This is a case that I encountered during my community outreach. The patient was Ms. Zhang, female, 43 years old. She had fresh blood in her stool, and something came out of her stool that she could not return on her own. She was diagnosed with “mixed hemorrhoids” through examination, and surgery was recommended. Surgery, after all, is not a small matter, so the patient went online to look up the relevant content, did her own “homework”, and finally chose a minimally invasive treatment, because the introduction said that this method is painless, and can be “cured on the go”. One day after March, she came to the community again, and the first thing she said at the door was: “I’ve been fooled, I should have listened to you”. It turned out that when she went to receive this treatment, she did not need to be hospitalized, but her condition after the operation was very bad. Pain, bleeding, couldn’t go to work at all, had to go every day to change the medication for a month. Not so, to 40 days after the operation, appeared stool thinning, difficult to discharge. I heard people say that the intestinal clear tea can laxative, so I bought it back and drank it every day, and now I feel that it is more and more difficult to pass stools. I check the localization, the anterior and posterior skin lesions of the anal canal are serious, showing obvious signs of stenosis. Surgery was needed to loosen the anus. This is a case of tragedy caused by minimally invasive, of course, Ms. Zhang is not the only one who has similar encounters. Minimally invasive surgery is supposed to reduce the pain of surgery, but why does it happen? 1. What is minimally invasive? I don’t think there is anyone who doesn’t have fear of “surgery”, fear of what? Fear of what? Pain, complications, after-effects. Surgery is used to correct our problem tissues and organs, is used to remove the foci of disease that erode our organism. While we are undergoing this treatment, it also causes some degree of damage to our body. The trend in surgery today is to try to minimize this damage while trying to improve the effectiveness of the treatment, hence the term “minimally invasive”. When we have a problem with our lungs, we need to remove a few ribs and open up the chest cavity. When we have a problem with our stomach, we need to cut open the belly and open the abdominal cavity. When we have problems with our uterus, we need to open the pelvis. When we have a problem with our head, we need to cut open the brain and open the skull. Of course, this is the past, now only need to open a few very small holes on the OK, this is a few days “minimally invasive” original face, the clinical application of the cavity mirror technology. In the past, we had to reach in and operate with several large hands, so the surgical channel had to be opened large enough, which was undoubtedly a huge trauma. Today, under the cavity mirror, some very small specialized tools instead of fingers, deep around the lesion for treatment, greatly reducing the trauma. Nowadays, almost more than 50% of surgical operations are done minimally invasively. Minimally invasive techniques cannot be separated from the development of modern science and technology, such as graphic technology, which has now evolved to 3D, and a large number of advanced surgical instruments, such as ultrasonic knives and microsurgical instruments. The development of minimally invasive surgery has experienced a hundred years of history, is the inevitable result of the high development of human material and spiritual civilization, is the inevitable direction of the development of surgery, the future goal must be a non-invasive method instead of traumatic methods, small trauma instead of large trauma methods. 2, tasteless minimally invasive First tell a real joke. Today this hemorrhoid is very heavy, so whether the operator, assistant and observer are focused on the surgical process. The operating room is very quiet, only clicking scissors sound. The patient who was lying on the operating table suddenly asked loudly, “Doctor, isn’t it minimally invasive, didn’t you say it was done with a computer, why is there the sound of scissors, you’re cheating, aren’t you?” Ah ah, I suddenly do not know how to answer is good. Doctor: “Who told you that minimally invasive is done by computer?” Patient: “The internet says it’s all computerized.” Doctor: “You’re too deep in the virus, lie still, I’ll give you a good cure.” Look at what our patient’s head has been washed into. When minimally invasive in the field of surgery in full bloom at the same time, the field of anal and intestinal also not willing to lag behind, in a timely manner, the hot word to lead over. In Baidu to promote the unit, there is no one is not publicizing the “minimally invasive”, and even some “minimally invasive anorectal hospital”. If colorectal cancer with minimally invasive, there is no problem, the past need to abdominal perineum joint opening, trauma is very large, now 3D lumens have begun to be widely used in clinical applications, trauma is greatly reduced. But the problem is that these minimally invasive anorectal above speaks of hemorrhoids. Here we look at minimally invasive hemorrhoid surgery refers to what technology? “Baidu Encyclopedia” on the introduction of “minimally invasive hemorrhoid surgery” mainly HCPT, PPH, TST, STARR, COOK gun, are some fashionable foreign name, I briefly introduce the following. HCPT, is what we usually call “electric knife”, a cutting tool, which and minimally invasive what relationship? This device is not only not minimally invasive, improper use, will cause more damage to the local tissue. PPH, introduced earlier, mucosal resection anastomosis, foreign cautious application, the effect is doubtful. Domestic application of the process of many problems, limited scope of adaptation, the effect is also doubtful, the key to most of the hemorrhoids still need to cooperate with other methods of joint application, especially after the operation of the proportion of many adverse reactions is not low, so that it and “minimally invasive” can not be equated. Many scholars believe that this method is more problematic than the classical anal surgery method. The following is a letter I received from a patient. “Professor Wang Hello, I am 49 years old, in November 2013, I was in a local hospital PPH hemorrhoid surgery, postoperative anal distension and pain. 2014 February, I really can not stand it, in another local specialized hospital for the second operation, surgery to take out some titanium nails, but also do the sinusitis, but also said that there is an anal stenosis, but also to the operation. After the operation, the anus was still distended and painful, and in July, the provincial people’s hospital did pain point excision surgery and nerve block. Now the anus is not only distended and painful but also the postoperative wound is not healing, life and spirit are going to collapse, kneeling down to ask Prof. Wang to relieve my pain, so that I can get out of the sea of suffering earlier and see the light of day again, thank you!” TST, is an improved method based on PPH. Considering the rectal stenosis that may be caused by the circumferential resection of rectal mucosa in PPH, the method was changed to selective resection anastomosis of rectal mucosa. However, this has little therapeutic significance for hemorrhoids, and it is difficult to obtain satisfactory results for most hemorrhoids when stripping is no longer used at the same time. So, with both methods added together, is this still minimally invasive? STARR, is also a ring cut anastomosis, but unlike PPH, it not only cuts the mucosa, but also cuts the muscle, which is equivalent to cutting off a section of the rectum, and is now mainly used to treat constipation with outlet obstruction. Due to the many postoperative problems, it is now used less and less. COOK gun, also known as RPH, is a method that relies on equipment to ligate hemorrhoidal nuclei, ligation and ligation are to block the blood circulation of the hemorrhoidal root, so that the hemorrhoidal nuclei are ischemic and necrotic and fall off, the clinical effect, side effects and hemorrhoidal nuclei size, location, number, ligation (ligation) technique and the stump of the injected drugs have a relationship. Compared with the traditional ligation method, it improves the convenience of operation, especially the rectal mucosa with higher location, but the safety is worse than the ligation method. Therefore, now many anorectal departments boast of these minimally invasive methods, with the true meaning of minimally invasive is far away, or has changed flavor. 3, the role of tools Minimally invasive need the support of tools, but tools are not methods, and can not be synonymous with minimally invasive. If you take an ultrasonic knife and tell others that this is minimally invasive, it will surely make people die of laughter. What is a tool? It’s a plate and a saucer, a sickle and a hoe, a bicycle and a tricycle. What is the method? To make a dish, fried, stewed or cold. Similarly, an operation, scalpel, electric knife, laser knife, ultrasonic knife, is only a tool, not a method. A surgery with what kind of tools, depending on what kind of method, and the choice of method depends on what kind of disease. The development of medicine can not be separated from the improvement of medical equipment and method of innovation, but surgery, when it will be human-led. Zhang Daqian’s paintings are worth a lot of money, while my paintings are worthless, also with a brush, why? It is the same reason as a surgery. Patients often ask me, “Do you use laser? Do you use HCPT? I do surgery, what tools to use still want you to choose, not to mention that you ask these two tools are not at all good. This is actually confusing the concept of the tool as the method, the method as the efficacy. 4, please do not ask me the method If you ask me what is going on with this disease, I will tell you, but if you ask me what method, I generally will not tell you. Why? Because you want the answer is very simple: “minimally invasive”. Many patients look forward to the “minimally invasive technology” advertised on the Internet, but do not dare to believe in it, so they come to the hospital to find out. As soon as many patients ask me if they want to know if there is minimally invasive technology, they will say, “How do you know I want to ask this? I said that you are “poisoned” too deeply, I am a doctor, will see. Once a patient with circumferential hemorrhoids repeatedly asked me, “Doctor, can you treat me with minimally invasive treatment?” There was no way not to answer, and I said, “Yes, but you probably won’t agree.” “Why?” “Cutting it all off is traditional, cutting half and leaving half is partially minimally invasive, and not cutting at all is the most minimally invasive, so which do you choose?” . The patient was embarrassed and smiled and stopped asking. This is in jest, but there is a point to remind us, want to minimally invasive, we have to seek medical help at the earliest possible stage of the disease. 5, thinking about minimally invasive anorectal Is there minimally invasive anorectal? What exactly is minimally invasive anorectal? Today we must think carefully about these questions. Surgery is a means of treatment of disease, is a rapid completion of the human body lesions, deformities, trauma, inactivation, excision, repair or reconstruction of the treatment method. Surgery invariably causes trauma to normal tissues in the course of accomplishing these operations, and when this trauma is small, its effect on us may be transient, causing no local or province-wide disability. But if it is large, it will cause a decline in certain physiological functions of our body. Therefore, as long as the surgery, there is the question of whether or not “minimally invasive”, anal surgery is no exception. For hemorrhoids, anal fistula and other anorectal diseases, in fact, also belongs to a body surface surgery, there is no surgical access to the problem of damage, also do not need to resort to luminal surgery, that minimally invasive anorectal surgery in the end what is it? In fact, luminal or ultrasonic knife or PPH, this is something superficial, the real meaning of minimally invasive is a new medical concept, this concept is a kind of human-oriented thinking, a kind of philosophical thinking. Rectal cancer, in the past, the concept of surgery is to cut as much as possible the better, and all the work should be subordinate to this big goal. So after surgery, many patients have to reroute their feces to the abdomen, the anus is completely abandoned, and many people lose their sexual function. And today? More refined stripping and cutting, preserving the anus, preserving anal function. This more humane surgical pursuit is minimally invasive! Anal fistula surgery, who understand, will damage the anal sphincter, sphincter damage will inevitably affect the decline in anal function. Then this surgery in the end is to do or not to do. Foreign countries in the absence of a good method before the fistula is not in order to cure the anal sphincter to risk damage to the anal sphincter, but to take a compromise method called “survival with a fistula”, in the fistula put a leather band, do not let the fistula infected, but also do not damage the sphincter. Of course, we will laugh at the foreigners, why are they so irresponsible, or that the level of foreigners is not good. In fact, this is a kind of human-oriented minimally invasive thinking is playing a leading role. Why is minimally invasive still a kind of philosophical thinking? Let me cite two examples. First, recognize the evidence and apply the method. Reasonable control of the disease condition, stage and method of correspondence and rational use. For example, for the early stage of internal hemorrhoids, when the drug is difficult to control the symptoms, the most minimally invasive and reasonable method is what? Injecting a small amount of sclerosing agent into the hemorrhoid nucleus can solve the problem without much pain or adverse reaction. But for a three-stage internal hemorrhoids, we have to consider removing the lesion, this time ligation or ligation is the best method. Second, grasp the main contradiction. For example, a ring of ring hemorrhoids, surgery, how to do? Which cut which stay? Cut more cut less? All these need us to use philosophical thinking to weigh, choose. At this time we can grasp the main contradiction, both to solve the harm of the disease and pain, but also to protect the normal function of the anus. A complex anal fistula, a thousand things, which is the main problem, which is a secondary problem, which can be retained, which can be cut, which all need to be analyzed, discursive to see, and ultimately make a reasonable trade-off. Therefore, minimally invasive anorectal surgery is, in the final analysis, a kind of awareness of the protection of anorectal function. If we do not have such an awareness, and if we do not have an understanding of local physiology and anatomy, what is the use of holding modern tools? If we are not careful, we will make a mistake, and minimally invasive becomes severely invasive.