Circumferential mixed hemorrhoids have a high incidence in hemorrhoid disease and are one of the 16 difficult-to-treat diseases in anorectology announced by the State Administration of Traditional Chinese Medicine. The disease is accompanied by frequent blood in the stool, in addition to the prolapse of the anus during stool. The external hemorrhoid part of the disease is distributed in 360°, and the nucleus of the hemorrhoid often cannot be separated from the normal skin, and the pathological pattern is characterized by connective tissue hyperplasia and varicose veins; the internal hemorrhoid is generally above degree II, and the clinical treatment is more difficult. Mr. Kou Yuming has been engaged in the diagnosis and treatment of anorectal diseases for more than 30 years, and as one of the first batch of national famous veteran Chinese medicine doctors with apprenticeship trainees from the Ministry of Health, he is deeply influenced by the true tradition of the famous anorectal disease expert Zhou Jimin, and has achieved satisfactory results in the surgical method of removing and suturing external hemorrhoids and ligating and injecting internal hemorrhoids for circumferential mixed hemorrhoids. It is popular among patients because of its thorough treatment, less pain for patients, ideal long-term efficacy, and no sequelae such as anal stenosis and anal canal skin defects. The author is fortunate to learn from his teacher and has benefited greatly from his experience in treating circumferential mixed hemorrhoids. 1.Pre-operative preparation. The Kou division makes detailed surgical plans for patients of different ages, genders, and physical conditions, including intestinal preparation, anesthesia, and surgical incisions, to be well informed. Particular attention is paid to preoperative conversation with patients to eliminate their doubts and reduce the impact of psychological factors on intraoperative and postoperative. 2. Surgical method. The patient was placed in the lateral position, and the skin of the operation area was routinely disinfected with iodophor, and 0,5% lidocaine was used for infiltration anesthesia at 3,6,9,12 points after spreading sterile towel, and 0,5% lidocaine with a little epinephrine was used for local infiltration anesthesia of external hemorrhoids. Routinely disinfect the anal canal and lower rectum, dilate the anus with the index finger or trumpet-shaped anoscope, then touch the arterial pulsation above the parent hemorrhoid area with the index finger, prepare a 1:1 concentration of injection solution (1 ml of 0,5% lidocaine plus 1 ml of anti-hemorrhoid injection solution) with 0,5% lidocaine and anti-hemorrhoid injection solution, and inject according to the four-step operation (the first step is to inject in the superior rectal artery area; the second step is to inject in the submucosa layer; the third step The amount of injection should be determined according to the size of the hemorrhoid nucleus and the relaxation of the rectal mucosa. After the injection is completed, the index finger probes into the internal hemorrhoid area gently so that the injection area is evenly distributed with the drug. Then perform external hemorrhoid dissection. The external hemorrhoid in the parent hemorrhoid area is first selected for debridement. The external hemorrhoid is lifted with hemostatic forceps in a “V” shape, and a radial incision is made and extended to 0.5 cm above the dentate line. The external hemorrhoid flap and a portion of the ligated internal hemorrhoid are cut off with a “7” gauge wire ligation at the base of the clamped internal hemorrhoid. Other external hemorrhoids are treated in the same way. The bridge of the anal canal between the external anal margin incision and the incision is often folded and protruding, so the bridge is cut off transversely, the venous plexus or hyperplastic tissue of the external hemorrhoid is peeled out under the skin, the excess skin is removed, and the skin is closed with small triangular needle “1” silk suture. After the operation, anti-inflammatory pain plugs are placed in the anus, and Vaseline oil gauze, gelatin sponge or collagen sponge are wrapped with pressure. 3. Surgical features. 3.1 Anesthesia. This procedure requires maintaining the natural dilated state of the anus, so local infiltration anesthesia of the anus is exceptionally important. In order to avoid damage to the male prostate or female vagina, special attention should be paid to the 12-point infiltration anesthesia, which prohibits the needle from going too deep and requires the right amount of anesthetic solution. When infiltrating anesthesia, the syringe needle should not go straight in, and the tip of the needle should be deviated from the anal canal outward at an angle of 45° from the longitudinal axis of the anal canal, in order to avoid the direct injection of anesthetic solution into the nucleus of internal hemorrhoids, which will artificially cause the nucleus to increase. 3.2 The use of anti-hemorrhoid spirit. For internal hemorrhoids, the injection dose should be determined according to the size of the hemorrhoid nucleus and the relaxation of the rectal mucosa. Each hemorrhoid nucleus should be injected in sufficient quantity, otherwise it will not have a therapeutic effect. When injecting each hemorrhoid nucleus, it should be hierarchically separated to avoid injecting at the same level to form a ring, which can cause anal stenosis. The needle should come out slowly to prevent excessive bleeding from the hemorrhoids. After injection, the injected solution must be rubbed evenly to prevent local necrosis due to uneven injection of the solution. 3.3 Incision. The choice of surgical incision for external hemorrhoids is particularly important during surgery, and excessive excision of the anal canal skin should be avoided, and attention should also be paid to the degree of aesthetics of the healed incision. Kouji generally sets 4~6 surgical areas according to the different morphology and size of hemorrhoid nuclei; and emphasizes that it is better to make several more incisions and never excise too much or damage the skin bridge and mucosal bridge in one large area to avoid postoperative anal canal skin defects. The incision selection includes the following principles: ① Lift the external hemorrhoid in a “V” shape, and make a radial shuttle-shaped incision, with the upper end to 0.5cm above the tooth line and the lower end to 0.5~0.8cm at the outer edge of the external hemorrhoid body; ②The incision should be trimmed in parallel, and try not to excise too deep, so as not to damage the superficial layer of the external sphincter, and trim smoothly to facilitate drainage; ③The incision should not be too wide. The incision should not be too wide to prevent damage to the perianal and anal canal skin; ④ the incision should be long enough to facilitate decompression and drainage and to prevent postoperative edema and pain; ⑤ the width of the anal canal skin bridge between the incision and the incision should be retained at 0,5cm or more, the skin bridge outside the anal verge often appears as a wrinkle-like protrusion, Kushi advocates making a transverse incision to cut the skin bridge, the cut portion should be at the inner end of the outer anal verge, try to retain the anal canal skin and peel it off under the skin The external hemorrhoidal plexus or hyperplastic tissue should be peeled off under the skin, the excess skin should be excised, and the skin should be closed with a small triangular needle “1” silk suture. 3.4 Others. Bending vascular forceps clamps in stripping the base of external hemorrhoids, the site should be appropriate, the direction of clamping should be parallel to the longitudinal axis of the anal canal, clamping sites in stripping the base of external hemorrhoids, 0, 5cm on the dental line, should be appropriate to the mucosa loose tight. To clamp the internal hemorrhoids as little as possible to prevent too much damage to the mucosa and cause rectal stenosis. When clamping, care must be taken not to damage the normal tissue. The remaining hemorrhoid nucleus was ligated with a “7” wire, and the pain of the wound was greatly reduced because of the high position of the ligature (in the upper part of the tooth line). After the operation, Dr. Kou paid special attention to the pressure dressing of the incision, requiring that the adhesive tape should be applied as far as possible to the inner thigh root and that the pressure dressing should be secure. Although this may lead to a significant postoperative foreign body sensation in the anus, it can greatly reduce the possibility of postoperative bleeding. In addition, the entire procedure should be performed gently and carefully, and the hemorrhoid body should not be forcibly stretched when ligating internal hemorrhoids or peeling external hemorrhoids, but should be in a natural tension-free state. Avoid excessive clamping of anal canal tissues, and trim the incision neatly to avoid postoperative anal pain and induced urinary difficulties or urinary retention. 4. Postoperative treatment. In general, take broad-spectrum antibiotics orally for 3 d and control stool for 48 h. No fasting is needed. Before the first stool, take a sitz bath with warm water to facilitate defecation and prevent edema of the incision caused by forceful struggle. After the first bowel movement, a decoction of Chinese herbal medicine “Exorcism soup” was used to clear heat and detoxify, activate blood circulation and reduce swelling. Routinely use chlorhexidine for local cleaning and disinfection, and change the medication with gauze of raw muscle yu red cream, and remove the stitches on the 3rd or 4th day depending on the incision condition. Paying attention to postoperative drug exchange is an important part of reducing postoperative infection and edema. The local cleaning and disinfection of chlorhexidine should be thorough during the dressing change, and special attention should be paid to the cleaning of the incision because the contraction of the anal sphincter after the stool causes the stool to be easily stored in the incision. Because of the local appearance of the anus is “depressed”, Kou Shi advocates that the gauze should be folded and placed in the “depression” when changing medication, and then the clean gauze should be applied outside and fixed with adhesive tape. This can play the role of pressure, thus reducing the possibility of edema. 5. Conclusion. At present, the clinical treatment of circumferential mixed hemorrhoids is mostly done by cricothyrotomy and ligature resection. The former is easy to cause severe mucosal ectasia, mucus flowing from the anal part and pain due to the excision of excessive anal canal skin; at the same time, the low rectal mucosa and anal canal are removed, which destroys the normal defecation reflex and causes sensory anal incontinence; some patients suffer from rectal stenosis due to the formation of scar. Although the latter method uses internal hemorrhoid stitching and external hemorrhoid peeling and opening, it cannot completely avoid the postoperative complications and sequelae such as secondary hemorrhage and anal stenosis; in China, external peeling and internal ligature are mostly used, which is still not an ideal method because the skin bridge folds, incision and skin bridge part are extremely easy to edema, and uneven external hemorrhoids are still left in the anal part after surgery. When treating cricoid mixed hemorrhoids surgically, reducing the damage to the perianal and anal canal skin and rectal mucosa is the direction of surgical improvement. According to Dr. Kou, the aesthetic appearance of the postoperative anal margin is also a desirable requirement for surgery. The surgical method of external hemorrhoid excision and suture, internal hemorrhoid ligation and injection is generally free of sequelae such as defect of anal canal epithelium and mucosal ectasia because a certain number of anal canal skin bridges are preserved, sutures are carried out differently, the ligature area is small and the pain is painless on the dentate line. Since the sclerosing agent is injected into the hemorrhoid artery and nucleus, the chance of postoperative hemorrhage is reduced, and the postoperative sitz bath with the herbal medicine “Exorcism soup”, which clears heat and detoxifies the blood and reduces swelling, is generally free of edema, and accelerates the healing of the incision and shortens the treatment time.