Hemorrhoids surgery's "Minimally Invasive" Debate

Because of the change of living habits and working methods, hemorrhoids have become a common anorectal disease, "ten people and nine hemorrhoids". Many patients need surgery to relieve their pain, but the choice of surgical methods is very particular.

Hello, I want to do minimally invasive surgery.

What's your situation? What do you want to do minimally invasive?

Hemorrhoids should be minimally invasive.

Oh, let me see.

Well, it depends. Are there any female doctors?

Aren't you going to have an operation? Don't you know how to do it?

We doctors are male and female, so don't be shy.

……

good

(under inspection) ...

You want to be PPH.

Right, right, right, that's the H of this PP. I'm talking about this minimally invasive surgery. I saw it in Baidu, but I didn't want to do it in those small hospitals, so I came.

Oh, she wants to do PPH surgery to treat hemorrhoids, but PPH is not strictly minimally invasive!

I wanted to explain it to her in detail, but I saw many patients waiting in line to see a doctor? ……

Ok, this is a minimally invasive operation. You should go to the hospital first, and I will explain it to you later. ...

The development of modern surgery takes minimally invasive as the development direction, that is, to obtain the best treatment effect with minimal trauma. Many traditional surgical methods have been replaced by minimally invasive surgery, and a large number of advertisements for "minimally invasive treatment" have appeared on the Internet. Many patients will take the initiative to do minimally invasive treatment when they seek medical treatment, just like the last patient. However, not all diseases are so-called "minimally invasive"!

Injection therapy was officially reported in 1896. It is mainly suitable for I, II and III internal hemorrhoids, internal hemorrhoid bleeding and mixed hemorrhoids, but not for external hemorrhoids and patients with surgical contraindications. Xiaozhiling injection is a common injection in China. Its mechanism is that local aseptic inflammatory reaction occurs after injection, which fixes local fibrosis, blocks part of blood supply and shrinks hemorrhoid nucleus.

The treatment of hemorrhoid ligation is developed from traditional Chinese medicine ligation. This method is to tie a small rubber ring at the root of the internal hemorrhoid with a special instrument, and block the blood supply of the internal hemorrhoid by using the elasticity of the rubber ring, so that the hemorrhoid nucleus falls off and heals itself after ischemia and necrosis. This method is suitable for internal hemorrhoids and mixed hemorrhoids at all stages. For other patients with incomplete retraction of hemorrhoid or anal pad after treatment, rubber band ligation can also be used as an auxiliary treatment. Among all non-surgical treatments, it can be said that the effect of apron ligation is the best.

Morinaga is equal to 1995. It is the first time to report the application of proctoscope with ultrasonic Doppler probe combined with ultrasonic Doppler flowmeter for hemorrhoid artery ligation. The mechanism is as follows: (1) After suture, the arterial blood flow decreases, the blood pressure in the anal pad decreases, the hemorrhoid core contracts, and the bleeding stops automatically; (2) During suture, the rectal mucosa and hemorrhoid nucleus are directly sutured and fixed on the muscular layer, which leads to inflammatory reaction and scar formation, thus playing a fixing role and preventing the anal cushion from moving down. This operation is suitable for internal hemorrhoids with bleeding as the main symptom. It is simple, effective and less painful for patients.

19 19 was put forward by Miles, and then Milligan and Morgan improved the operation method, that is, Milligan-Morgan operation, which is considered as one of the most classic operations and is still an important operation method. This method has a good radical effect, mainly emphasizing the thorough removal of varicose veins and hemorrhoids. The method is to cut or strip the external hemorrhoid and tie the internal hemorrhoid on the tooth line.

On 1998, Italian Longo invented PPH operation based on the theory of anal pad hemorrhoid formation, which is effective for patients with stage ⅲ and ⅳ internal hemorrhoids, severe rectal prolapse, mild and moderate rectal mucosal prolapse, rectocele and other patients. PPH is based on Thomson's anal pad theory. Circular excision of loose mucosa and submucosa above dentate line with stapler can complete proximal and distal anastomosis at the same time, make the anal pad move up and reset, and restore the normal anatomical tissue at the lower end of rectum, thus blocking the blood supply of hemorrhoid area and leading to postoperative hemorrhoid atrophy. The biggest advantages of this operation are: (1) The ability of defecation control after operation is not affected; (2) Postoperative pain and edema were slight; (3) The surgical effect is remarkable; (4) Short operation and hospitalization time; (5) Less postoperative complications and quick recovery.

There are other operations derived from PPH, such as TST and Starr.

Wow, so many surgical methods!

Yes, there are so many surgical methods.

Each one is used in clinic.

However, these two methods are only effective for internal hemorrhoid and mixed hemorrhoid, but the treatment effect for internal hemorrhoid and annular mixed hemorrhoid with severe prolapse is relatively poor. Sometimes, if the drug injection is not mastered well, it will lead to a large area of necrotic infection of anal skin and mucosa, and some even develop into necrotic fasciitis (severe necrotic infection of skin and soft tissue). Rubber band ligation of hemorrhoids is an excellent choice for the treatment of internal hemorrhoids. It should be said that it is the safest minimally invasive treatment method, without hospitalization and anesthesia, but it may also need repeated treatment, and postoperative bleeding complications may occur.

However, for multiple and annular mixed hemorrhoids, there are many complications such as excessive surgical trauma, postoperative pain, poor wound healing and anal stenosis.

However, strictly speaking, this kind of operation can not be said to be minimally invasive, because its total wound surface is equivalent to or larger than that of traditional surgery, but the operation design is very good, avoiding some complications such as severe pain after traditional surgery. Moreover, the surgical instruments used in this kind of surgery are relatively expensive, and social security can be reimbursed, but it is really unacceptable at its own expense; For patients with multiple and annular mixed hemorrhoids or with rectal mucosal prolapse, proctoptosis and bleeding, the operation is cost-effective. In other cases, this operation method is a bit overqualified, and the cannon hits mosquitoes.

Hemorrhoids are not like appendicitis, but appendectomy is the only treatment, because it is the best treatment, and other methods are ineffective; Hemorrhoids are complicated and varied in types. No surgical treatment can replace other methods and become the so-called "gold standard" for treatment. Each method has advantages and disadvantages, and different schemes should be adopted according to different situations.

There is always stool in the anus, and hygiene cannot be guaranteed. Everyone who does hemorrhoids surgery will face the problems of postoperative pain and long healing time. If we insist on "minimally invasive", I would rather call those treatment schemes with proper surgical selection, reasonable design, light postoperative pain and quick recovery "minimally invasive" than simply "minimally invasive".

Because of the diversity of hemorrhoid treatment, there is a certain recurrence rate if you don't master it well, and the threshold of treatment is very low, so you may see hemorrhoids advertisements all over the street, such as "minimally invasive", "non-invasive" and "no medicine and no surgery" ... You must polish your eyes and distinguish clearly, and most of them may be liars. The most important sentence-don't look at the advertisement, look at the effect! ! !

Associate professor, deputy chief physician, doctor of surgery, tutor of master's degree.

Deputy Director of Anorectal Surgery, Sixth Affiliated Hospital of Sun Yat-sen University

Yi Shu of Anorectal Meridian-Zhu Qun

Young Member and Secretary-General of the Professional Committee of Colorectal and Anorectal Diseases of China Society of Integrated Traditional Chinese and Western Medicine

China medical doctor association anorectum professional Committee deputy director physician assessment branch

Member of the Third Council of World Zhonglian Anorectal Disease Professional Committee

Member of anorectal physician branch of Chinese Medical Association.

Member of the first professional Committee of transanal endoscopic minimally invasive surgery (research group) of the professional Committee of colorectal cancer of Chinese Medical Association.

Member of TEM (minimally invasive anorectal surgery) group of colorectal cancer professional committee of China Anti-cancer Association.

Standing Committee of Anorectal Professional Committee of Guangdong Traditional Chinese Medicine Association

Member of the Professional Committee of Gastrointestinal Surgery of Guangdong Medical Association.

Medical expert member of South China Medical Association of Guangdong Clinical Medical Association.

European Journal of Gastroenterology. Hepatology

Colorectal examination technique

He is good at the diagnosis and treatment of anorectal benign and malignant diseases, pelvic floor diseases, intractable constipation, complicated anal fistula, hemorrhoids, anal fissure and colorectal benign and malignant tumors.