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1、 Concept of hemorrhoidectomy:
Traditional hemorrhoidectomy (Milligan Morgan operation) is the gold standard of hemorrhoidectomy for more than 60 years. However, postoperative pain and long healing time have always been two difficult problems for patients and doctors. In addition, some unacceptable postoperative complications, such as anal stenosis and varying degrees of incontinence, force us to try to find a better surgical treatment.
After that, a new surgical procedure, stapler hemorrhoidectomy, was developed and reported in 2002. Since March 2000, more than 600 cases have been used clinically.
Most hemorrhoids can be relieved or eliminated by non-surgical treatment. Hemorrhoids requiring surgery account for only about 1 / 3.
Grade III and IV hemorrhoids are unrecoverable pathological anal pads. If they are not treated, their symptoms are difficult to be relieved.
Resection and closure is to remove the increased excess pathological tissue with the help of Huaxia stapler, and close the remaining anal pad tissue at the same time, which can be completed at one time without leaving the wound. This method can also cut and close single or multiple hemorrhoids, not necessarily circular resection and anastomosis. Therefore, it is named stapler ex cision closed hemorrhoidectomy, which is different from the traditional hemorrhoidectomy.
2、 Indications for hemorrhoidectomy:
It is applicable to grade III ~ IV hemorrhoids.
3、 Preoperative preparation for hemorrhoidectomy:
Preoperative local skin preparation, fasting on the same day and low-pressure cleaning enema.
4、 Anesthesia for hemorrhoidectomy:
Saddle anesthesia, sacral anesthesia and local regional nerve block can be used.
5、 Preparation of surgical instruments:
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6、 Patient position:
Stone cutting position or prone folding knife position, and those with shallow hip groove can also be in lateral position.
7、 Components of stapler:
The stapler produced by Guangzhou Huaxia Medical Instrument Co., Ltd
Nail pusher: made of stainless steel and can be used repeatedly.
Needle holder: made of stainless steel and can be used repeatedly.
Kiss cutting component: including cutting knife and anastomosis nail. It is disposable and sterilized.
Cutting board (selling board): made of plastic, disposable, sterilized.
The above components are connected together.
8、 Operation steps of incision and closure:
After the anesthesia takes effect, hemorrhoids can be seen out of the anus without anal dilatation or slightly anal dilatation.
Use 3 ~ 4 allis forceps to clamp the hemorrhoid root mucosa above the tooth line and pull it outward. Pay attention not to clamp any tissue below the tooth line to avoid postoperative pain. After the above treatment, the tooth line moves down to the outside of the anus with the hemorrhoids, which is clear and recognizable during the operation.
Under direct vision, use thick silk thread as purse suture at least 1.5cm above the tooth line. Generally, there are about 6 stitches in a circle. Pay attention to that the direction of the sewing needle is always parallel to the tooth line. The needle needn't be too deep. It can penetrate to the submucous membrane. Choose not to tighten the suture. Open the sterilized kiss cutting assembly, take out the knife cushion ring (DIP plate), lower the side with concave groove into the nail seat and press it tightly.
Insert the nail butting seat with the knife pad ring into the intestinal cavity through the anus.
Tighten and half fix the finished purse suture on the center rod of the nail butting base, and cut the remaining thread.
In addition, butt the stapling assembly with the stapler pusher body, tighten and lock clockwise.
Rotate the knot nut at the bottom of the stapler pusher body counterclockwise to make the spring tube in the pusher extend beyond the stapling assembly.
Butt the center rod of the nail butting seat with the spring tube of the nail pusher. At this time, you can hear a "click", even if the three components of the stapler are connected as a whole.
Rotate the bottom adjusting nut clockwise to make the stapling assembly close to the stapling seat. When the connection between the spring tube and the central rod retracts into the stapling assembly, the stapling seat has been fixed with the stapler body.
Continue to rotate the bottom adjusting nut and gently pull the whole stapler to the outside of the intestine while rotating, so as to plug the hemorrhoids around the central rod under direct vision.
When tightening, the assistant shall remove the skin around the anus by hand to ensure that there is no error, screw the nut to the maximum limit, align the indicator scale at the bottom, and then screw it until it cannot be screwed.
Then fire it. A click indicates that the fire is successful.
Loosen the adjusting nut at the bottom of the stapler counterclockwise and gently withdraw it.
Check whether there is bleeding. If there is slight bleeding, slightly press the anal door. In case of pulsatile bleeding, suture and hemostasis are needed.
Fill the anus with a little gauze.
The cut tissue was examined as a circle of hemorrhoid tissue about 2cm wide.
The cut tissue was sent for pathological examination.
The fused hemorrhoids are in the shape of multiple valves of different sizes, which is a small fusion between the mother hemorrhoids in the process of multiple hemorrhoids prolapse.
9、 The operation points of this type of hemorrhoids are the same as those of circular hemorrhoids:
The difference is that when making purse string suture, you only need to place a needle 1.5cm above the tooth line of large hemorrhoids, and then sew the second hemorrhoids and the third hemorrhoids. For the sub hemorrhoids between the fused hemorrhoids, the needle can not be hung, or the needle can be hung slightly, which depends on the size of the sub hemorrhoids. The purse is also fixed on the central rod after suture and tightening. Other steps are the same as annular hemorrhoids. In this way, the cut hemorrhoid tissue is beaded or isolated. In this way, the anal pad tissue between hemorrhoids and hemorrhoids is retained to a great extent.
A single grade III ~ IV hemorrhoid is a rare type, in which only one large hemorrhoid prolapse is seen. The operation points of this type of hemorrhoids are the same as those of circular hemorrhoids.
The difference is that a single needle is hung at the protruding point of hemorrhoids above the tooth line, and the suture is fixed on the central rod and cut and closed in the same way.
In order to protect the perianal tissue from being cut, the stapler can be tilted slightly and the perianal tissue can be removed. As long as you pay attention to protection, it is very safe under direct vision. The hemorrhoid tissue was isolated.
10、 Hemorrhoids prolapsed outside rectal mucosa:
The effect of hemorrhoidectomy and closure is not good for this type of hemorrhoids. We must first deal with mucosal prolapse, and then deal with the notice. First, purse string suture was performed on the detached mucosa about 4cm away from the tooth line, and the first incision and closure was performed first. Then the second incision and closure was performed at 1.5cm on the tooth line. It can ensure that 1cm normal mucosal band is reserved between the two anastomotic nails to prevent mucosal ischemia and necrosis. Be careful not to overlap or cross between the two laps. In this way, two circles of mucosa and submucosa with a width of 2cm were cut. If the extramucosal prolapse of rectum is light, one-time incision and closure can also achieve the purpose, which is determined according to the specific situation.
11、 Giant hemorrhoids:
The hemorrhoids with too large hemorrhoids cannot be accommodated within the range of the cutter, so it often needs two times of cutting and closing to achieve the purpose. The operation needs careful design. Treatment principle of combined external hemorrhoids: when combined with varicose external hemorrhoids, such external hemorrhoids can generally retract after internal hemorrhoids are cut and closed.
When combined with connective tissue external hemorrhoids, if there are no symptoms, it can not be treated, and it needs to be cut off if it is not treated.
There is no need to deal with the combined dermatophytes.
12、 Treatment principle of combined anal fistula:
Hemorrhoid surgery is a polluted operation, while anal fistula is an infected operation. Doing these two operations together has the risk of infection in hemorrhoid surgery. Simple anal fistula can be solved at the same time, and complex anal fistula can be solved by times. It can be treated according to the principle of giving priority to main symptoms. At the same time, we should be alert to special types of anal fistula, and pay attention to anal Crohn's disease, cancerous anal fistula, leukemia, tuberculous anal fistula, etc. The removed tissue must be sent for pathological examination.
13、 Postoperative treatment:
It is very important to keep the stool unobstructed after operation and not to defecate hard. It can be given volumetric (car front glue) or permeable (Fusong) laxative or oil laxative. You can eat a regular diet or a fibroin diet. Oral antibiotics were given for 3 ~ 4 days. Check the anus on the first day after operation, pull out the drainage strip, rinse the part, and do not conduct finger examination. After defecation, take a hot bath. The first digital examination was performed 7 days after operation. After that, follow-up visits or telephone follow-up visits were made at 1 month, 2 months, 3 months, 6 months, 12 months, 2 years, 3 years and 5 years after operation, and records were made.
14、 Several diagnostic problems before hemorrhoid surgery:
Colonoscopy: sigmoidoscopy was routinely performed for < 50 years old, and total colonoscopy was routinely performed for > 50 years old. If the colon is found to have lesions, first deal with them, and then deal with hemorrhoids. The doctor has great merit in finding out the tumor due to hemorrhoids. When the anorectal center of our hospital performed colonoscopy on inpatients aged > 50, about 10% of the patients found the evaluation of the tumor's overall condition within one year: Although hemorrhoids are minor diseases, they must be paid attention to, especially the middle-aged and elderly patients. They should pay attention to the functions of their heart, liver, kidney, lung and other organs. To think that there may be a serious illness behind a minor illness, if you relax this vigilance, you may have a major problem due to a minor illness.
Differential diagnosis of local anal and perianal lesions: for patients hospitalized for hemorrhoids, the local conditions of anus and perianal should be checked in detail before operation. Especially for patients who had hemorrhoid surgery in other hospitals before, if they still have symptoms after operation, they should carefully check whether they are combined with other diseases, such as tumor, Bowen's disease, Crohn's disease, syphilis, eczema like cancer (anal Paget's disease), tuberculosis, etc. This happens from time to time. A well-trained specialist in anorectal diseases should have considerable general knowledge and basic internal medicine knowledge, not only the knowledge of anorectal anatomy and physiology, but also the concept of system and whole body. Therefore, hemorrhoid surgery must not be taken lightly, develop the habit of observing and thinking more, and strive for correct operation.
15、 The difference between resection and closure and PPH:
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16、 Conclusion:
The operation of preserving anal pad is reasonable: Stapler PPH operation; Stapler closure; Other operations to preserve anal pad.
Stapler hemorrhoidectomy is a safe, reliable, simple and less painful surgical method for the treatment of severe hemorrhoids.