Multiple mixed hemorrhoids (including annular mixed hemorrhoids) are one of the difficult diseases in anorectology, and their clinical treatment is mainly surgical, and there are various surgical methods, especially the residual hemorrhoid nucleus is prone to edema and recurrence after treatment by simple segmental ligation open surgery, and the complete removal of the lesion is prone to complications such as anal stenosis and different degrees of incontinence, which makes the surgical effect unsatisfactory. At present, the aim is to remove the lesion and eliminate the symptoms, and the segmental ligation method or the female hemorrhoid area ligation method is often used. In order to explore a reasonable surgical method for the treatment of multiple mixed hemorrhoids and to reduce the occurrence of postoperative complications. From June 2006 to January 2009, we used mucosal suture on hemorrhoid + multiple mixed hemorrhoids segmental peeling and internal ligation to treat multiple mixed hemorrhoids (including cricoid mixed hemorrhoids), and achieved satisfactory results through clinical observation and postoperative follow-up. Now we summarize and report as follows: 1. Clinical data (1) General data: According to the “Provisional criteria for the diagnosis of hemorrhoids” [1] formulated by the Anorectal Surgery Group of the Chinese Medical Association’s Surgery Branch in 2002, we selected patients who met the criteria of multiple mixed hemorrhoids (including circumferential mixed hemorrhoids) among the inpatients of the Department of Anorectal Surgery of the Affiliated Hospital of Jining Medical College from June 2006 to January 2009. Among them, 280 were male, aged 18-67 years, with an average age of 41.0 years, and the duration of disease was 1.1-30.7 years, with an average of 17.4 years; 227 were female, aged 20-69 years, with an average age of 40.2 years, and the duration of disease was 1.4-42.5 years, with an average of 24.3 years. 24.3 years. The causative factors were overexertion, spicy stimulation, excessive alcohol consumption, dry stool, etc., and the factors of childbirth in female patients. The symptoms are mainly varicose veins, internal hemorrhoids prolapse and bleeding. (2) Treatment method Preoperative preparation Preoperative blood and urine routine, coagulation routine, liver and kidney function, biochemistry, ECG and chest X-ray were checked to exclude contraindications to surgery. Fasting for 6 hours and water fasting for 4 hours before surgery, and clean enema for 3 hours before surgery. Antibiotics were given half an hour before surgery to prevent infection. Phenobarbital sodium 0.1g can be given intramuscularly half an hour before surgery for those who are nervous. a. Surgical method: The patient is placed in prone position, the anus is fixed with wide tape, and the operative field is exposed. 2% lidocaine 10ml, 0.75% levobupivacaine 5ml, and 5ml of water for injection are given to the sacral canal (lumbar point) anesthesia, and after satisfactory anesthesia, the operative area and the anal canal are routinely disinfected, sterile towels are laid, and the anal canal is again disinfected with rectal iodine, and rectal palpation combined with anoscopy is performed to find out the site, number, size, and relationship of the hemorrhoid nucleus. The incision is designed according to the size of the mixed hemorrhoid nuclei, the protrusion of external hemorrhoids and their distribution, and three parent hemorrhoid areas are selected as the sites for mucosal suturing and external and internal peeling of hemorrhoids (this is the main orientation). First of all, choose a parent hemorrhoid area, and suture the hemorrhoidal artery with a No. 7 silk thread through the upper pole of the hemorrhoid nucleus about 1.0 cm (rectal mucosal relaxation bulge), and suture 3 stitches continuously upward, about 2-3 cm, tighten the ligature above the rectal mucosa (pay attention to the depth of the suture, do not suture too deep, suture to the sphincter patients with severe postoperative pain, too shallow hemorrhoidal artery suture incomplete, easy to hematoma). Then select the more obvious hemorrhoid nucleus as the center of a segment, generally divided into three to five segments, segments and segments as far as possible between the natural depression of the skin on both sides of the hemorrhoid body as the boundary, retain the anal canal skin bridge and rectal mucosal bridge, cut the skin of the base of the external hemorrhoid, from the lower part of the skin along the external sphincter and the internal sphincter superficially facing upward to peel the external hemorrhoid venous plexus to 0.5 cm above the dentate line, try to retain the Treitz muscle intact, large curved vascular forceps along the incision The base of the internal hemorrhoid nucleus should be clamped in the direction of the incision, ligated with a No. 7 silk thread under the large curved vascular clamp, and the stripped external hemorrhoid should be cut out together with 2/3 of the internal hemorrhoid, and the wound edge should be trimmed so that the incision is “V” shaped to facilitate drainage. (The stump of the hemorrhoid is staggered into a tooth shape, and a skin bridge of not less than 0.3 cm is kept between the two adjacent hemorrhoid nuclei, so that the skin covering the anal canal is smooth and beautiful). The excess external hemorrhoid between the two points will be excised by making a minimally invasive incision, paying attention to the removal of the blood sinus and varicose vein mass under the incision. After the operation, the hemorrhoid stump and its downwardly displaced tissues are reset well toward the rectum of the anal canal with the index finger, methylene blue and levobupivacaine mixed with the wound edge injection, and the wound is filled with Kyowa red gauze, covered with tower dressing, wrapped with dingbat tape and fixed with wide adhesive tape. b.Postoperative treatment: 4h on the day after surgery, semi-liquid diet on the 1st day after surgery, and normal diet on the 2nd day after surgery. Among them, 176 cases had defecation on the second postoperative day, 304 cases had defecation on the third postoperative day, and 27 cases did not have defecation on the fourth postoperative day or above, and were given 600 ml of soap and water enema. After defecation, the anus was routinely changed and antibiotics were routinely used for 3-5 d to prevent infection. 2. Results 2.1 Observation index: (1) Operation time. (2) Postoperative hospital stay. (3) Postoperative anal pain: refer to WHO pain degree grading standard [2]: grade 0, no pain or slight downward discomfort; grade I, slight pain is tolerable, no need to apply painkillers, does not affect sleep; grade II, heavy pain or anal downward sensation, relieved by oral painkillers, slightly affects sleep; grade III, heavy pain, not tolerable, seriously affects sleep, poor effect of oral painkillers, requires intramuscular injection of painkillers The pain can only be relieved by intramuscular injection of pain medication. (4) Postoperative secondary bleeding. (5) Urinary retention: catheterization and indwelling urinary catheter are required on the postoperative day. (6) Edema of the trabecular margin. (7) Postoperative rectal stricture of the anal canal. (8) The criteria for determining the efficacy refer to the Standards for the Treatment of Hemorrhoids [3]. Cured: disappearance of symptoms, elimination of prolapsed hemorrhoids and normal anal function; improved: relief of symptoms and reduction of prolapsed hemorrhoids; not cured: no change in symptoms and signs. (9) Anal function evaluation criteria according to Hiltunen’s standard. Normal: anal control of stool, intestinal fluid and intestinal gas were normal; Anal partial incontinence: anal control of loose stool, intestinal fluid and intestinal gas was not possible, or contaminated underwear; Anal complete incontinence: anal control of formed stool was not possible. 2.2 Efficacy All 507 cases in this group were cured with normal anal function, and the average operation time was 26.3 minutes, none of them had postoperative hemorrhage, perianal infection, anal stenosis or anal incontinence. Some patients had temporary poor recovery of bowel function and edema of the trabecular margin, which were relieved by psychological intervention, physiotherapy, sitz bath and other corresponding symptomatic treatments. The average hospital stay was 9.1 days, and all patients were followed up for 1 year-3 years without recurrence or long-term sequelae such as anorectal mucosal ectasia, anal stenosis, or sensory anal incontinence. 3, Discussion External stripping and internal ligation was first proposed by Miles in 1919, and in 1937, St? The procedure was modified by Milligan and Morgan [4] at St. Mark’s Hospital in England in 1937, and is generally known as the Milligan-Morgan procedure, which is one of the most commonly used surgical procedures in clinical practice. In 1975, Thomson [5] proposed the “theory of submigration of the anal cushion”, suggesting that hemorrhoids are not only caused by venous stasis due to varicose veins in the submucosa of the anal canal, but also by pathological hypertrophy and displacement of the anal cushion. This theory is increasingly recognized, but the inconsistency of the doctrine has led to a variety of clinical procedures. According to the anal cushion doctrine, in 1998, Italian surgeon Antonio Longo [6] proposed a new method of treating III and IV degree prolapsed internal hemorrhoids by circumferential resection of the mucosa and submucosal tissue of the lower rectum, and designed PPH based on this mechanism, but its main treatment mechanism is not to treat the hemorrhoid nucleus itself, but to remove the rectal mucosa above the hemorrhoid area and pull back the prolapsed hemorrhoid nucleus through the pulling action The main treatment mechanism is not the removal of the hemorrhoid itself, but the removal of the rectal mucosa above the hemorrhoid area and the pulling back of the prolapsed hemorrhoid nucleus through the pulling action. The important principle of modern treatment of hemorrhoids is to protect the anal cushion and to restore the pathologically hypertrophied and displaced anal cushion to normal [7]. It emphasizes that hypertrophy and subluxation of the anal cushion is the pathological basis of symptomatic hemorrhoids and that unrestricted excision of the anal cushion inevitably leads to loss of normal anorectal physiological function, but does not explicitly reject the traditional segmental external peeling and internal ligation of multiple mixed hemorrhoids.Read et al [8] concluded that the integrity of the anal cushion and its sensitivity are not indispensable factors for bowel control and that anal cushion sensation plays a role, but not a major role, in anal self-control. Therefore, restrictive resection does not affect anal bowel control. Based on this principle, we modified the traditional procedure by using multiple mixed hemorrhoids with external stripping and internal ligation + suprahemorrhoidal mucosal sutures, and selected the suprahemorrhoidal mucosal sutures in points, effectively avoiding the main complication of postoperative anorectal stenosis, which is significantly better than PPH, in addition to the following advantages: (1) performing suprahemorrhoidal mucosal sutures, not only ligating the hemorrhoidal artery, blocking the dilated blood vessels of hemorrhoids, making them atrophy and disappear, but also (1) By using the sutured rectal mucosa as a suspension fulcrum, the prolapsed anal canal mucosa and anal canal skin can be restored to their normal anatomical position, which can eliminate the sensory dysfunction formed by the rectal mucosa entering the anal cushion area, and also facilitate the judgment and treatment of only the hyperplastic pathological tissues, preserving the normal anal canal mucosa, anal canal skin and anal margin skin, which can protect the fine stool control ability of the anus to the greatest extent, thus effectively avoiding the occurrence of anorectal mucosal ectasia, anal stenosis and sensory anal incontinence. (2) The scar tissue formed after external peeling and internal ligation of the pathological tissue can re-fix the anal canal tissue that has regained its normal anatomical position, and reconnect the Treitz muscle with the anal canal mucosa through the scar tissue to restore the physiological function of the Treitz muscle, which is more conducive to the fixation of the anal canal mucosa. (3) Certain skin and mucosal bridges are preserved between the hemorrhoid nuclei, and the subcutaneous varicose vein mass is subliminally stripped between each incision of the external hemorrhoid, which makes the postoperative perianal dermatome and edema of the trabecular margin significantly reduced, which improves the cure rate of multiple mixed hemorrhoids and reduces the postoperative recurrence rate. The following points should be noted during the operation: (1) According to the site, number, morphology and gap of the multiple mixed hemorrhoids, design the segmentation of the hemorrhoids and the site and distance of the mucosal bridge of the preserved anal canal skin bridge. (2) Preserve not less than 0.3 cm of skin bridge between two adjacent hemorrhoid nuclei, and mucosal bridge more than 0.5 cm, while the internal ligature surface should be in different planes to avoid postoperative anal stenosis. (3) The “V” shaped incision of external hemorrhoids should be reduced in tension to facilitate drainage and avoid edema. (4) When multiple mixed hemorrhoids are sectioned and lanced, the excess external hemorrhoids between the two points should be removed by making a minimally invasive incision, paying attention to the removal of blood sinuses and varicose veins under the incision. (5) After the operation, the stump of the hemorrhoid and its subluxation must be reset with the index finger in the anus towards the rectum. Some patients had no significant complications and sequelae after surgery, except for temporary poor recovery of bowel function. In conclusion, we use suprahemorrhoidal mucosal suture + multiple mixed hemorrhoids segmental external peeling and internal ligation to treat multiple mixed hemorrhoids, based on the theory of anal cushion, which is a modification of the traditional external peeling and internal ligation, effectively reducing the probability of postoperative bleeding and edema of the wound edge, avoiding long-term sequelae such as mucosal ectasia, anal stenosis and sensory anal incontinence, improving the cure rate of multiple mixed hemorrhoids and reducing the postoperative recurrence rate, which is a reasonable and effective treatment for multiple mixed hemorrhoids. It is a reasonable and effective procedure for the treatment of multiple mixed hemorrhoids and should be promoted. Note: The above patients have been followed up so far, and in general, painful bleeding and prolapse symptoms no longer occur under living and working conditions, and slight anal symptoms will appear after over-eating spicy, fatigue, dry stool and other undesirable stimuli, which will disappear with improved life or 2-3 days relief by medication.