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 swelling in the anus during stool. If the prolapsed swelling cannot be returned in time, it will lead to impaction and necrosis, which seriously affects the physical and mental health and quality of life of patients. The external hemorrhoids are distributed 360°, and the nucleus and nucleus often cannot be separated from the normal skin, and the pathological pattern is characterized by connective tissue hyperplasia and varicose veins; the internal hemorrhoids are generally above degree II, and the clinical treatment is more difficult.
1.Pre-operative preparation.
For patients of different ages, genders, and physical conditions to make a detailed surgical plan, including intestinal preparation, anesthesia, surgical incisions, etc., to be well informed. Pay special attention to the preoperative conversation with patients to eliminate their doubts and reduce the impact of adverse psychological factors on intraoperative and postoperative.
2.Surgical method.
Under sacral anesthesia, the patient should take the bladder truncated position, disinfect the skin of the operation area with conventional iodophor, routinely disinfect the anal canal and lower rectum, dilate the anus with the index finger or trumpet-shaped anal mirror, then touch the arterial pulsation above the parent hemorrhoid area with the index finger, prepare the injection solution with 0.5% lidocaine and anti-hemorrhoid spirit injection to 1:1 concentration (l0mL of 0.5% lidocaine plus l0mL of anti-hemorrhoid spirit injection), and inject according to the four-step operation method ( The first step is injected in the superior rectal artery area; the second step is injected in the submucosa: the third step is injected in the lamina propria; the fourth step is injected in the cavernous vein area), and the dose of injection is determined according to the size of the hemorrhoid nucleus and the laxity of the rectal drusen. After the injection is completed, the index finger probes into the internal hemorrhoid area and rubs lightly so that the drug is evenly distributed in the injected area. Then perform external hemorrhoid dissection. The external hemorrhoid in the parent hemorrhoid area is first selected for stripping. 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 part of the ligated internal hemorrhoid are cut off. 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 by small horizontal or longitudinal incisions as appropriate, and the external hemorrhoidal plexus or hyperplastic tissue is peeled out under the skin, and the excess skin is excised and closed with small triangular needle “1” silk suture to the skin. After the operation, anti-inflammatory pain plugs are placed in the anus, and Vaseline oil gauze and gelatin sponge are wrapped with pressure.
3.Surgical features.
(1) The use of antihemorrhoid 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 caused by uneven injection of the solution.
(2) Incision.
The choice of incision for external hemorrhoid surgery is particularly important and should avoid excessive excision of the anal canal skin and also pay attention to the aesthetics of the incision after healing. Generally, according to the different shapes and sizes of hemorrhoid nuclei, 4-6 surgical areas are set, and it is better to make several more incisions and never to excise too much or damage the skin bridge and mucosal bridge at one time to avoid postoperative anal canal skin defects. Incision selection includes the following principles:
① Lift the external hemorrhoid in the shape of a “v” and make a radial incision in the shape of a shuttle, with the upper end to 0.5cm above the tooth line and the lower end to the outer edge of the external hemorrhoid body 0.5-0.8cm;
②The incision should be trimmed in parallel, try not to excise too deep, in order not to damage the subcutaneous layer of the external sphincter, and trim flat to facilitate drainage;
③The incision should not be too wide to prevent damage to the perianal and anal canal skin;
④The 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 kept above 0.5 cm, and the skin bridge outside the anal verge often appears to be wrinkle-like protrusion, so small transverse or longitudinal incisions can be made to cut off the skin bridge, and the cut-off part should be at the lateral inner end of the anal verge, preserving the anal canal skin as much as possible, peeling out the external hemorrhoid plexus or hyperplastic tissue under the skin, removing the excess skin, and using a small triangular needle “l The skin should be sutured with a small triangular needle “l” size silk thread to the skin.
(3) Other.
Curved vascular forceps clamp in stripping the base of external hemorrhoids, the site should be appropriate, the clamp direction should be parallel to the longitudinal axis of the anal canal, the clamp site in stripping the base of external hemorrhoids, 0.5 cm above the dentate line, should be appropriate for mucosal loosening and tightening. 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 is ligated with “7” silk wire, because the location of the ligature is higher (in the upper part of the tooth line), so the pain is greatly reduced on the day of creation.
The whole 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 trimming of incisions should be neatly done to avoid postoperative anal pain and induced urinary difficulties or urinary retention.
4.Postoperative treatment.
After surgery, generally use antimicrobial agents for 3 d, take oral diosmin and control stool for 48 h. No fasting is needed. Before the first bowel movement, anal plug can be given to facilitate defecation and prevent edema of the incision caused by forceful struggle. After the first stool, we can give compound cypress solution to sit in the basin and Ma Yinglong hemorrhoid cream to change the medication, and remove the stitches on the 3rd or 4th day depending on the incision. The importance of postoperative medication changes is an important part of reducing postoperative infection and edema. The cleaning and disinfection of Neosporin should be thorough during the dressing change, and the cleaning of the incision should be paid special attention because the contraction of the anal sphincter after the stool causes the stool to be easily stored in the incision.
5.Conclusion.
At present, the clinical treatment of cricoid mixed hemorrhoids mostly uses cricothyrotomy and ligature excision. The former is easy to cause severe mucosal ectasia, fecal fluid flow and pain in the anal part 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 have rectal anal canal stenosis because of the formation of scar. Although the latter method uses internal hemorrhoid suturing and external hemorrhoid peeling and opening, complications and sequelae such as secondary hemorrhage and anal stenosis after surgery cannot be completely avoided. In China, external peeling and internal ligation are mostly used, but it is still not an ideal method because the skin bridge folds, incision and skin bridge part are very 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. We believe that the aesthetics 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, ligation area is small and painless area on the dentate line, and postoperative pain is also mild and often disappears within 24h. Since the sclerosing agent was injected into the hemorrhoidal artery area and hemorrhoidal nucleus, the chance of postoperative hemorrhage was reduced, and oral diosmin was given after surgery to promote local venous and lymphatic reflux of the incision, and compound cypress solution was given to sit on the basin after stool, which reduced edema, and also accelerated the healing of the incision and shortened the treatment time.