RU2237439C2 - Modification of hemorrhoidectomy operation at acute thrombosis of hemorrhoidal nodes - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should apply ligature in submucous layer around the whole vascular bundle of node's pedicle at applying the latter into submucous layer. One should perform incision at pedicle in projection of disposition of the main internal hemorrhoidal node. Mucosa covering thrombotic node up to the upper level of hemorrhoidal node should be prepared, then node should be protruded into the wound to dissect all components of hemorrhoidal node. In case of chronic hemorrhoid stage III-I one should additionally fix mobilized mucosa to anal sphincter, as for external hemorrhoidal nodes being in projection of internal ones they should be dissected through the same incisions. The method enables to modify ways of operative treatment in patients at acute thrombosis of hemorrhoidal nodes.

EFFECT: higher efficiency of modification.

2 cl, 4 dwg

Description

The invention relates to the question of surgical treatment of patients with acute thrombosis of hemorrhoidal nodes.

The aim of the invention is to improve the technique of surgical treatment of patients with acute thrombosis of hemorrhoidal nodes in order to improve the results of treatment of patients, reduce the length of hospitalization, reduce the frequency of postoperative complications. In the emergency proctology surgery department of the SSCC of the Ministry of Health of the Russian Federation on the basis of Moscow Clinical Hospital No. 15 for the treatment of patients with acute thrombosis of hemorrhoidal nodes, surgical treatment methods were used using two modifications of Milligan-Morgan operation developed in the SSCC for the treatment of chronic hemorrhoids.

When deciding on the tactics of surgical treatment of patients with acute thrombosis of hemorrhoidal nodes, the most important is the assessment of the clinical picture of acute thrombosis of hemorrhoidal nodes, namely the prevalence of thrombotic process, the presence or absence of differentiation of nodes, necrosis and its vastness, secondary inflammation of the mucous membrane of thrombosed nodes, and the severity of perianal edema tissues. According to clinical manifestations, three degrees of severity of acute thrombosis of hemorrhoidal nodes are distinguished - mild, moderate and severe.

With a mild degree of acute thrombosis of hemorrhoids and medium without perianal edema, an urgent radical operation is indicated, performed in the first 24 hours from the moment of hospitalization of the patient.

In patients with a severe degree of the disease and moderate with the presence of perianal edema, delayed (early or late) radical surgery is shown, performed later than 24 hours from the time of hospitalization. This tactic is dictated by the need for preoperative conservative therapy to eliminate perianal edema, secondary inflammation, the appearance of differentiation of hemorrhoidal nodes in order to create the most favorable conditions for the operation and to minimize the possibility of complications in the postoperative period.

To date, two methods of hemorrhoidectomy have been widely used in the practice of surgical treatment of patients with acute thrombosis of hemorrhoidal nodes. This is a hemorrhoidectomy technique with suturing of two mucocutaneous edges of the wound to its bottom, and a hemorrhoidectomy technique with suturing postoperative wounds tightly.

The use of these two modifications of hemorrhoidectomy often led to serious complications in the immediate postoperative period.

These shortcomings made it possible to develop a new technique for the operation of submucosal hemorrhoidectomy with the leading end branches of the upper rectal artery, which was specially developed in the clinic specifically for the radical surgical treatment of patients with acute thrombosis of hemorrhoids.

We studied the immediate and long-term results of surgical treatment of 132 patients with acute thrombosis of hemorrhoidal nodes who underwent emergency hemorrhoidectomy. Of these, 73 patients underwent suturing of postoperative wounds tightly with separate sutures and in 59 patients submucosal hemorrhoidectomy with ligation of the terminal branches of the rectal artery.

It was noted that constant pain in the anal canal during the entire patient’s stay in the hospital was observed in 26 (35%) patients with nodal sutures and in 7 (12%) patients operated on using the submucosal hemorrhoidectomy surgery technique.

Pain in the anal canal during the first defecation was observed in 51 (70%) patients with suturing wounds with interrupted sutures and in 21 (36%) patients with submucosal hemorrhoidectomy.

Bleeding developed in 4 (5%) patients who had suturing wounds with interrupted sutures. Bleeding was stopped by doping a bleeding vessel. It must be emphasized that this complication did not occur in any patient after submucosal hemorrhoidectomy.

Blood excretion during the act of defecation, which did not have the nature of profuse bleeding, was observed in the immediate postoperative period in 17 (23%) patients after nodal suturing and only in 3 (5%) people after submucosal hemorrhoidectomy.

The causes of severe edema of perianal tissues were infection attachment and the remaining external not removed hemorrhoidal fringes, which occurred in 7 (9%) patients with nodular sutures and in 1 (2%) patient operated on using the submucosal hemorrhoidectomy technique.

The remaining external hemorrhoidal fringes were excised 6-7 days after hemorrhoidectomy.

The reasons for the inconsistency of postoperative sutures and discrepancies in the edges of postoperative wounds after surgery with suturing postoperative wounds with nodal sutures, we consider mechanical injury during bowel movements, especially when it is difficult. This complication was observed in 4 (6%) patients after nodal suturing and was not observed at all in patients operated on by an alternative technique.

Hyperthermia in the immediate postoperative period was noted after hemorrhoidectomy in 16 (22%) patients after suturing wounds with interrupted sutures and in 6 (10%) patients with submucosal hemorrhoidectomy.

Reflex urinary retention, which lasted for 2-6 days, was observed in 14 (19%) patients with nodular sutures and in 1 (2%) patient operated on using the submucosal hemorrhoidectomy technique.

In the long-term pain period during an act of defecation, 11 (15%) patients were noted in whom wounds were sutured with interrupted sutures and only 1 (2%) patient had submucosal hemorrhoidectomy.

Narrowing of the anal canal occurred in 2 (3%) patients after nodal suturing. To eliminate this complication, scars were made that narrowed the lumen of the anal canal. A similar complication did not occur in patients operated on using the submucosal hemorrhoidectomy technique.

The long-term results of surgical treatment of patients operated on in the delayed period by two hemorrhoidectomy techniques were tracked in 105 patients over a period of 6 months to 1 year.

In 62 patients, wounds were sutured with interrupted sutures and 43 patients were operated on using the submucosal hemorrhoidectomy technique.

Inpatient treatment after hemorrhoidectomy with suturing wounds with nodal sutures lasted an average of 8–9 days, outpatient treatment lasted an average of 18–19 days. After the operation of submucosal hemorrhoidectomy with doping of the terminal branches of the rectal artery, inpatient treatment averaged 6-7 days, and outpatient treatment was reduced to an average of 6 days.

Thus, our data indicate that the incidence of postoperative complications and the timing of wound healing in patients with acute thrombosis of hemorrhoidal nodes operated on by the method of submucosal hemorrhoidectomy with doping of the terminal branches of the upper rectal artery compare favorably with those in patients operated on by suturing postoperative wounds with interrupted sutures.

Description of the operation procedure

First, we perform doping of the terminal branches of the upper rectal arteries that feed the internal hemorrhoidal nodes. To do this, using a round needle, we conduct a ligature (chrome catgut) in the submucosal layer around the entire vascular bundle of the node leg. We tie the ends of the ligature with three knots. After cutting the threads, the node is immersed in the submucosal layer. Doping of vascular bundles in the legs of nodes at 3, 7 and 11 hours is carried out at different levels. We make a semi-oval incision on the skin 2-2.5 cm long 1 cm from the Hilton white line in the projection of the location of the base of the internal hemorrhoidal node (Fig. 1). The skin edges of the wound are parted by Alice clamps. Under the control of the index finger of the surgeon, introduced into the lumen of the anal canal, the mucous membrane covering the thrombosed node is dissected to the upper level of the hemorrhoid. Then, the index finger inserted into the anal canal, the node protrudes into the wound, the thrombus is removed and all components of the hemorrhoid are excised - thrombosed cavernous veins and bodies (Fig. 2). A thorough hemostasis is performed. If acute thrombosis of hemorrhoids occurred on the background of chronic hemorrhoids of stage 3-4, in some cases, to prevent the mobilized mucosa from falling out and to eliminate the formed submucosal tunnel, we fix the mobilized mucosa to the anal sphincter with nodal catgut sutures (Fig. 3). In a similar way, the remaining nodes are deleted. In the presence of external hemorrhoidal nodes located in the projection of the internal, they are excised through the same skin incisions. The edges of the skin wound are sutured with rare nodal catgut subcutaneous sutures with the capture of the bottom of the wound (figure 4).

Sources of information

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Claims (3)

1. A method of hemorrhoidectomy, including ligation of vascular bundles in the legs of nodes at 3, 7 and 11 hours at different levels and their excision, characterized in that the ligature is carried out in the submucosal layer around the entire vascular bundle of the legs of the node with the latter dipping into the submucous layer, an incision is performed on the leg in the projection of the location of the base of the internal hemorrhoid, dissect the mucous membrane covering the thrombosed node to the upper level of the hemorrhoid, protrude the node into the wound and excise all the heme components rroidalnogo node. 2. The method according to claim 1, characterized in that in chronic hemorrhoids of the 3-4th stage, the mobilized mucosa to the anal sphincter is additionally fixed. 3. The method according to claim 1 or 2, characterized in that the external hemorrhoidal nodes located in the projection of the internal excised through the same skin incisions.

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