Hemorrhoids are a common clinical disease and a frequent disease, and our folklore has “nine hemorrhoids in ten people”. The pathogenesis of the internal organs of the deficiency, sitting for a long time, heavy travel, or long-term constipation or diarrhea or toilet squatting for a long time, or diet, can lead to dysfunction of the internal organs, wind, dryness, dampness and heat, blood stasis in the pranic door, stasis of blood and turbid gas stagnation does not disperse, tendons and veins across the solution and the birth of hemorrhoids. If you have a deficiency of qi over time, the nucleus of the hemorrhoid can’t be taken in. Mixed hemorrhoids are the fusion of internal and external hemorrhoids, and its incidence accounts for 24.13% of hemorrhoid disease. The key to treatment is to remove the nucleus of the hemorrhoid while protecting the form and function of the anus, so mixed hemorrhoid surgery has always been a difficult procedure in hemorrhoid surgery. At present, there are various methods of treatment for mixed hemorrhoids, and each procedure has its own characteristics, which can be summarized into three main categories: open surgery, closed surgery, and semi-open and semi-closed surgery. 1 open surgery 1.1 external peeling and internal ligation, that is, Milligan-Moran method, the main point of this operation is to make a “V” shaped incision at the junction of the skin and mucosa of the lower end of the hemorrhoid and peel upwards, then ligate the corresponding point of the internal hemorrhoid at the base. This method is used clinically and is known as the gold standard for mixed hemorrhoid surgery. Qu et al. believe that external peeling and internal ligation is simple and cheap, but the surgical wound healing is slow and the pain lasts for a long time, which can produce serious complications such as anal canal stenosis, anal incontinence and anal fistula. Wang believes that although external peeling and internal ligation of mixed hemorrhoids is the main procedure for the treatment of mixed hemorrhoids, postoperative pain, bleeding, slow healing of the wounds and excessive tissue damage is an urgent problem to be solved. 1.2 Modified external peel and ligate procedure In order to preserve more anal canal skin and tooth line and avoid postoperative complications such as anal stricture and fecal incontinence, many doctors have modified the traditional external peel and ligate procedure. Ding et al. used segmental dentate ligation, the key of which is that the line connecting the apex of both external hemorrhoid separation and internal hemorrhoid ligation is dentate, thus making the traumatic scar contracture not in the same plane and preventing anal stricture. According to Tian, the modified external peel and internal ligation with curved suture reduces the formation of anal wound edema and superfluous external hemorrhoids; preserving the dentate line reduces the impact on defecation function; preserving the perianal skin of the anal canal effectively avoids sequelae by maximizing the preservation of the perianal skin; removing less skin affects the sensory function to a lesser extent; and the postoperative wound heals quickly with less scar formation. Zhang adopts multi-regional external peeling and internal ligation to treat varicose mixed hemorrhoids and annular mixed hemorrhoids, completely removing the varicose vein plexus and removing the excess mucosa and skin of the hemorrhoid mass to maintain a smooth anal canal and anus for the purpose of healing the hemorrhoid nucleus and anal reshaping. According to Peng, a modified segmental external peeling and internal ligation is used to treat cricoid mixed hemorrhoids, selecting the more obvious hemorrhoid nucleus for excision and leaving a skin bridge between the incision and cut El, which is conducive to the repair of anal tissues and normalize the function of anal defecation. 2 Closed surgery 2.1 PPlH surgery PPH surgery is a representative procedure based on the doctrine of liner downward migration, through the anastomosis above the hemorrhoid circular excision of the lower rectal mucosa and submucosa tissue, so that the prolapsed internal hemorrhoid is suspended and pulled upward, no longer prolapsed, and its treatment mechanism is mainly: (1) cut off the blood supply from the superior rectal artery to the hemorrhoid; (2) circumcision of the rectal mucosa on the tooth line 4 – (2) circumcision of the rectal mucosa 4-5 cm above the tooth line and circumferential anastomosis with an anastomosis, thus lifting the hemorrhoid upwards. According to Yang et al, the PPH procedure is simple to perform, allowing previously complex hemorrhoid circumcision to be easily performed. The surgical trauma and intraoperative reactions are light, which reduces surgical pain; the surgical bleeding is low; it makes the procedure safer; and because the anal cushion is not removed, the ability of fine rectal stool control is not affected. According to Wang, PPH surgery can ensure that the mucosa-to-mucosa anastomosis is placed above the anorectal ring, and part of the internal hemorrhoids and the mucosa and submucosa tissues on the hemorrhoids are removed and anastomosed in a circular fashion without damaging the anal cushion, which not only blocks the blood supply to the hemorrhoids and removes the root cause of hemorrhoid recurrence, but also suspends and fixes the slipped tissues and preserves the anal cushion, which can better protect the anal function. Ning et al. concluded that PPH patients have less postoperative pain, faster wound healing, no need for routine sitz baths, and no strict dietary restrictions, which shortens the time for patients to return to normal work. According to Gao et al, PPH surgery is effective in treating mixed hemorrhoids. It treats hemorrhoids by circumferential excision of the mucosa and submucosa on the hemorrhoid, so that the anal cushion is moved upward, which is less painful, non-invasive El and bleeding, and heals quickly. According to Zhang et al, PPH is mainly applicable to the clinical treatment of severe hemorrhoids, and its fine postoperative stool control ability is not affected; there are no complications such as severe pain in the anal region and anal stenosis; the operation time and average postoperative hospitalization time are significantly shortened, and the postoperative recovery is fast. 2.2 Hemorrhoidectomy The hemorrhoidectomy is developed on the basis of PPH, which focuses on the hemorrhoid body itself and directly removes the prolapsed and displaced hemorrhoid body, while not completely removing the anal cushion tissue, effectively protecting the anal function. According to Ko et al, this procedure has the advantages of the Milligan-Morgan method and PPH by surgically removing all the severely diseased hemorrhoid tissue while preserving as much of the less severely diseased anal cushion as possible, which is less likely to cause postoperative complications. Zhang believes that hemorrhoidectomy avoids the painful area, so there is less postoperative pain; the incision is chosen away from the anus, so the chance of anal edema is reduced; the wound has been anastomosed, so the factor of postoperative bleeding is greatly reduced; the postoperative pain is less severe, and the chance of urinary retention is also less. In Liang’s opinion, hybrid hemorrhoidectomy is an ideal procedure, and its operation time, wound healing time, return to work time, and postoperative pain are all better than other modes of surgery. Li believes that cut-and-close surgery is a new procedure that is easy to perform, has a high safety factor, is inexpensive, is lightly painful, has a quick recovery, and has satisfactory recent results. 3 Half-open, half-closed surgery 3.1 Cut-and-close suture This procedure is characterized by excision of internal hemorrhoids and interrupted sutures, ligation of the superior hemorrhoidal artery with minimal disruption of the dentate line, and exposure of the external hemorrhoidal incision. According to Jiang et al, this procedure shortens the wound healing time, the wound is not directly irritated, postoperative pain is reduced, and the corresponding urinary disorder is reduced. According to Li et al, the advantage of this procedure is that it preserves and reconstructs the skin-mucosal bridge, which facilitates regeneration, prevents severe anal stenosis and pain, reduces postoperative complications and sequelae, and reduces reoperation due to recurrence. Xiong et al. concluded that the advantage of this procedure is that the preserved and reconstructed skin-mucosal bridge is conducive to regeneration and prevents severe anal stenosis and pain, and reduces postoperative complications. 3.2 Incision and closure plus external hemorrhoidectomy Characteristically, external hemorrhoids are removed during surgery to reduce postoperative foreign body sensation and complications caused by external hemorrhoids. Xiang et al. concluded that cut-and-close plus external hemorrhoidectomy reduced postoperative anal pain and the effect of surgery on anal defecation, and reduced the incidence of anal edge edema and foreign body sensation. Deng et al. concluded that external hemorrhoidectomy is performed after completion of internal hemorrhoidectomy, when it becomes easier to deal with external hemorrhoids because the skin of the anal canal is lifted, and no postoperative bowing of the anal canal flap is seen, which makes it less likely to form a skin flap. The small internal and external fan-shaped incision has a better drainage effect than the traditional “V” incision, and the damage to the anal canal skin and the dentate line is also smaller, which is beneficial to the healing of the wound. 4 Discussion In summary, the basic principles of surgical treatment of mixed hemorrhoids have been agreed upon, but there are still differences in some specific operation plans. Some scholars believe that open surgery is simple, less expensive and easily accepted by patients; some scholars believe that the use of closed surgery for the treatment of mixed hemorrhoids is characterized by short operation time, less surgical pain, less bleeding, high surgical safety and unaffected ability of fine rectal stool control; some other scholars believe that the use of half-open and half-closed surgery is beneficial to wound regeneration, prevents severe anal stenosis and pain, and reduces Some other scholars believe that the use of semi-open and semi-closed surgery facilitates wound regeneration, prevents severe stenosis and pain, reduces postoperative complications and sequelae, and avoids reoperation for recurrence. Previous studies have not yet resolved this controversy, and it is necessary to optimize the standardized surgical operation plan for mixed hemorrhoids through systematic controlled observations and experimental studies to make it authoritative and convenient for clinical reference by anorectal professionals, in order to reduce patient pain and economic burden, postoperative complications and the impact on anorectal function.