2021年2月18日星期四

what does a hemorrhoids look like,Talking about the evolution of hemorrhoid surgery

    Hemorrhoids are masses formed by pathological hypertrophy, downward movement of the anal cushion, and stagnant blood flow of the perianal subcutaneous vascular plexus. Hemorrhoids can be accompanied by symptoms such as bleeding and prolapse. It is a common and frequently-occurring disease. As the pathogenesis of hemorrhoids continues to update, the concept of surgical treatment has changed from resection of the hemorrhoids to the main purpose of relieving symptoms such as prolapse and bleeding. Surgical treatment has been transformed from the classic surgical external stripping and internal ligation based on the theory of varicose veins (ie Milligan-Morgan method), developed to the current state of the art based on the most popular theory of anal cushion downshifting, an anastomosis of the prolapse and hemorrhoids and circumcision of the mucosa (ie PPH). The surgical method has changed from overall resection to minimally invasive, from simply eliminating the disease to restoring physiological functions and protecting normal tissues.

    The surgical treatment of hemorrhoids in Chinese medicine can be traced back to the earliest recorded in the "Fifty-two Prescriptions for Diseases" of the Qin and Han Dynasties that "the male hemorrhoids live beside the orifice, and the larger ones are like jujube...Tie a small rope and cut with a knife." to the Song Dynasty. In the "Tai Ping Sheng Hui Fang", there is a record of "Use spider silk to tie the nipples of hemorrhoids, unconsciously." Until the Ming and Qing Dynasties, in the "World Medicine Effective Recipe", "Ancient and Modern Medical System", "Medical In Zong Jinjian, there are records of hemorrhoids with medicine thread. In Western medicine, Hippocrates, known as the "Father of Western Medicine", first proposed the concept of "hemorrhoids", thinking that "hemorrhoids are not a disease, and bleeding is the excretion of normal waste from the body" and "hemorrhoids bleeding is a normal life phenomenon." Due to the influence of this view, the research and development of the treatment of hemorrhoids in western medicine is also restrained. The earliest recorded method for surgical treatment of hemorrhoids is the hemorrhoid circumcision reported by Whitehead in 1882, but due to its serious complications, it has been rarely used. Now let's make a brief analysis of the hemorrhoid surgery that is widely used in clinical practice:

    1. External stripping and internal ligation

    The Milligan-Morgan method [1] was first proposed by Miles in 1919. In 1937, Milligan and Morgan of St. Mark's Hospital in the United Kingdom improved the operation method, which is generally called Milligan-Morgan operation. The main point of this operation is to make a V-shaped incision at the junction of the skin and mucous membrane at the lower end of the hemorrhoid, peel it up along the surface of the internal sphincter to the top of the internal hemorrhoid, suture and ligate the hemorrhoid root, and remove the hemorrhoid at a distance of 0.3 cm from the ligation line. The advantage of this method is that the operation is simple, and the effect is good for single or relatively isolated internal hemorrhoids. Its disadvantages are the long operation time, postoperative pain, edema, heavy bleeding, long time, hospital stay, anal exhaust time and recovery time, anal stenosis and anal incontinence and other complications.

    2. Segmented tooth ligation

    It is an improved external stripping and internal ligation, a surgical method for the treatment of advanced internal hemorrhoids and circular mixed hemorrhoids created by Professor Ding Zemin [2]. When separating and ligating the hemorrhoids, this method consciously staggers the adjacent hemorrhoids up and down, so that the line of separation and ligation apexes are distributed in a tooth shape, so that the wound is not on the same plane after the scar contracture, and it prevents postoperative anal stenosis. However, in order to retain enough "skin bridges" and "mucosal bridges", the hemorrhoids under the "skin bridges" and "mucosal bridges" are difficult to be completely treated; in order to pursue a thorough treatment, the remaining anal canal epithelium is less and the anal cushion is more removed. In many cases, the anus tends to become narrow after surgery, leading to difficulty in defecation, and some damage to the physiological structure and function. At the same time, there are also shortcomings of postoperative pain, edema, heavy bleeding, long time, hospitalization time, anal exhaust time, and long recovery time.

    3. The closed operation refers to resection and suture

    Including semi-open suture and complete suture. Semi-open suture is Parks hemorrhoidectomy [3], the specific operation is to incise the mucosa of the anal canal and rectum, remove the hemorrhoid tissue under it, and then reattach the mucosa. The purpose of this operation is to remove the hemorrhoid tissue without damaging the squamous and columnar epithelium covering the surface; complete suture is Ferguson hemorrhoidectomy [4], vascular clamp clamps the hemorrhoid, blunt or sharp free the whole hemorrhoid The vascular pedicle is stitched together to tie the pedicle, the hemorrhoids are removed, and the wound is sutured. The advantage of the closed operation is that the wound is sutured. If no infection occurs, the wound will heal faster and relieve pain. However, since the suture wound is prone to infection after this operation, the patient needs to control his diet and defecation for several days after the operation.

    4. Surgery for hemorrhoids with anal canal epithelium and anal pad

    This procedure was proposed by Japanese scholar Masahiro Takano in 1989 based on the theory of downward shifting of the anal cushion [5]. This procedure uses dumbbell-shaped incisions to preserve as much of the anal canal as possible. After healing, the integrity and integrity of the anal canal can be maintained. Continuous, plays an important role in maintaining the normal function of the anus. Save the anal cushion, avoid removing too much subcutaneous and submucosal tissue, and avoid moving the anal cushion down. However, there are still shortcomings such as open wounds, obvious pain, and sensory incontinence of the anus after the removal of the sensory epithelium in the tooth line and the tooth line area.

    5. Procedure for prolaps and hemorrhoids (PPH)

    It was first reported by Italian scholar Longo in 1998[6], which is based on the theory of anal cushion and anal cushion downward movement. The purpose of PPH surgery is not to remove the prolapsed anal cushion, but to restore its normal anatomy. In PPH, a 2 to 3 cm wide rectal mucosa is circularly removed 2 to 3 cm above the dentate line, and the two stumps are anastomosed at the same time. The lowered anal cushion is lifted and fixed to restore it to the normal anatomical position. Its advantages: ① postoperative pain reduction or no pain; ② short operation time; ③ fast postoperative recovery; ④ short hospital stay; ⑤ less postoperative complications, no anal stenosis and anal incontinence; ⑥ smooth anal appearance. The short-term effect of this kind of surgery is relatively positive, but most of the postoperative patients have frequent bowel movements and a sense of urgency to defecate, and occasionally serious complications such as recto-vaginal fistula occur. Research and improvement are needed. The long-term efficacy also needs to be observed and demonstrated, and PPH stapler The price is higher.

    6. Summary

    From the evolution of the above-mentioned surgical methods, it can be concluded that the current surgery for hemorrhoids has changed from completely removing the anal cushion to retaining part of the anal cushion, and finally to completely retaining the anal cushion. This is due to the continuous updating of the concept of hemorrhoid treatment. The advantage of PPH is that it completely preserves the anal cushion tissue and restores the prolapsed anal cushion to its normal anatomical structure. The patient recovers quickly and has little pain after surgery, but the long-term effect of PPH needs further observation. And the price of PPH stapler is higher. However, the traditional external stripping and internal ligation and its modified operation, resection and suture, and hemorrhoid surgery that preserve the anal canal epithelium and anal pad have certain advantages and disadvantages. Therefore, the use of individualized surgical treatment plans for patients in different situations, on the basis of ensuring the efficacy, and minimizing the occurrence of complications, should be the continuous pursuit of each of our anorectal surgeons.

    references:

    1. Milligan ETC, Morgan CN, Nanton LE, et al. Surgical anatomy of the analcanal and the operative treatment of hemorrhoids[J]. Lancet, 1937, 2(1): 111.

    2. Ding Zemin, Ding Yijiang, Wang Yehuang. Ding's hemorrhoid science [M]. Shanghai: Shanghai Science and Technology Press, 1989.201-208

    3.Park AG. Hemorrhoidectomy. Adv Surg 1971;5:1

    4.Ferguson JA .Heaton JR. Closed hemorrhoidectomy. Dis Colon Rectum 1959;108:115

    5. Masahiro Takano. Anal epithelial Cushion warm-preserved hemorrhoid radical resection[J]. The Japanese Society of Colon and Anal Diseases,1989,42:1-9

    6.Longo A. Treatment of hemorrhoids disease by reduction of mucosa and hemorrhoidal proplse with a circular suturing device: a new procedure[J]. Rome, Italy: proceedings of the 6th World Congress of Endoscopic Surgery, 1998, 122(75): 3.

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