RU2258471C2 - Method for hemorrhoidectomy - Google Patents

Abstract

FIELD: medicine, proctology.

SUBSTANCE: the present innovation deals with surgical treatment of chronic hemorrhoid: one should apply a clamp onto the bottom of internal hemorrhoid by capturing a vascular stem, one should suture at first under the clamp applied the bottom of hemorrhoid with linear horizontal uninterrupted reverse suture, moreover, after fixing ligature's end with a knot every next puncture-in should be performed at one side of hemorrhoid bottom being 3-4 mm ahead the next puncture-in, and at another side of hemorrhoid bottom every next puncture-in should be fulfilled being about 1-2 mm behind puncture-out of previous stitch. Each stitch should be tightened immediately, stitches should be applied being parallel to the clamp, hemorrhoid bottom should be sutured, hemorrhoid should be dissected above the clamp, the latter should be removed. The suggested method for hemorrhoidectomy enables to improve adaptation of wound edges and its hermetic sealing, decrease blood losses during operation and increase the quality of hemostasis, shorten terms to apply sutures, decrease the length of through canal developed at suturing procedure.

EFFECT: higher efficiency.

1 cl, 1 dwg, 1 ex

Description

The invention relates to medicine, namely to proctology, and can be used in the surgical treatment of chronic hemorrhoids.

Despite the rapid development and improvement of minimally invasive methods of treating hemorrhoids, at present, with the III-IV stages of the disease, the main treatment method is hemorrhoidectomy. The relevance of developing new methods for the surgical treatment of hemorrhoids is not always determined by satisfactory results of the operation, since the issues of prevention of postoperative complications: bleeding, scarring of the anal canal, infectious complications, and relapse of the disease are not completely resolved. A relatively large number of complications leading to a long postoperative period and rehabilitation require an improvement in surgical procedures.

To date, the most widespread pathogenetically substantiated method of Milligan-Morgan hemorrhoidectomy in the 2nd modification of SSC coloproctology with a natural desire to completely restore the mucous membrane of the anal canal / V.L. Rivkin, Yu.V. Dultsev, L.L. Kapuller. Hemorrhoids and other diseases of the anal canal. - M., Medicine, 1994. - P.96-100 /. The method includes applying a Billroth clamp to the base of the internal hemorrhoid with the capture of the vascular pedicle and cutting off the hemorrhoid over the clamp. The vascular leg of the cut off hemorrhoid is bandaged with the formation of its stump. The clamp is removed and the wound is sutured with separate sutures.

The presence of a stump of the vascular pedicle of the internal hemorrhoid, which does not hide under the mucosa, causes pain during defecation. In addition, there is a risk of bleeding from the stump when the ligature slides from it. Despite the preliminary ligation of the vascular pedicle, a relatively large loss of blood from the bed of the removed site to the closure of the wound is likely.

A known method of hemorrhoidectomy, including clamping the base of the internal hemorrhoidal node with the capture of the vascular pedicle, the application of a linear suture to the base of the node and its subsequent cut-off / Ibid. - S. 101-102 /. In this method, the clamping of the base of the internal hemorrhoid and its flashing is carried out using a stapler US-30. Applying a linear mechanical suture eliminates blood loss and reduces the time of surgery. However, the use of US-30 is difficult due to the limited size of the anal canal. Using hemorrhoidectomy of modern staplers for applying a linear suture is extremely expensive.

The closest analogue that does not use expensive staplers is a hemorrhoidectomy method, including applying a Billroth clamp to the base of the internal hemorrhoidal node with the capture of the vascular pedicle, cutting off the node, flashing the base of the node under the clip and removing the clip / Ibid. - S. 101 /. In this method, the assembly is cut off immediately above the clamp immediately after being applied. Then, separate sutures are placed under the clamp with the stitching of all layers of the mucous membrane and the bottom of the wound without tightening them. When the sutures are applied along the entire wound surface, the ligatures are pulled and the clamp removed. Keeping the ligatures taut, they are tied in turn. The operation is completed by the introduction of turunda with Levosin into the anal canal. The method eliminates the formation of a separate stump of the vascular pedicle and the associated negative consequences. However, the method is not without drawbacks:

- the presence of an open wound after cutting off the hemorrhoid and removing the clamp can lead to infection of the surgical wound and the occurrence of inflammatory complications;

- when stitching all layers of the mucous membrane and the bottom of the wound, there is a high probability of infection of the through channel of the wound due to its large extent;

- the inability to simultaneously tighten all the sutures after removing the clamp leads to insufficient hemostasis and blood loss;

- the imposition of individual sutures leads to incomplete adaptation of the edges of the wound and the possibility of the formation of submucosal hematomas with their secondary infection and lengthening the healing period of the wound;

- cutting off the hemorrhoid before suturing can lead to bleeding when the clamp is broken;

- a large investment of time for tying individual seams.

The problem to which the claimed invention is directed is to reduce the frequency of postoperative complications by preventing bleeding and reducing the likelihood of infection, as well as reducing the healing time of wounds.

The technical result achieved by the invention:

- reducing blood loss during surgery and increasing the reliability of hemostasis while maintaining a low cost of surgery;

- the absence of an open wound when suturing;

- reducing the length of the through channel at the edges of the wound formed by suturing;

- improving the adaptation of the edges of the wound and its tightness;

- reduction of suturing time.

This technical result is achieved by the fact that in a hemorrhoidectomy method including applying a clamp like Billroth clamp to the base of the internal hemorrhoidal node with the capture of the vascular pedicle, cutting off the node above the clamp, flashing the base of the node and removing the clamp, the author suggests first to sew the base of the hemorrhoidal node under the applied clamp, why use a linear horizontal continuous return suture, in which, after fixing the end of the thread with a knot on one of the sides of the base of the hemorrhoidal node, each the subsequent injection is performed 3-4 mm ahead of the previous injection, and on the other side of the base of the knot, each subsequent injection is 1-2 mm behind the puncture of the previous stitch, the author proposes to tighten each stitch and lay the stitches parallel to the clamp, after which the hemorrhoid can be cut off and remove the clamp.

Imposing a linear continuous return suture until the hemorrhoid is cut off eliminates the appearance of an open wound and improves the adaptation of the edges of the wound during suturing, which reduces the likelihood of infection of the wound and accelerates its healing. Imposing on the base of the internal hemorrhoidal node a continuous horizontal return suture with the specified stitch parameters, where each stitch is tightened and the stitches are parallel to the clamp, provides complete compression of the base tissue of the node and the vessels passing through it, which increases the reliability of hemostasis and prevents bleeding during subsequent cutting of the node over clamping and removing the clamp, without the use of expensive staplers. In addition, the application of such a suture ensures the tightness of the wound and reduces the length of the through channel at the edges of the wound, reducing the likelihood of infection, and also provides a good comparison of the edges of the wound, reducing its healing time. The application of a continuous return seam takes less time compared to the individual seams used in the prototype.

Known continuous vertical return seam according to Heidengain / G.M. Semenov, V.L. Petrishin, M.V. Kovshova. Surgical stitch. - St. Petersburg: Peter, 2001. - P.64-65 /, applied to the edge of the wound to achieve hemostasis, but it is not intended to connect tissues.

The drawing shows a diagram of the overlay of a continuous suture applied to the base of the hemorrhoidal node under the clamp - top view (hemorrhoidal node is not shown).

The method is as follows. After moderate sphincter anus sphincter divisions and revision of the walls of the anal canal using a rectal mirror or anal retractor, internal hemorrhoids at 3, 7, 11 hours are alternately captured by Luer clamps. On the base 1 of the hemorrhoidal node in the radial direction, close to the walls of the anal canal, Billroth's clamp is applied from the outside to the inside, capturing the vascular pedicle and the base of the cavernous bodies. Without cutting off the knot and without removing the clamp, a continuous horizontal linear return suture is applied under the catgut with the catgut starting outward from the depth of the anal canal. After fixing the end of the thread with knot 2 at a distance of 5-6 mm from it, make the first stitch 3 on one of the sides of the base 1 of the hemorrhoid, after stitching on the other side, make stitch 4 with the thread returning at a distance of 3-4 mm from this puncture. Next, each subsequent injection on one side of the base of the hemorrhoidal node is performed 3-4 mm in front of the previous injection, and on the other side of the base of the node, each subsequent injection is 1-2 mm behind the previous stitch, providing overlapping seams. Each stitch is tightened, stitches are laid parallel to the clamp. When each stitch is tightened, this tissue section is clamped, which ensures optimal hemostasis and tightness of the wound. It was experimentally established that when overlapping stitches of less than 1 mm on one side of the base of the knot and less than 3 mm on the other, cutting through the tissues of the hemorrhoidal node is possible. Overlapping stitches of more than 2 mm on one side of the base of the knot and more than 4 mm on the other can lead to wound deformation and not provide reliable hemostasis. After stitches are applied to the entire base of the knot, the thread is tied, the hemorrhoidal knot is cut off over the clamp and the clamp is removed. A linear strip of tightly connected tissues is formed without the formation of a separate stump of the vascular pedicle. Similarly, all internal hemorrhoidal nodes are sequentially removed without deformation of the anal canal with suturing of all wound surfaces completely. Due to good hemostasis, there is no need to plug the anal canal.

Example. Patient B., 56 years old. He entered the department of coloproctology with a diagnosis of chronic hemorrhoids of the III degree. He has hemorrhoids for about 10 years with a periodic complication of hemorrhoidal nodes with thrombosis. The last year marks a deterioration: prolapse of nodes during straining with the need to put them in the anal canal by hand. Objectively: the condition is satisfactory. An rectal examination at 3, 7, 11 hours revealed enlarged internal hemorrhoidal nodes, falling out of the anal canal when straining. Under spinal anesthesia, a hemorrhoidectomy was performed according to the claimed method. The operation time is 20 minutes. Blood loss 20 ml. The postoperative period without complications. The first and subsequent bowel movements without blood secretion with moderate soreness. Discharged from the hospital on the 5th day. During control examinations, epithelization of the wounds of the anal canal on the 9th day. Disability period 25 days after surgery. Examined after 3 months - daily stool without pain and blood secretions. The result of the operation is rated as good.

This method operated on 34 patients. The average blood loss during surgery was 20 ml. Wound healing of the anal canal occurred in all patients no later than 10 days. There were no complications in the near and distant postoperative period. The average disability after surgery did not exceed 25-28 days.

Thus, the claimed method of hemorrhoidectomy prevents complications of the postoperative period (bleeding and infection of the postoperative wound) and reduces the healing time of wounds.

Claims (2)

1. A method of hemorrhoidectomy, including applying a Billroth-type clamp to the base of the internal hemorrhoid with a vascular pedicle grasp, cutting off the knot above the clamp, flashing the base of the knot and removing the clamp, characterized in that the base of the hemorrhoid is first stitched under the clamp with a linear horizontal continuous suture, in this case, after fixing the end of the thread with a knot, each subsequent injection on one side of the base of the hemorrhoidal node is performed in front of the previous injection, and on the other side each subsequent node base vkoly operate behind vykoli previous stitches, each stitch is once tightened is applied in parallel stitches nip after suturing the base of the haemorrhoid that node is cut off and remove the clamp. 2. The method according to claim 1, characterized in that each subsequent injection on one side of the base of the hemorrhoidal node is performed 3-4 mm in front of the previous injection, and on the other side of the base of the node each subsequent injection is 1-2 mm behind the previous stitch .