soft tissues will lead to slow healing of the wound after healing, heavier scars, sphincter spasm, and secondary anal fissures. We keep a small amount of vascular plexus and knot tissue on the surface of the muscle during the operation, and try to cut the blood vessel method, which is conducive to wound healing and can reduce scars after healing.

    5. Keep the tooth line?

    l Past circumcision ignores the role of dentition, resulting in sensory anal incontinence. Now some operations are going to the other extreme, and the dental floss surgery that treats internal and external hemorrhoids separately. The author believes that this procedure is suitable for simple internal or external hemorrhoids, but not for mixed hemorrhoids, especially circular mixed hemorrhoids. What is mixed hemorrhoids? The internal and external hemorrhoids are connected as a whole, and the tooth line has left its normal position, bulged or prolapsed. How to retain such a tooth line, and what is the use of retention? We believe that although the usual external stripping and internal ligation will remove part of the tooth line, it will certainly not have much impact on the anal sensory function, and there is no need to cast a rat trap.

    6. Suspended?

    l Under the influence of PPH, "suspension" has become a fashion in anorectal surgery, and has become synonymous with protecting anal cushions. The author believes that the suspension method has a certain effect on internal hemorrhoids and rectal mucosal relaxation, but it is difficult to achieve results by suspending instead of external hemorrhoids. Even for varicose external hemorrhoids, it is better to destroy the venous mass through a small incision.

    7. Conclusion

    l Incomplete external stripping and internal ligation and internal injection method. By improving the traditional external stripping and internal ligation and organically combining with the injection method, it fully preserves the skin bridge and mucosal bridge while taking into account the thoroughness of the treatment, without cutting off the internal anal sphincter It can prevent anal stenosis and is an effective, low-invasive, and safe method for the treatment of circular mixed hemorrhoids. It has realized the surgical principle proposed by Calman 40 years ago.

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