Although every gastrointestinal (anorectal) doctor can perform PPH surgery, the details that should be paid attention to may not be mastered. Now I will make a brief excerpt from the literature.
Indications: Internal hemorrhoids III degree and above/II degree conservative treatment recurrence; early (I/II degree) is not recommended
PPH cannot solve the problem of external hemorrhoids, so you must communicate clearly with the patient/family before surgery
Preoperative preparation: dietary conditioning + 2 enemas before surgery // whole bowel preparation (polyethylene glycol), + (-) preventive antibiotics are all available (currently there is no consensus, I recommend using it for 24 hours)
Preoperative examination: digital anus examination; for elderly women, be careful with rectal/vaginal prolapse; and stubborn bloody stools (or "black stools"), it is recommended to do "electronic colonoscopy" to exclude other colorectal diseases; (careful!! ) Coagulation dysfunction, arteriovenous malformations, long-term oral anticoagulants, etc.
Regarding anesthesia: combined spinal-epidural anesthesia is preferred; (limited conditions) local anesthesia (2 triangles of the perineum-Arcock Canal)
Position: Lithotomy position//Prone folding knife position is acceptable (appropriate head low and high feet-reduce perineal blood flow and rectal bleeding); most scholars prefer the former (lithotomy position)-it is more convenient to "intraoperative" vaginal examination Whether the back wall is damaged (very important!!)
Several details during the operation:
Traction of the buttocks skin (both sides) is more conducive to exposing the anal opening (wide tape fixed skin posterior and lateral traction)
CAD (Circular Anal Dialator) 33 Do not forcibly insert into the anus, which may cause hemorrhoids to rupture and hemorrhage during the operation.//Damage to the stent muscles; expand the anus first, sew the CAD fixation thread and insert...
The 4 stitches of the CAD fixation thread (up, down, left and right) should be fixed on the skin tag edge of the anal mouth, not the normal perianal skin (as shown in the figure below); it is better to pull the tooth thread out (to protect the tooth thread//to reduce the difficulty of suture)
In the case of poor bowel preparation, 2 gauze can be used to fill the upper rectum, which must be taken out first after surgery
Purse-string suture (2-0 Prolene):
2 Half purse // 2 Full purse // 1 Full purse either;
The stitch length should be slightly closer to the submucosal layer (appropriately with some muscle layer);
3-4cm on the tooth line or 2cm on the upper edge of the hemorrhoid; the pulling line is best to end at 3 or 9 o'clock (lithotomy position), especially for women;
At the upper edge (12 o'clock in the stone cutting position), care should be taken to avoid damage to the posterior wall of the vagina;
About the stapler Fire:
Lift the purse cord and slowly tighten the PPH03 (recommended to the tightest position-Max in the green zone), wait at least 1min (some scholars recommend 2-5min) and then fire;
Female patients must check the posterior vaginal wall again before Fire (if there is vaginal wall depression, it must not be rashly stimulated);
After Fire, wait 2 minutes to loosen 1.5 turns and slowly take out the stapler; if there is resistance to pulling out, avoid strong pulling, and it can be withdrawn together with CAD;
Be sure to check the integrity of the mucosa and anastomosis;
Intraoperative anastomotic bleeding-electrocoagulation // 3-0 Vicryl suture ("8" suture, non-horizontal suture-easy to cause anal stenosis) | Hemostatic gauze packing
Discharge on the same day after surgery (relatively safe to discharge within 1-2 days), Sits Bath, oral analgesics (NSAIDs), stool softening
In addition, the parachute method (1/2 Purse PPH) is more suitable for surgical treatment of intractable constipation in addition to internal hemorrhoids.
References: "MasterTechniques in Surgery", "SRB's Surgical Operations Text and Atlas", "Scott-Conner & Dawson ESSENTIAL OPERATIVE TECHNIQUES and ANATOMY"