I got hemorrhoids in 1998, and the doctor said it was internal hemorrhoids.

According to the position of internal hemorrhoids, it can be divided into primary internal hemorrhoids (mother hemorrhoids) and secondary internal hemorrhoids (child hemorrhoids). This is related to the vascular branches, and the main terminal branches of the superior rectal artery are distributed in the right front, right back and left middle rectum. The relative flexion of three parallel superior rectal veins is called internal hemorrhoid venous plexus. For example, the venous plexus of the right front, right back and left middle internal hemorrhoids dilates, twists and congestion, and becomes primary internal hemorrhoids. There may be 1 ~ 4 secondary internal hemorrhoids, which are often connected with the right posterior position and the left median female hemorrhoids (because the veins there branch again). However, the vein at the right front female hemorrhoid is no longer branched, so it often occurs singly and infinitely (Figure 1). However, the benefits of mother hemorrhoids and child hemorrhoids are also different, some are isolated, and some are connected. If both the mother hemorrhoid and the child hemorrhoid protrude out of the anus and show plum blossom shape, it is called circular hemorrhoid. If the prolapse and edema of internal hemorrhoids cannot be recovered, it is called incarcerated internal hemorrhoids, and if there is blood circulation disorder, it is called strangulated internal hemorrhoids.

Figure 1 Location of three female hemorrhoids

The small picture shows the relationship between the branch of superior rectal artery and postpartum hemorrhoids.

I. Staging

Internal hemorrhoids are divided into four stages. 1 period: no obvious symptoms, but there is blood, blood dripping or blood spraying only during defecation, and there is more bleeding. Hemorrhoids do not protrude from the anus. Anal mirror shows that the straight column is enlarged and nodular on the tooth line. The second stage: intermittent bleeding, bleeding or spraying blood during defecation, moderate bleeding. When defecating, the hemorrhoid comes out of the anus and flows back on its own after defecation. The third stage: internal hemorrhoids prolapse during defecation, or prolapse after fatigue, walking for too long, coughing. Internal hemorrhoid prolapse can't return by itself, so it can only be returned by hand or bed rest. The amount of bleeding is very small. The fourth stage: hemorrhoids are outside the anus for a long time and cannot be returned or come out immediately after returning. Because of the fibrosis of anal cushion, the bleeding is not big, and the last three stages of hemorrhoids develop into mixed hemorrhoids. Because prolapsed hemorrhoids are large, they have involved the internal and external venous plexus of hemorrhoids, and their surfaces are covered by rectal mucosa and anal canal skin. Therefore, mixed hemorrhoids are the result of increased hemorrhoids.

Second, the clinical manifestations

Bloody stool

Painless, intermittent and bright red blood after defecation is its characteristic, and it is also a common symptom of internal hemorrhoids or mixed hemorrhoids in the early stage. Hemorrhagic stool is mostly caused by tearing mucous membrane or severe defecation, which causes the dilated blood vessels to rupture and bleed. Most of the light cases are major cases or there is blood on the toilet paper, and then there are blood drops. In severe cases, it is jet bleeding, and bloody stool often stops automatically after a few days. This is of great significance for diagnosis. Constipation, dry stool, drinking and eating irritating food are all causes of bleeding. Anemia can occur after repeated bleeding for a long time, which is not uncommon in clinic and should be differentiated from hemorrhagic diseases.

Prolapse of two hemorrhoids

It is often a late symptom, usually with bloody stool first and then prolapse. Due to the increase of hemorrhoids in the later stage, they gradually separated from the muscle layer and were pushed out of the anus during defecation. The light person only prolapses when defecating, and can recover on his own after defecation. Heavy people need to push back with their hands, and more serious people will come out of the anus with a little abdominal pressure. For example, if abdominal pressure such as coughing and walking increases slightly, hemorrhoids will emerge, making it difficult to recover and unable to participate in labor. A few patients complain that prolapse is the first symptom.

Three pains

Simple internal hemorrhoids have no pain, and a few have a feeling of heaving. There are different degrees of pain when edema, infection and necrosis occur in the incarcerated internal hemorrhoids or mixed hemorrhoids.

Four itching

In the late stage of internal hemorrhoids, hemorrhoids prolapse and anal sphincter relaxation often discharge secretions. Due to the stimulation of secretions, itching and discomfort often occur around the anus, and even skin eczema occurs, which makes patients extremely uncomfortable.

Third, diagnosis and differential diagnosis

The diagnosis of internal hemorrhoids mainly depends on anorectal examination. First of all, do an anal examination, and pull the anus to both sides with both hands. Except for the first-stage internal hemorrhoids, the other three-stage internal hemorrhoids can be seen under anal examination. For prolapsed patients, it is best to observe immediately after defecation in squatting position, so that you can clearly see the real situation of the size, quantity and position of hemorrhoids, especially for the diagnosis of annular hemorrhoids, which is more meaningful. Secondly, digital rectal examination: internal hemorrhoids are not easy to be diagnosed without thrombosis or fibrosis, but the main purpose of digital rectal examination is to know whether there are other rectal lesions, especially to exclude rectal cancer and polyps. Finally, do anoscopy: first observe whether there is congestion, edema, ulcer, mass and so on. In the rectal mucosa, and then after excluding other rectal diseases, observe whether there are hemorrhoids on the upper part of the tooth line. If there is, it can be seen that the internal hemorrhoids protrude into the anoscope and are dark red nodules. At this time, we should pay attention to their quantity, size and location.

According to the typical symptoms and examination of internal hemorrhoids, the diagnosis is generally not difficult, but it needs to be differentiated from the following diseases.

1. Rectal cancer is often misdiagnosed as hemorrhoids in clinic, which delays treatment. The main reason for misdiagnosis is that only symptoms are diagnosed, and rectal digital examination and anoscopy are not done, so the diagnosis of hemorrhoids must be done with the above two examinations. Rectal digital examination can detect rectal cancer with uneven mass, ulcer on the surface, narrow intestinal cavity and blood stains on finger cuffs. In particular, internal hemorrhoids and circular hemorrhoids can coexist with rectal cancer. Never look at internal hemorrhoids or circular hemorrhoids, but be satisfied with the diagnosis of hemorrhoids and treat them until the symptoms of patients get worse. This painful experience and lesson of misdiagnosis and mistreatment is not uncommon in clinic and deserves attention.

2. Low pedicled rectal polyp, if it comes out of anus, is sometimes misdiagnosed as hemorrhoid prolapse, but it is more common in children. It is round, substantial, pedicled and movable.

3. Anorectal prolapse is sometimes misdiagnosed as irregular hemorrhoids, but the mucosa of rectal prolapse is annular with smooth surface, and the sphincter is relaxed during rectal digital examination; The mucosa of circular hemorrhoid is plum blossom petal-shaped, and the sphincter is not slack.

Fourth, treatment.

At present, there are several views on the treatment of hemorrhoids.

1. Hemorrhoids are asymptomatic and do not need treatment. As long as you pay attention to your diet, keep your stool unobstructed and keep your perineum clean, you can prevent the occurrence of hemorrhoids. Only bleeding, prolapse, thrombosis and incarceration need treatment. Hemorrhoids rarely lead to death directly, but serious complications can be fatal if they are not treated properly. Therefore, the treatment of hemorrhoids should be cautious and not taken lightly.

2. The purpose of various non-surgical treatments for internal hemorrhoids is to promote the fibrosis of perihemorrhoidal tissues, and fix the exfoliated anorectal mucosa on the muscular layer of the rectal wall to fix the loose anal pad, so as to achieve the purpose of stopping bleeding and preventing prolapse.

3. Surgery should be considered only when conservative treatment fails or connective tissue supported around internal hemorrhoids in the third and fourth stages is widely destroyed.

According to the above viewpoint, the treatment of internal hemorrhoids should focus on alleviating or eliminating its main symptoms, not treatment. Therefore, the relief of hemorrhoid symptoms is more meaningful than the change of hemorrhoid size, which is regarded as the standard of therapeutic effect.

There are many treatments for internal hemorrhoids, which can be selected according to the condition.

One-shot therapy

There are many drugs used for injection therapy, but they are basically sclerosing agents and necrosis agents. Because there are many complications caused by necrosis agent, the use of sclerosing agent is advocated at present, but necrosis can occur if the dosage of sclerosing agent is too high. The purpose of injection therapy is to inject sclerosing agent around hemorrhoids to produce aseptic inflammatory reaction, so as to achieve the purpose of small blood vessels occlusion, fibrous hyperplasia, sclerosis and atrophy in hemorrhoids. Commonly used hardeners are 5% carbolic acid vegetable oil, 5% sodium morrhuate, 5% quinine urea aqueous solution and 4% Gong Ming aqueous solution. High dose injection with 5% carbolic acid vegetable oil has the following advantages: ① With 5% concentration, the total dose can reach 10 ~ 15 ml, and there is generally no adverse reaction. However, with other sclerosing agents, the curative effect is not good at a small dose, and it can cause mucosal necrosis or ulcer at a large dose. ② The solution prepared by vegetable oil is easy to be absorbed and the reaction is small, while the drugs prepared by other mineral oils are not easy to be absorbed, which may lead to adverse consequences. (3) Carbonic acid itself has bactericidal effect, which is beneficial to the easily contaminated parts of anus. ④ There were less local scars after injection. 100 clinical practice has proved that injection therapy has no hidden harm to human body and has become a recognized therapy.

1. Internal hemorrhoids without complications can be treated by injection. Primary internal hemorrhoid, complaining of hematochezia without prolapse, is most suitable for injection treatment. Control bleeding, stop bleeding with one needle, the effect is obvious, and the cure rate is high in two years. Prolapse can be prevented or alleviated after the second and third injection of internal hemorrhoids. If bleeding or prolapse occurs again after hemorrhoidectomy, it can still be injected. The injection can be used for the elderly, the infirm, patients with severe hypertension, heart disease, liver disease and kidney disease.

2. Contraindications Any external hemorrhoid and internal hemorrhoid with complications (such as embolism, infection or ulcer) are not suitable for injection treatment.

3. Methods (Figure 2) Before the injection, the patient emptied his stool, took a lateral position or knee-chest position, disinfected the injection site, and inserted the needle tip into the submucosa about 0.5cm above the hemorrhoid root on the tooth line, which proved that the needle could move left and right in the submucosa. If the penetration is too deep, and it enters the muscularis mucosa or sphincter, the needle tip is not easy to move left and right, so it is necessary to pull out the needle a little, and if there is no blood return after suction, you can inject it. Needle should not pierce the central venous plexus of hemorrhoid block to prevent sclerosing agent from entering blood circulation and causing acute hemorrhoid venous embolism. Injection of 5% carbolic acid vegetable oil depends on the degree of mucosal relaxation and the size of hemorrhoids. Generally, 2 ~ 4 ml is injected into each hemorrhoid nucleus, and 6ml can be injected if the mucosa is very relaxed. Total injection amount of 3 cases of female hemorrhoids 10 ~ 15 ml. When the liquid medicine is injected into the submucosa, the injection site becomes a reddish and slightly white bulge, and sometimes microvessels can be seen on the surface of the bulge. This phenomenon is called "stripe sign". If the injection time is too long, you can immediately see that the mucosa at the injection site turns into a white bulge, which will leave a superficial ulcer after necrosis and shedding. If the injection is too deep and penetrates into the muscle layer of intestinal wall, it can cause pain immediately; If injected below dental floss, it will also cause severe pain immediately. So the depth of injection is related to the success or failure of this therapy. It is not advisable to puncture and inject in the front center because it is easy to damage the prostate, urethra or vagina. After the injection, observe whether there is bleeding at the puncture point after the needle is pulled out. If there is bleeding, you can press it with a sterile cotton ball for a while to stop the bleeding. Usually, when the anoscope is taken out, the sphincter contracts to prevent pinhole bleeding or sclerosing agent from flowing out of the pinhole. Injection 1 time every 5 ~ 7d, with no more than 3 internal hemorrhoids each time, and 1 ~ 3 times is a course of treatment. The site of the second injection should be lower than 1 injection site. If 10% carbolic acid vegetable oil or 5% sodium morrhuate is used, each injection shall not exceed 1ml, and it is best to inject with tuberculin syringe.

Fig. 2 Injection treatment of internal hemorrhoids

4. Precautions for Injection Therapy ① The first injection is the most important, and the injection is sufficient and effective, and it is better to inject several times. 9 # long puncture needle should be used for injection needle, because the liquid medicine is too thin to push in, and it will bleed if it is too thick. ② There should be no pain during and after injection, such as pain, which is often caused by injection too close to dental floss. Therefore, the penetration point of the needle tip must not be lower than the tooth line. ③ Do not defecate within 24 hours after injection to prevent hemorrhoid prolapse. If there is prolapse, the patient should be informed to return immediately to avoid hemorrhoid vein embolism. ④ Before the second injection, do a digital rectal examination. If the hemorrhoid has hardened, it means that the mucosa has been fixed, so it is not appropriate to inject it again, or explore it through anoscope with a blunt needle. If the mucous membrane on the hemorrhoid surface is slack, inject again. ⑤ If the injection site is too deep, it may lead to local necrosis, pain or abscess formation. ⑥ Stay in bed for a period of time after injection to prevent collapse and other reactions.

5. Complications It is safe to treat internal hemorrhoids with 5% carbolic acid vegetable oil injection, with few complications, such as incorrect injection depth. If the injection is too shallow, it can cause local necrosis and ulcer; If the injection is too deep, it will cause injury. For example, if the injection is too close to the anterior center, it will damage the prostate and urethra and cause hematuria. Extrarectal injection can damage prostate and urethra, causing hematuria; Extrarectal injection can lead to stenosis, abscess and anal fistula. So pay attention to injection technology.

6. Results Marti( 1990) reported that injection of 5% carbolic acid vegetable oil in the second phase of 1 ~ 2 cured 75% of internal hemorrhoids, and Kilbourne( 1934) reviewed 25,000 cases, with an estimated recurrence rate of 1.5% within three years.

(2) nail therapy for withered hemorrhoids

The principle is that the dry hemorrhoid nail is inserted into the center of hemorrhoid block, causing "foreign body stimulates inflammatory reaction", which makes hemorrhoid tissue liquefied and necrotic, gradually healing and fibrosis. It is suitable for stage II and III internal hemorrhoids or mixed hemorrhoids. However, this therapy is not suitable for acute inflammation of anus and rectum. There are two kinds of hemorrhoid nails: hemorrhoid nails and hemorrhoid nails. At present, Huang Er hemorrhoid nail made of Cortex Phellodendri and Radix et Rhizoma Rhei is widely used, which has both the curative effect of hemorrhoid nail and the disadvantage of hemorrhoid poisoning.

Methods: Take the lateral position, disinfect the towel according to the routine, and slowly suck out the internal hemorrhoids with an anal aspirator. The operator fixes the hemorrhoid block with the middle finger of his left hand, and then disinfects the mucosa on the surface of the internal hemorrhoid. Hold the posterior segment of the dry hemorrhoid nail with the thumb and the second finger of the right hand, parallel to the anal canal or not more than 15. After inserting the dry hemorrhoid nail into the mucosa of internal hemorrhoid with a little force, insert it gently, generally about 1cm deep, and do not exceed the diameter of hemorrhoid block. Cut off the dry hemorrhoid nail remaining outside the mucosa of internal hemorrhoids, so that the residual nail is 0. 1cm higher than the mucosa. The nail spacing is about 0.2 ~ 0.4 cm, and the nail spacing is about 0.2cm from the tooth line. The number of inserted nails depends on the size of hemorrhoid. Generally, 4 ~ 6 nails are inserted into each hemorrhoid nucleus at a time, first into the small internal hemorrhoid, and then into the large internal hemorrhoid. After insertion, the internal hemorrhoids are sent back to the anus. It is forbidden to defecate within 24 hours after operation, so as to prevent the drug nail from falling off and bleeding and internal hemorrhoid prolapse, causing edema, incarceration and pain. Hot potassium permanganate solution should be used for sitting bath after defecation. During the treatment, Chinese and western medicines with hemostatic, anti-inflammatory and laxative effects were given according to the condition.

(3) rubber band ligation therapy

The principle is that a small apron is inserted into the root of internal hemorrhoid through instruments, and the blood supply of internal hemorrhoid is blocked by the strong elasticity of apron, so that hemorrhoid is cured by ischemic necrosis and shedding. It is suitable for all stages of internal hemorrhoids and mixed hemorrhoids, but the second and third stages of internal hemorrhoids are the most suitable. Not suitable for internal hemorrhoids with complications.

There are two kinds of internal hemorrhoid ligation instruments: pull-in ligator (Figure 3) and suction ligator (Figure 4). Take the traction ligator as an example. The ligator is made of stainless steel and is divided into three parts: ① The front end of the ferrule is a ligating ring with a diameter of 1cm and an inner ring and an outer ring. After the inner ring is inserted into a small rubber ring (specially made or replaced by a bicycle valve hose), hemorrhoids are trapped, and the outer ring can move back and forth. ② Rod: It is a 20cm long metal rod with a handle, which is divided into an upper rod and a lower rod. The upper rod is connected with the outer ring. When the handle is pressed, the outer ring can move forward, and the small rubber ring on the inner ring is pushed out to cover the hemorrhoid root. The lower rod is connected to the inner ring and does not move. (3) The expansion apron cone is used to install the small apron into the inner ring.

Fig. 3 traction ligation of internal hemorrhoids.

1. Internal hemorrhoids are pulled into the ligation ring; 2. The small apron has been put on the internal hemorrhoids; 3. Internal hemorrhoid ligation is completed; 4. Hemorrhoid necrosis and shedding

Fig. 4 Internal hemorrhoids are treated by suction ligation.

1. Methods The patient took knee-chest position or lateral position, and inserted anoscope to expose the internal hemorrhoids to be ligated. After local disinfection, the assistant fixes the anoscope, and the operator holds the ligator in his left hand and the hemorrhoid forceps (or bent wheat forceps) in his right hand, which extends into the anus from the cuff, clamps the hemorrhoid block, pulls it into the ring of the ligator, and then pushes out the apron. Ligate the hemorrhoid root, then loosen the hemorrhoid forceps and take it out together with the ligator, and finally take out the anoscope. Generally 1 ~ 3 hemorrhoids can be ligated at one time. If there is no ligation device, two vascular forceps can be used instead (Figure 5).

Fig. 5 ligation of internal hemorrhoids with vascular forceps

2. Note: ① The patient complained of pain during hemorrhoid clamping, indicating that the hemorrhoid clamping place is close to the skin of anal canal, and it is necessary to clamp hemorrhoid again at this time. Keighley( 1993) suggested that ligation on dental floss at 1.5 ~ 2 FCM can relieve pain, even without pain. ② Put two aprons on each hemorrhoid block at the same time to prevent the aprons from breaking. Aprons should not be autoclaved, so as not to increase brittleness and lose elasticity. ③ Ligating no more than 3 hemorrhoids at a time can reduce anal discomfort. Circumferential hemorrhoids can be ligated by stages. ④ It is not advisable to defecate within 24 hours after ligation to prevent prolapse of hemorrhoid, which may cause edema, incarceration or bleeding of hemorrhoid. ⑤ If the ligation site is close to the tooth line, or the mixed hemorrhoid is ligated, the skin on both sides of the hemorrhoid can be cut off in a V shape under local anesthesia, and the external hemorrhoid tissue can be stripped upwards, and then the stripped external hemorrhoid and internal hemorrhoid can be ligated together, which can alleviate postoperative pain and edema. ⑥ Sit bath with hot potassium permanganate solution after operation.

3. Complications ① Hemorrhage: Generally, there is a small amount of hematochezia when internal hemorrhoids fall off, but a few cases have secondary massive hemorrhage within 7 ~16 days after ligation. If a small amount of 4% alum solution is injected into the hemorrhoid after ligation, postoperative bleeding can be prevented and apron slippage can be prevented. Some people also inject a small amount of anesthetic into hemorrhoids to relieve the pain. ② Perianal skin edema: It mostly occurs in mixed hemorrhoids and circular hemorrhoids. The prevention method is to do high ligation and stay away from the tooth line, which can relieve pain and perianal skin edema. When ligating mixed hemorrhoids, first cut the external hemorrhoids into a "V" shape.

The advantages of this method are simple and rapid operation, and no special preparation is needed before operation. If the case is properly selected and the ligation method is correct, it can achieve painless, less infection and less bleeding. The disadvantages are occasional pain, edema and bleeding, and the recurrence rate is higher than that of surgical resection. Marty (1990) comprehensively analyzed 2025 cases of ligation by four authors. The cure rate was 69% ~ 95%, the symptoms were improved 10% ~ 25%, and it was ineffective 1% ~ 10%.

(4) Cryotherapy

Liquid nitrogen (-196℃) is used to contact the hemorrhoid block through a special probe, which causes the hemorrhoid tissue to freeze, necrosis and fall off, and then the wound surface gradually heals. Suitable for primary and secondary internal hemorrhoids. If this method can correctly grasp the depth and scope of freezing, the effect is good. The disadvantage is that there is mucus flowing out of anus for a long time after operation, the pain lasts for a long time, the wound heals slowly and the recurrence rate is high. If the rubber band is ligated first and then the ligated hemorrhoid nucleus is frozen, the tissue damage, necrosis and secretion can be reduced. Keighley( 1979) compared with cryotherapy, rubber band ligation therapy and high fiber diet therapy, the effective rates were 38.9%, 65.7% and 24.3% respectively. It is considered that cryotherapy is not superior to high fiber diet therapy, but rubber band ligation therapy has obvious effect in controlling symptoms. So cryotherapy is not recommended.

(5) infrared radiation therapy

Through infrared radiation, submucosal fibrosis is produced, anal pad is fixed, prolapse is reduced, and the purpose of curing hemorrhoids is achieved. It is suitable for the first and second stages of internal hemorrhoids.

Methods (Figure 6): In the lateral position, the hemorrhoid nucleus was exposed by anoscope, and the bottom of hemorrhoid nucleus was irradiated by infrared ray in 3 women. According to the size of hemorrhoids, each hemorrhoid is irradiated at 4 points, and each point is irradiated with1~1.5s. Each pulse can produce a necrotic area with a diameter of 3 mm and a depth of 3 mm. The advantages of this method are simple, rapid, painless and can be treated for many times. Ambrose( 1985) once compared infrared photocoagulation therapy and apron ligation therapy, and thought that the two therapies had similar curative effects, but the former had fewer side effects. Ambrose also compared infrared therapy with injection therapy, and thought that injection therapy required fewer people to be treated. Keighley thinks that infrared therapy is only good for first and second degree hemorrhoids, but not for third degree hemorrhoids.

Fig. 6 Internal hemorrhoids are treated by infrared radiation.

(6) Anal canal dilation therapy

Lord (1969) thinks that the existence of hemorrhoids is related to the stenosis of the lower rectum and the exit of anal canal. During normal defecation, the sphincter of anal canal can relax automatically, and the stool is easy to be discharged without increasing the rectal internal pressure. If there is adhesion at the sphincter, the anal canal is not completely relaxed, and the fecal mass can only be squeezed out under pressure. If the pressure is too high, the hemorrhoid venous plexus will be congested, resulting in hemorrhoids. Hemorrhoids further block the anal canal, forming a vicious circle of "congestion-obstruction-congestion". If the stenosis is widened by anal canal dilatation or internal sphincter amputation, the vicious circle can be interrupted and hemorrhoids can be cured. This therapy is suitable for patients with severe pain such as anal canal hypertension, resting pressure > 9.8 kPa (100 cmH2O) or strangulated internal hemorrhoids. Not suitable for the elderly, enteritis and diarrhea. Methods: See the third anal fissure. After anal dilatation under local anesthesia, anal dilator should be used regularly for several months. Complications include skin tear of anal canal, submucosal hematoma and temporary anal incontinence. Long-term follow-up showed a high recurrence rate. Keighley( 1979) treated 37 young men (< 45 years old) with anal canal hypertension and hemorrhoid pain and bleeding by anal canal dilatation. After 1 year follow-up,1/cases were asymptomatic, 14 cases improved, and the effective rate was 76% (25/ 10). 5 cases were ineffective, 4 cases were changed to other treatments, and 3 cases were lost to follow-up. Complications: bleeding in 4 cases, prolapse in 2 cases, urinary incontinence 1 case. Keighley and others also compared the results of anal dilatation, internal sphincterotomy and high fiber diet in patients with anal hypertension, and thought that anal dilatation was far superior to internal sphincterotomy, and Keighley would not use internal sphincterotomy to treat internal hemorrhoids in the future.

(7) Surgical treatment

It is suitable for the second, third and fourth stages of internal hemorrhoids, especially for mixed hemorrhoids with external hemorrhoids as the main part. 1. External dissection and internal ligation are external hemorrhoid dissection and internal hemorrhoid ligation respectively. Step (Figure 7): ① Lie on your side. After local anesthesia, clamp the hemorrhoid skin with tissue forceps and pull it outward to expose the internal itching. Make a V-shaped incision on the skin on both sides of the hemorrhoid base with small scissors. When injecting, only the skin is cut, not the hemorrhoid venous plexus. ② Take skin and separate external hemorrhoid venous plexus with fingers wrapped with gauze. Separate upward between the external hemorrhoid venous plexus and the internal sphincter, and cut a little mucosa on both sides of the hemorrhoid block to fully expose the pedicle of the hemorrhoid block and the lower edge of the internal sphincter. (3) Clamp the pedicle of the hemorrhoid block with a pipe bender, tie one at the pedicle with No.7 thick silk thread, sew another through it to prevent bleeding due to loose ligation, and finally cut off the hemorrhoid block. If the hemorrhoid is large, you can also use 2-0 winding catgut to sew the hemorrhoid pedicle continuously. The skin incision does not need suture to facilitate drainage. ④ The other 2 cases of female hemorrhoids were removed by the same method. Generally, a normal mucosa and skin with a width of about 1cm must be reserved between two hemorrhoids to avoid anal stenosis. Vaseline gauze is applied to the wound.

Fig. 7 External hemorrhoid peeling and internal hemorrhoid ligation for mixed hemorrhoids.

2. Annular hemorrhoidectomy is suitable for patients with severe annular hemorrhoids or internal hemorrhoids with rectal mucosal prolapse. The advantage is that the annular hemorrhoid can be completely removed at one time. Disadvantages are large surgical trauma, postoperative infection will form anal stenosis, and there are many complications, so it is not commonly used at present.

Method (Figure 8): After spinal anesthesia or sacral canal anesthesia, expand the anal canal at the lithotomy position, place a special cork with a diameter suitable for the expanded anal canal in the anal canal, fix the hemorrhoid on it with a tack, make a circular incision near the tooth line, and leave as much anal canal skin as possible to prevent mucosal prolapse in the future. All varicose veins are carefully separated and removed, and cut and sutured at the same time. Pay attention to the length of the mucosa at the lower end of rectum, so as to prevent the mucosa from everting after operation. Intermittent suture of mucosa and skin with 3-0 chrome catgut. If there is bleeding, you can add a few stitches to the mucosal margin. After the incision is healed, a digital rectal examination should be done. If there is a tendency to stenosis, anal dilatation should be done regularly to prevent anal canal stenosis after operation.

Fig. 8 Circumferential hemorrhoidectomy

(1) Insert the cork, pull out the hemorrhoid and fix it on the cork with a pin; ⑵ Incise mucous membrane in a circular way on dental floss; ⑶ The separation of hemorrhoid nucleus is obvious; ⑶ Fix the mucosa on the soft plug at 1cm above the hemorrhoid with a pin; 5] Cut the seam 0.5cm below the upper row of needles; [6] Appearance after hemorrhoidectomy.

3. Surgical treatment of acute incarcerated internal hemorrhoids Prolapse and incarceration of internal hemorrhoids, especially acute prolapse and incarceration of circular hemorrhoids (also known as acute hemorrhoids), have extensive thrombosis and edema. I didn't dare to use surgery before, for fear that the spread of infection would lead to complications such as portal phlebitis. Conservative treatment is commonly used. The disadvantage is that the treatment time is long, the patient suffers greatly, and sometimes there will be complications such as necrosis and infection. In recent years, it is considered that acute edema of hemorrhoids is caused by obstruction of venous and lymphatic reflux, not inflammation. Even if hemorrhoids have ulcers, inflammation is mostly on the surface of hemorrhoids, not in deep tissues, which does not affect the operation. At the same time, perianal tissue has strong resistance to bacterial infection, so emergency hemorrhoidectomy should be performed, and the complications are not higher than those of elective surgery, and the postoperative pain and edema are greatly reduced or disappeared. If the patient is not suitable for hemorrhoidectomy or hemorrhoidectomy, lateral incision of internal sphincter is feasible to relieve pain. De Roover reported that 25 cases of acute hemorrhoids were treated by lateral sphincterotomy. Results Postoperative pain disappeared immediately, and edema, vascular embolism and prolapse gradually improved within a few days after operation, with an average hospitalization of 3 days (0 ~ 13 days). Among 25 cases, 20 cases underwent simple internal sphincterotomy, and 5 cases underwent hemorrhoid ligation several months later. Follow-up for 26 months (1 ~ 56 months) showed that 23 cases were very satisfied and 2 cases were satisfied. De Roover thinks that the advantages of this operation are simpler than internal hemorrhoidectomy, immediate pain relief, short hospitalization time, only one operation and only a small amount of ligation after operation.

There are many treatments for internal hemorrhoids. Because non-surgical treatment has a good effect on most internal hemorrhoids, surgical treatment is rarely used at home and abroad in recent years. Injection therapy has a good effect on most internal hemorrhoids, especially hemorrhagic internal hemorrhoids, and should be the first choice. Prolapsed internal hemorrhoids can be treated by rubber ring ligation. Because there are some complications in surgical treatment, we should strictly grasp the indications, and the operation is limited to those who fail or are not suitable for conservative treatment.

Verb (abbreviation for verb) complications

We can't mistake hemorrhoidectomy for minor surgery. If we take it lightly and carelessly, serious complications and even great tragedies may occur. Buls( 1978) analyzed 500 consecutive cases of hemorrhoidectomy. The complications were as follows: anal fistula 0.4%, anal fissure 0.2%, anal canal stenosis 1.0%, anal incontinence 0.4%, skin prolapse 6.0%, fecal impaction 0.4%, thrombotic external hemorrhoid 0.2%, and urinary retention 65433.

1. There are two reasons for postoperative bleeding of internal hemorrhoids: early and late. The former is caused by loose knot and slippage; The latter occurred about 7 ~ 10 days after operation, which was caused by infection at the ligation site. Because of the function of anal sphincter, blood mostly flows back into the intestinal cavity instead of out of the anus, so the phenomenon of "red dressing" will not be found in clinic. Therefore, this kind of "acute bleeding" is often not easy to find early. All the following phenomena should be considered as early signs of "occult bleeding": ① Paroxysmal bowel sounds, painful bowel sounds and urgency; ② The patient was accompanied by dizziness, nausea, cold sweat and rapid pulse. In any of the above cases, digital rectal examination or microscopic examination should be performed immediately when the pain is relieved, so as to make timely diagnosis and treatment. Stop bleeding in time when bleeding is diagnosed. If there is a lot of blood in the anus and rectum, and the bleeding point can't be seen clearly, you can stop bleeding with an air bag first (Figure 9). If there is no balloon, you can wrap the 30 # anal canal with vaseline gauze, tie both ends with silk thread, apply anesthetic ointment, and put it into the anus to stop bleeding (Figure 10). Generally this method can stop bleeding. If the bleeding point is found, suture can be used to stop bleeding, and hemostatic drugs and antibiotics can be applied all over the body.

Fig. 9 Oxygen balloon compression hemostasis

Figure 10 Anal canal compression hemostasis

2. Careful surgery and early anal canal dilatation can prevent anal canal stenosis. Stenosis can be at anal margin, tooth line or tooth line. Anal margin stenosis is mainly due to excessive excision of anal margin skin mucosa, which leads to wound contraction and anal margin stenosis. Scars are often accompanied by anal fissure, which is caused by tearing during defecation. Manipulation and instruments are not effective in dilating anus, and many operations are often needed. Tooth line stenosis can occur after closed hemorrhoidectomy. Because the ligation of hemorrhoid root is too wide, the latter can be replaced by multiple small ligations. Anal canal dilatation is often effective, but if it is not, it needs surgical correction.

3. Urinary retention Urinary retention is the most common complication after hemorrhoid or other anal canal surgery, and about 6% need catheterization (Crytal 1974). The following measures can be taken to prevent urinary retention: ① instruct patients to limit drinking water before and after operation12 hours to cause mild dehydration. Some people think this is an important measure, because the bladder expands prematurely before anesthesia disappears, which often leads to urinary retention. ② Use sedatives as little as possible after operation. ③ Early morning activities. (4) when urinating for the first time, go to the toilet to urinate, causing conditioned reflex. ⑤ It is best to use local anesthesia. ⑥ The skin wound at the anal margin should not be sutured as far as possible, and there should be no anal canal or large gauze in the rectum as far as possible, which can be used for postoperative compression and hemostasis, which can reduce postoperative pain and primary urinary retention.

Intransitive verb result

Keighley( 1993) collected 543 cases of Milligan-Moragan's long-term curative effect (6 months to 7 years) from 8 authors. The patients were satisfied and most of them were satisfied, accounting for 93% ~ 100%. It shows that hemorrhoidectomy is effective.