Many patients suffering from constipation put their last hope on surgery, but surgeons believe that surgical treatment should be avoided as much as possible, considering the uncertainty of efficacy and possible complications of surgery. Surgical treatment of chronic constipation has been carried out in China for decades, but progress has been slow and few surgeons have been involved. There is a great deal of controversy about which surgical methods should be used for various types of constipation. There is a lack of large-sample studies on the effectiveness, objectivity and persuasiveness, and there are few reports on reoperation rates and long-term efficacy. Therefore, patients should not expect too much from surgical treatment. I. When to choose surgery? For patients, this choice is difficult. In general, surgical treatment should be considered in the following cases. 1.It is really ineffective through medication and dietary adjustments. 2.Severe impact on one’s work, life and study. 3.The appearance of obvious organic changes, such as megacolon, colonic redundancy, intestinal obstruction. 4, There is conclusive evidence of exit obstruction, such as inability to pass stool, fecal imaging, etc.. 5, fully recognize the advantages and disadvantages of surgery, and have to deal with postoperative adverse reactions may occur mental preparation. Surgical treatment of constipation with outlet obstruction Constipation with outlet obstruction, also known as rectal constipation, is an organic functional abnormality of the tissues around the outlet of defecation, which leads to difficulty in defecation. The main causes include rectal mucosal intussusception, anterior proptosis of the rectum, hypertrophy or loss of relaxation of the puborectalis muscle, and relaxation of the pelvic floor muscles. 1.Rectal mucosal ligation and fixation is suitable for constipation with outlet obstruction caused by rectal mucosal laxity and intussusception. The surgical procedure is multi-row longitudinal suture or ligation through the anus, which increases the effective volume of the rectum and the internal pressure of the rectum, promotes the elimination of feces, and relieves the symptoms of constipation. Submucosal injections of sclerosing agents for relaxation can be taken for milder degrees of condylomata. Because this type of surgery belongs to transanal surgery, the surgical trauma is smaller, the speed of surgical recovery is faster, and the patient is easy to accept. It should be pointed out that PPH is not recommended because the procedure will form a transverse scar ring at the lower end of the rectum, like a threshold, which will sometimes block the normal discharge of feces. 2.Rectal proptosis repair Suitable for female patients with rectal proptosis. This kind of patients have difficulty in defecation, press the back wall of the vagina can be discharged, rectal fingerprinting can feel the weakness of the protrusion into the vagina. On defecography, the protrusion is more than 37.5 px deep. The aim of the surgery is to narrow the flaccid anteriorly protruding rectovaginal diaphragm by suturing. There are two types of surgery: one is transanal and the other is transvaginal. Both methods are equally effective. The risk of this procedure is to guard against postoperative rectovaginal fistulae, both by careful intraoperative maneuvering and postoperative prevention of infection. In addition, there is a certain recurrence rate. 3.Puborectal muscle release This kind of patients in the process of defecation, due to the puborectal muscle function abnormality, paradoxical contraction or can not relax, resulting in fecal retention caused by constipation, therefore, through the puborectal muscle release surgical treatment, can be a fundamental relief of this symptom. The current methods of relaxation are cut off, partial excision and hanging wire, the author believes that hanging wire operation is simple, reliable efficacy, due to the first two methods. However, the depth of the hanging wire should be well mastered during the operation, so that it can serve the therapeutic purpose without causing anal incontinence. The operation of this procedure is relatively simple, the postoperative long-term effect is good, in the case of a clear diagnosis, is a very good choice of constipation surgery. 4.Transanal anastomotic rectal resection (STARR) is suitable for defecation obstruction caused by anterior proptosis of the rectum and intramucosal condyloma of the rectum and other redundant tissues of the rectum. The surgical principle is transanal anastomotic partial rectal resection, the difference with PPH is that this surgery is to cut the mucosa and muscle layer, not simply only the rectal mucosa. The mechanism may be to facilitate fecal evacuation by improving rectal compliance and sensibility. Since the invention of the loop anastomosis in the 1980s, the use of loop anastomosis for the treatment of outlet-obstructed constipation has become a clinical hot spot. However, the pathologic basis of severe outlet-obstructive constipation is pelvic floor laxity, and rectal mucosal prolapse may be only one of multiple pathoanatomical changes; therefore, the results of STARR reported in the literature vary widely, with efficacy rates ranging from 90% in the short term to 45% at 18 months. In addition, STARR has more complications, including bleeding, anal incontinence, severe anal pain, rectovaginal fistulae, and even lethal pelvic sepsis, and is now being used less and less in clinical practice. Third, the colon slow transmission type constipation surgical treatment constipation, there are about 1/3 of the patients belong to the colon slow transmission type, this kind of patients are very stubborn, general drug treatment effect is not obvious, the patients can be used to remove the colon of the method of treatment. A century ago there are reports of the use of colon resection for the treatment of constipation. The therapeutic principle is that the residual shorter colon can reduce the colon transportation time and the amount of formed feces in the rectum.After 1984, the international practice of colectomy was limited to patients diagnosed with slow-transport constipation.Clinical application peaked in the early 1990s, but after the 2l century, many studies found that the long-term efficacy of this procedure was not satisfactory, and although it remains one of the most important constipation procedures, its use is somewhat limited. Although it is still an important constipation procedure, its application has been limited. Currently, it is generally recognized that colon resection should only be used in cases where the diagnosis of slow-transmission constipation seriously affects the quality of life and non-surgical treatment fails to improve the symptoms. Specific methods are mainly the following. 1, total colectomy Remove all of the colon and the upper part of the rectum, and then the ileum and rectum anastomosis connection. This operation is originally used for ulcerative colitis which is ineffective by internal medicine treatment or complications, family polyposis suspected of malignant change and multiple cancers of colon. It is also the most prominent procedure for constipation surgery. With the development of minimally invasive surgery and the wide application of laparoscopic technology, total colorectal resection under the guidance of laparoscopy reduces the trauma of the operation, the speed of postoperative recovery, and is more easily accepted by patients. 2, colorectal resection ileal storage bag anal tube anastomosis 1978 parks first used this procedure for the treatment of ulcerative colitis, and is now used for the treatment of familial adenomatous polyposis and constipation at the same time. The presence of an ileal storage pouch relieves the problem of excessive bowel movements as opposed to total colon resection. The basic procedure of this type of surgery is to resect the entire colon from the terminal portion of the ileum to the dentate line, and then use 750 px of ileum to create a 375 px J-shaped storage pouch, and then finally to perform an anastomosis of the anal canal of the ileocecal storage pouch. The surgery is characterized by large resection area, high trauma, and complicated surgical operation. Postoperative complications such as dysuria, pouch inflammation and anastomotic leakage may occur. Complications such as anal incontinence, diarrhea and intestinal obstruction are also found in the long-term follow-up, and the rate of secondary surgery is about 10%. 3.Secondary total colectomy Considering the huge trauma caused by total rectal excision and the persistent diarrhea after surgery, partial (secondary total) colectomy came into being. This type of surgery is divided into two types depending on the site of resection: (1) Surgical resection of the middle portion of the ascending colon to the rectum, followed by recto-caecal anastomosis. Unlike total resection, the patient retains the ileocecal valve and the cecum portion after surgery, which enables the patient to control the formation of new feces by controlling the rate at which the chyme enters the colon, maintains the normal absorption function of water and vitamins, and reduces the incidence of diarrhea. The disadvantages are the complexity of the procedure, the possibility of intraoperative injury to the pelvic autonomic plexus, and the need to preserve 6 to 200 px of the ascending colon during the recto-caecal anastomosis, which may cause recurrence of postoperative abdominal pain and constipation. (2) Surgical resection of the middle and lower portions of the cecum to the sigmoid colon, followed by sigmoid-ileal anastomosis. There is little literature on this procedure, and the postoperative results and improvement in quality of life are not promising. 4, colon absenteeism A surgical procedure dedicated to the treatment of colon slow transmission constipation, the operation cut off the terminal part of the ileum, the ileum will be pulled down with the rectum end side anastomosis, do not remove the colon. This procedure has the advantages of simple operation, small trauma, fast postoperative recovery, and low complications. However, postoperative fecal reflux may occur, resulting in abdominal pain, abdominal distension, nausea and other adverse reactions. Fourth, the surgical treatment of mixed constipation Mixed constipation is constipation caused by multiple factors such as oral obstruction and colonic transmission dysfunction. In fact, the so-called intractable constipation to help surgeons, the vast majority of mixed-type severe constipation, which is also a slow transmission type of constipation or a separate for the exit obstruction type of constipation and the main reason for the design of the surgical treatment effect is not good. For this type of constipation, should the slow transmission problem or the outlet obstruction problem be solved first? Or both? Split surgeries can cause fear in patients due to longer recovery periods and complications. At the same time, a single operation has satisfactory clinical results, but the disadvantage is that the patient may suffer from severe diarrhea in the short term after the operation. Domestic “Jinling surgery” is performed to lift the cause of slow transmission by subtotal resection of the colon, and at the same time, the ascending colon and rectum (posterior wall) lateral anastomosis is performed to correct the anatomical and functional disorders of the pelvic floor, thus lifting the cause of the outlet obstruction, and the therapeutic effect is satisfactory.