RU2553937C1 - Method for minimally invasive treatment of patients suffering from stage 3 and 4 haemorrhoid - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves a transanal Doppler controlled dearterialisation of internal haemorrhoids. Haemorrhoid vessel branches are underrun through an anoscope at the haemorrhoid base. A figure-of-eight non-traumatic absorbable suture is applied. The rectal mucosa and haemorrhoid are anchored with the same suture. A submucosal suture is applied in the distal direction towards an apex of the haemorrhoid. Then it is turned perpendicularly and encloses the submucosal layer. The suture is placed back towards the ligatured haemorrhoid and the second free end of the suture. After the needle pricks out, the suture ends are tied together. The haemorrhoid is ligatured to pull up and fixed to the point of vascular underrunning above the anorectal line.

EFFECT: method provides the minimally invasive treatment of the patients suffering from stages 3-4 chronic haemorrhoid by limiting the blood flow along the haemorrhoid arteries, fixing and preventing haemorrhoid prolapsed with the minimum deformity of the anal canal, preserving its function and observing the good functional and aesthetic effect.

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Description

The invention relates to medicine, in particular to surgery, namely to coloproctology, and can be used in minimally invasive treatment of patients with 3-4 stages of chronic hemorrhoids.

It is known that hemorrhoids is one of the most common coloproctological diseases, the incidence rate reaches 130-145 cases per 1000 adult population, and among diseases of the rectum and anus is about 40% (Shelygin Yu.A., Blagodarny L.A., 2012 ; Riss SI, Weiser FA, 2012).

With the development of new technologies in the treatment of hemorrhoids, minimally invasive methods of treatment are increasingly being used. They make it possible to treat up to 80% of patients with hemorrhoid symptoms on an outpatient and inpatient basis (E. Semionkin, 2004).

The study of patent and medical literature has allowed to identify the following methods of minimally invasive treatment of chronic hemorrhoids, referred to analogues of the claimed invention.

A known method for treating hemorrhoids and prolapse of the rectal mucosa is the Longo method (Longo A., Bergani JI Hainles haemorrhoidectomy and mucousectotomy for prolaps mucosae. Ethicon onco - surgery, Johnson - Jonsjn compani, 1997, Italy, p.3-27) circular resection and suturing of the rectal mucosa using a 33 mm circular hemorrhoidal stapler (HCS 33) at a height of 5 cm from the dentate line.

The disadvantages of this method include:

- circular resection of the rectal mucosa, which contributes to its narrowing, does not allow selective excision of the mucous membrane in the area of the precipitated hemorrhoid, precipitated mucosa or anoderm;

- the need to perform surgery ″ blindly ″, since the stitching and resection of the rectal mucosa is carried out without visual inspection;

- a temporary violation of the blood supply to the intestinal mucosa below the circular suture;

- frequent bleeding from under the stapler suture with the need for additional manual stitching;

- the high cost of the operation.

Known methods for sclerosing hemorrhoidal vessels under the control of Doppler, for example, a method for the treatment of hemorrhoids (RF patent No. 2202290, 04/20/2003), including the introduction of a sclerosing solution, characterized in that by rectal ultrasound dopplerometry, the location of the terminal branches of the superior hemorrhoidal artery is detected and a sclerosing solution is injected into the area of the terminal branches of the upper hemorrhoidal artery into the submucosal layer of the lower ampullar part of the rectum above the internal hemorrhoidal nodes.

The disadvantages of this method:

- there is no direct effect on the terminal branches of the superior hemorrhoidal artery, since the sclerosing solution is not injected into the lumen of the vessel, but into the submucosal layer in the vascular region;

- the method is applicable in the initial stages of the disease, when the nodes do not fall out of the anal canal;

- the introduction of a sclerosing solution into the submucous layer of the lower ampullar part of the rectum above the internal hemorrhoidal nodes does not affect dystrophic changes in the ligamentous apparatus of hemorrhoidal nodes.

A known method for the treatment of hemorrhoids (RF patent No. 2350282, 03/27/2009), including the introduction of an anoscope before the appearance of internal hemorrhoids in its lumen, vacuum ligation of the hemorrhoids, characterized in that capron thread No. 5 is applied to the end of the ligation in the form of a double loop with a long loop ends, overlay two nodes, after ligation through the anoscope make a transverse incision of the mucosa of the anal canal with a length of 0.3-0.5 cm between the dentate line and the ligated internal node closer to the imposed loop and, without cutting the threads, anosko n is removed from the rectum, while the ends of the threads are left to control the stage of hemorrhoidal necrosis.

The disadvantages of this method:

- vacuum ligation of the hemorrhoidal node does not directly affect the terminal branches of the superior hemorrhoidal artery, but is aimed at removing cavernous tissue that forms the basis of the hemorrhoidal node;

- the application of this method is impossible in the absence of clear boundaries between the internal hemorrhoidal nodes;

- prolonged inflammation of the tissues with necrosis of the hemorrhoid can lead to excessive scarring in the anal canal and the development of its stenosis;

- this method does not provide for the impact on the damaged ligamentous apparatus of hemorrhoids.

A known method of minimally invasive treatment of hemorrhoids (RF patent No. 2427331, 08/27/2011.), Including the elimination of prolapse of the hemorrhoid by placing it in the rectum and its ligation, characterized in that it is further emptied from the blood before ligation of the hemorrhoid, after ligation is carried out its submucous high-frequency coagulation for 6-9 s at 1-3 points with a bipolar mode of 35 W, after which the rectal mucosa is fixed to the submucosa by applying to the mucosa the rectal sheath, having retreated 1-2 cm proximal to the site of ligation of the vascular pedicle of the hemorrhoid, the proximal sutures with two stitches to a depth of 3-5 mm with a seam pitch distance corresponding to the prolapse of the hemorrhoid, and the ligation of the vascular pedicle of the hemorrhoid is carried out by tying on three surgical nodes of the ends of the ligature, previously stitched through the mucosa of the rectum in the transverse direction at the proximal edge of the internal hemorrhoid from the projection of one of its sides Vågå edge to the opposite.

The disadvantages of this method:

- ligation of the hemorrhoid is carried out "blindly", without Dopplerometric control;

- submucous high-frequency coagulation of the hemorrhoid is difficult to control and can lead to intraoperative bleeding;

- proximal sutures with two stitches are aimed at pulling up a falling hemorrhoidal node from above and do not have a direct effect on the correction of impaired anatomical structures: Treitz muscles and Parks ligaments;

- flashing through the mucosa of the rectum in the transverse direction at the proximal edge of the internal hemorrhoidal node from the projection of one of its lateral edges to the opposite is possible if there are clear boundaries between the internal hemorrhoidal nodes and is impossible in the absence of boundaries.

A known method of ligation of the hemorrhoidal node (RF patent No. 2416369, 04/20/2011), including applying a ligature to the internal hemorrhoidal node, characterized in that a continuous suture is made from absorbable suture material, the first stitch of which is carried out under the base of the hemorrhoidal node in an oblique direction from the level of the dentate lines to the vascular leg of the node, then in the submucosal layer continue ligation with the outer part of the thread by applying stitches, sequentially wrapping the tissue of the internal hemorrhoid plexus, etc. This ligature is performed sequentially on the top, by the bottom surfaces of the assembly prior to full engagement of the cavernous tissue into the joint, wherein after applying each of the coils produce a gradual tightening of the ligature, which tie in the pedicle after the last vykoli needle at the point where the inner part of the filament.

The disadvantages of this method:

- ligation of the hemorrhoid is carried out "blindly", without Dopplerometric control;

- a multi-turn suture leads to cavernous tissue necrosis with the development of its inflammation, and subsequently to scarring of the walls of the anal canal with the threat of the development of its stenosis;

- the multi-stitch thread located in the submucosal layer has a considerable length and undergoes significant bacterial contamination, which will create conditions for the development of purulent complications.

The known HAL-RAR technique, which is closest in terms of the totality of features to the claimed method and is selected by the prototype of the present invention (Shelygin Yu.A., Grateful L.A. Handbook of Coloproctology, GEOTAR-Media, 2012, p. 80-81).

The minimally invasive HAL technology (Haemorrhoidal Artery Ligation - hemorrhoidal ligation under ultrasound dopplerometry control) was originally developed in 1995 by Dr. Morinaga in Japan. The method was supplemented at the end of 2005 by the RAR technology (“rectal repair” - lifting technique, ie node tightening). HAL is especially effective for stage II and III gsmorroi. Together with the RAR lifting method, this technique is used for stage III and IV hemorrhoids.

The HAL-RAR method forms one of the most effective and least aggressive methods of treating hemorrhoids. A special surgical device is used to transanal deserterization of internal hemorrhoidal arteries, otherwise HAL technology (hemorrhoidal artery ligation). The device consists of an anoscope, in the wall of which is mounted an ultrasonic sensor connected to a sound transducer. A transparent anoscope with backlight and a miniature Doppler sensor is inserted through the anus into the lumen of the rectum. When a hemorrhoidal artery is detected, the pulsation noise is converted into an audio signal - thus, the doctor is able to detect all arterial vessels passing in the output (lower ampullar) section of the rectum. This allows the surgeon to accurately determine the location of the hemorrhoidal artery leading to the hemorrhoid. The surgeon bandages each artery (a process called ligation) by placing a stitch around the artery and ties the ends of the thread, bandaging the artery. Since the sutures are placed in the lumen of the intestine, where there are no pain receptors, the procedure is performed painlessly. Anesthesia is necessary only for the painless administration of an anoscope.

The number of arterial vessels can vary from 3 to 10 or more pieces. Above the ultrasound probe in the anoscope there is a window through which flashing and ligation of the detected vessels is performed. This suture reliably eliminates the flow of arterial blood to the hemorrhoid. Subsequently, usually by the 30th day after the operation, the hemorrhoidal nodes subside, stop bleeding and, in most cases, are replaced by connective tissue. In addition, simultaneously with the ligation of blood vessels, the internal nodes are firmly fixed in the rectum. This procedure is inherently a radical intervention, since the restoration of blood supply in the hemorrhoidal nodes does not occur.

With a quick stitch made from the top of the hemorrhoid to its base, squeeze the tissue of the internal hemorrhoid. The anoscope device is so designed that it collects only the prolapsed tissue of the hemorrhoid. The ends of the threads are connected together, tightening the tissue of the internal hemorrhoid. A continuous suture provides the effect of lifting or “lifting” the hemorrhoid, which sags outward.

When lifting the internal hemorrhoid, we “put” the hemorrhoid in a normal position, as before the disease. Thus, we restore the normal functioning of the rectum, without cuts and scars, relapse of the disease.

The disadvantages of this method:

- this suture does not provide restoration of damaged anatomical structures: muscles of the Trent and Parks ligaments;

- the upholstery of the seam with multiple injections and punctures leads to additional trauma and infection of tissues;

- continuous suture “pulls the mucous membrane, leading to its ischemia;

- a continuous twisting seam makes it difficult to “slip the thread in the tissues, leads to its entanglement, does not provide a complete pulling of the knot;

- in the absence of clear boundaries between the external and internal nodes, there is a high probability of overlapping turns of the suture on the area of the dentate line and even lower than it, which will necessarily be accompanied by a pronounced postoperative pain syndrome;

- gross deformation with twisted seams of the walls of the anal canal;

- the inability to use at the 4th stage of hemorrhoids due to the insufficient effect of "lifting".

The objective of the claimed invention is to develop a method for minimally invasive treatment of chronic hemorrhoids, which allows to achieve: limiting blood flow through the hemorrhoidal arteries, fixing and preventing the loss of hemorrhoids with minimal deformation of the anal canal, maintaining its function and maintaining a good functional and cosmetic effect.

The problem is solved in that for minimally invasive surgical treatment of chronic hemorrhoids, transanal Doppler-controlled deserterization of the internal hemorrhoidal nodes and mucopexy are performed by flashing through the anoscope of the terminal branches of the hemorrhoidal vessels at the base of the hemorrhoidal node with an eight-shaped suture on an atraumatic needle with absorbable material. In this case, hemming of the mucous membrane of the rectum and hemorrhoidal node is performed using the same thread by applying a submucosal suture in the distal direction to the top of the hemorrhoidal node. Then the suture is applied in the perpendicular direction with the capture of the submucosal layer. Subsequently, the suture is applied in the opposite (proximal) direction to the second end of the ligature, where, after the puncture, the ends of the thread are tied together. Thus, the hemorrhoid is tightened and held by the ligature from the bottom up. By binding the ends of the ligature, the hemorrhoid is fixed to the site of the initial flashing of hemorrhoidal vessels above the anorectal line.

Thus, the claimed method of treating hemorrhoids provides for doppler-controlled desarterization of internal hemorrhoidal nodes in combination with mucopexy and the use of a submucosal suture, which tightens the hemorrhoid from the bottom up and fixes it in the anal canal above the dentate line.

The technical result obtained using this method:

- reducing trauma and preventing relapse of the disease,

- reduction of pain due to the absence of trauma to the anorectal line and anoderm,

- a decrease in the frequency of postoperative complications, such as purulent-inflammatory, reflex sphincterospasm and acute urinary retention, severe deformation of the walls of the anal canal with a violation of its function,

- getting a good cosmetic result and reducing the time of final recovery;

- the method eliminates the main pathogenetic links leading to the development and progression of the disease: the branches of the upper rectal artery are tied (blood stasis in the cavernous formations is eliminated), the dystrophic ligamentous apparatus of hemorrhoidal nodes is strengthened. In this regard, the method is indicated for 3-4 stages of hemorrhoids.

According to modern ideas about the pathogenesis of hemorrhoids (Vorobyev G.I., Shelygin Yu.A., Blagodarny L.A., 2006), the reason for its development are two main factors. The first factor is vascular. It is based on vascular dysfunction, which ensures the flow of arterial blood through the cochlear arteries to the cavernous bodies and the outflow through the cavernous veins, which leads to an increase in the size of cavernous bodies, which are a substrate for the development of hemorrhoids. The second factor is mechanical. Due to a violation of the elastic properties of the longitudinal muscle of the submucosal layer of the rectum (the muscle of the Traits) and Parks ligament, which blocks the internal hemorrhoid from the external, the internal hemorrhoid is prolated from the anal canal.

The method of minimally invasive treatment of hemorrhoids of stage 3-4 that we developed suggests the simultaneous elimination of these two pathogenetic factors. With the help of suture ligation of hemorrhoidal vessels performed through an anoscope with an ultrasound probe, the blood flow to the hemorrhoidal nodes is sharply reduced, thereby achieving their decline and the cessation of bleeding. Hemorrhoidopexy using a specially developed suture allows us to keep the internal nodes in a normal anatomical position and prevents them from falling out of the anal canal.

The invention is illustrated in the figure. Figure 1 presents a diagram of hemorrhoidopexy, where

1 - anal canal below the dentate line

2 - gear line

3 - suture site, place of the first injection - the third injection

4 - place of the first injection - second injection

5 - place of the second injection - third injection

A detailed description of the method and examples of its clinical implementation. In the conditions of an operating clinic or hospital, after preoperative preparation of the intestine (Fortran, Fleet, Lavacol), under caudal or spinal anesthesia, the patient is in the standard position for lithotomy, after processing the perianal skin and anal canal with Oktenisept solution, a transparent anoscope with backlight and Doppler the sensor of the apparatus "Angiodin-procto" of the domestic company LLC "AMBI", is introduced through the anus into the lumen of the rectum. The anoscope slot is installed in the area of the internal hemorrhoid for de-sterilization, which is carried out in any order in the projection for 3 hours on the conditional dial, in the projection for 7 hours on the conditional dial, in the projection 11 hours on the conditional dial. The Doppler sensor, located at the edge of the anoscope slot, takes readings of the pulsation of the hemorrhoidal artery, converts it into an audio signal. This allows you to accurately determine the location of the hemorrhoidal artery going to the hemorrhoid. Then, under doppler control, dearterization is performed: stitching with an eight-shaped suture and ligation of the visualized hemorrhoidal artery. Recommended suture material: safil 2/0, needle bend 5/8 circle. A suture is applied in the lumen of the intestine above the dentate line with the capture of the muscle layer, thereby achieving the cessation of arterial blood flow to the hemorrhoid and fixation of the mucosa (mucopexy). Then, after removing the anoscope from the rectum, hemorrhoidopexy is carried out directly, in which the thread is carried out in the submucosal layer, and the seam itself has the form of a triangle with a base in the region of the apex of the hemorrhoidal node. The suture is imposed with the same ligature, which previously was carried out de-sterilization under doppler control. The beginning of the suture is from the ligature node at the site of suture ligation of the hemorrhoidal artery. An atraumatic needle at the free long end of the suture carries out a submucosal injection next to the suture that was used for desarterization, located at the base of the hemorrhoid. Next, the thread is carried out with a suture in the submucosal layer, in the distal direction, to the top of the hemorrhoid, where the needle comes out. The second injection and injection is carried out in the region of the apex of the hemorrhoidal node as submucosally, in the perpendicular direction with the capture of the submucosal layer and the stitch length, which allows the needle to bend. In order to avoid entrainment of the anoderm in the suture, the needle is injected at the site of the last injection. The third injection returns the thread up towards the ligature knot and the second free end of the thread, where, after the puncture, the ends of the thread are tied together. Thus, the hemorrhoid is tightened and held by the ligature from the bottom up. The operation is completed by introducing Levomekol ointment into the anal canal using an insulin syringe.

The performance of the claimed method is confirmed by the following clinical examples:

Example 1

Patient A-ev, 48 years old, case history No. 1115-2013, was admitted to the surgical department with complaints of enlarged hemorrhoidal nodes falling out during a bowel movement and adjusting with manual help, pain, discomfort in the anal canal area that occur during defecation, periodically - the release of red blood at the end of the defecation. When examining the area of the anus, enlarged, precipitated hemorrhoidal nodes are detected at 7 and 11 hours of the conditional dial. Nodes without hyperemia, increased in size to 3.5 × 2.0 cm, slightly swollen, are adjusted with manual assistance. Per rectum: sphincter tone is not elevated, the study is moderately painful, the ampoule is empty. Anoscopy reveals significantly enlarged full-blooded internal hemorrhoidal nodes located at 3, 7, 11 hours of the conditional dial, while straining from the anal canal, nodes appear at 7 and 11 hours.

03/02/13 g under an epidural blockade the patient underwent an operation - transanal doppler-controlled deserterization of internal hemorrhoidal nodes with mucopexy and hemorrhoidopexia of falling out nodes at 7 and 11 hours according to the claimed method using a lifting submucosal suture (safil 2/0, needle bend 5/8 circle). The postoperative period was uneventful, the use of narcotic analgesics was not required, the first defecation was accompanied by a mild pain syndrome, subsiding after 10 minutes without the use of analgesics. No discharge of blood from the anal canal was observed. Discharged on the 3rd day. During follow-up examinations after 1, 3 and 9 months, the patient does not complain, while examining the anus, there is no narrowing of the anal canal, strong-willed efforts are sufficient, there is no pain in the study, the internal hemorrhoids are represented by moderately dense fibrous “pads” fixed in the anal canal above the dentate line .

Example 2

Patient Eev, 60 years old, medical history No. 1888-2013, was admitted to the department complaining of enlarged hemorrhoids, pain, discomfort in the anal canal arising during the act of defecation, occasionally - the appearance of a blood impurity in the feces. From the anamnesis: considers herself sick for 7 years, when enlarged hemorrhoids appeared, periodically during constipation she was bothered by pain in the anal area after the act of defecation, during the last 5 years, defecation was periodically accompanied by an admixture of blood in the feces, hemorrhoids, when falling out the anal canal during the act of defecation, ceased to be adjusted with the use of manual benefits. When examining the anal area, fallen out, enlarged internal hemorrhoidal nodes located at 3, 7, 11 hours, moderately edematous, not adjusted with the help of a manual are visualized. Per rectum: sphincter tone is elevated, the study is moderately painful, the ampoule is empty, the internal hemorrhoidal nodes are located typically: at 3, 7, 11 hours of the conditional dial in the supine position, 3.5 × 3.0 × 2.0 cm in size, mucous moderately hyperemic above them. When the anoscope is removed, the nodes fall out of the anal canal and are not completely repaired when applying the manual. With rectoscopy, no other rectal pathology was detected.

04/12/13 g, the patient underwent surgery: Transanal doppler-controlled desarterization of internal hemorrhoidal nodes with mucopexy and hemorrhoidopexy of falling hemorrhoidal nodes by 3; 7; 11 hours by the claimed method. Dopplerometry revealed additional branches of the superior rectal artery at the 1st and 5th hours, which were ligated by the suture method according to the claimed method using a lifting submucosal suture (safil 2/0, needle bend 5/8 circle). The postoperative period was uneventful. On the first day, moderate pain in the area of postoperative wounds, stopped by the administration of non-narcotic analgesics, bothered. On the 3rd day after surgery there was an independent stool without blood. Discharged on the 6th day. During follow-up examinations after 1, 3 and 8 months, there was a lack of prolapse of the internal hemorrhoids with complete restoration of the function of the anal canal.

Example 3

Patient K-ova, 38 years old, outpatient medical record No. 1121961 (2012), turned to the coloproctology office complaining of pain in the anus during an act of defecation, loss of hemorrhoidal nodes requiring manual use for their reduction. When examining the area of the anus, external hemorrhoidal nodes enlarged in size are located at 3, 7, 11 hours of the conditional dial. Internal hemorrhoidal nodes are located along the continuation of the external ones, enlarged to 3.5 × 3.0 × 2.5 cm, when straining, they drop out of the anal canal, they require manual use for reduction. The sphincter tone is increased. 2.07.12 g under the patient’s caudal blockade, an operation was performed - transanal doppler-controlled desarterization of internal hemorrhoidal nodes, with mucopexy and hemorrhoidopexy of the falling nodes according to the claimed method using a submucosal suture (safil 2/0, 5/8 circle needle bend). External hemorrhoidal nodes were excised using the Surgitron radiosurgical apparatus and suturing wounds with a continuous “cosmetic” suture. The postoperative period was favorable; in the first two days, a moderate pain syndrome was disturbed in the area of postoperative wounds of the anus, which was stopped by taking non-narcotic analgesics. Bleeding from the rectum, including during the act of defecation, was not noted. Control examinations were carried out weekly during the first month. Healing of postoperative wounds by primary intention. Blood excretion during bowel movements was not observed. 3 and 4 months after surgery - there were no difficulties with bowel movements, prolapse of internal hemorrhoidal nodes, there was no pain during the study.

The inventive method was tested in 14 patients in the surgical department of MBUZ "TsRB Tselinsky district of the Rostov region", coloproctology office of the consultative diagnostic clinic of Rostov State Medical University. As a result of the treatment, all patients experienced a complete recovery in the absence of complications.

Advantages of the minimally invasive treatment of hemorrhoids 3 and 4 stages of the disease:

- lack of wounds,

- short procedure time,

- 2-3 days of stay in a day hospital,

- the ability to perform on an outpatient basis,

- good functional and cosmetic effect,

- the possibility of returning to work after 2-3 days.

Thus, the proposed method for the surgical treatment of chronic hemorrhoids of the 3-4 stage allows to achieve effective treatment of hemorrhoids of the 3-4 stage in the absence of such postoperative complications as severe pain syndrome with reflex urinary retention, cicatricial narrowing and anal canal failure.

The method was tested in a clinic and can be recommended in coloproctological practice.

Claims (1)

A method for minimally invasive treatment of hemorrhoids of stage 3 and 4 of the disease, including transanal doppler-controlled deserterization of internal hemorrhoids and mucopexy, flashing through the anoscope of the terminal branches of the hemorrhoidal vessels at the base of the hemorrhoidal node with a suture on an atraumatic needle with a resorbable material, characterized in that the hemming of the gut mucosa and the rectum performed using the same thread by applying a submucosal suture in the distal direction to the top of the hemorrhoid of the knot, then in the perpendicular direction with the capture of the submucosal layer, and then in the opposite direction to the second end of the ligature, the thread is returned upward towards the ligature knot and the second free end of the thread, where, after the puncture, the ends of the thread are connected together, the hemorrhoid is pulled and hold the ligature from the bottom up, thereby fixing it to the place of the initial flashing of hemorrhoidal vessels above the anorectal line.

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