TISSUE STRUCTURE CHANGES AS THE GROUND TO CHOOSE A METHOD OF ELECTRIC WELDING OF CHRONIC HEMORRHOIDS

Abstract

Using of electric welding makes possible bloodless division of live tissues, reliable clamping of vessels. Due to this fact, the technology is successfully spreading through the surgical clinics. However, tissue structure changes, occurred as the result of current passage, are not studied sufficiently. Meanwhile, its knowledge is necessary for surgeons in order to understand the possibilities of technologies, indications and contraindications for its use. Objective of study: to investigate changes in the arterial wall up to 2.0 mm in diameter and venous wall up to 4.0 mm in diameter, adipose tissue and fascia as the result of use of basic modes of the apparatus Patonmed® EKVZ-300 for the purpose to determine their most effective application in the surgical treatment of chronic hemorrhoids. Material and methods. During the last 3 years surgical treatment of combined chronic hemorrhoids was performed on 58 patients, 32 males and 26 females at the age from 36 to 74 years. Surgical procedure was performed by means of main regular voltage modes, provided by Patonmed® EKVZ-300. In 58 patients 216 hemorrhoidal piles were found, including 32 of II degree, 143 of III degree and 41 of IV degree. Surgery consisted of hemorrhoidectomy beginning with mobilization of external piles which enabled to assess subcutaneous-submucosal blood flow in the transitional zone. At first, the zone of excision was outlined in order to avoid postsurgical anal stenosis. The perianal skin was cut by a scalpel up to the lower edge. The following stages of surgery were performed by means of welding. In the transitional zone and near the anal canal mobilization was performed by means of welding with modes of cutting (HL), coagulation (LL), automatic welding (DA) in different variants of power. Results and discussion. In case of high density of the superficial fascia varicose changed piles were isolated with HL-1 mode. All the varicose changed veins were mobilized in one block with completely controlled hemostasis. In case of significant destruction of superficial fascia, a grape-like varicose dilation of hemorrhoidal piles and their dense filling with blood the mode LL was used. Mobilization of one pile required 9-12 welding with HL-1 mode or 10-16 with LL-5 mode. Mobilization of one pile lasted 4.8±2.6 minutes and 7.3±3.8 minutes respectively. Near the edge of the transient zone for the purpose of mobilization only LL mode was used. Welding in the transient zone lasted 4,5±3,5 minutes. Welding of internal hemorrhoids was fully-fledged by using LL-5 mode in 93.1 % of cases, LL-4 – in 82.6 %, LL-3 – in 69 %. Mobilization of one pile took 11.4±4.6 minutes. In 26 cases when the diameter of a pile was up to 8.0 mm, undamaged serratus line and the absence of large dilation of veins in its projection, transmucous welding was applied by two-three time voltage supply. Welding was successful in case of LL-5 mode used in 50 % of observations, DA-3 – in 87.5 % DA-5 – in 87.5 %. Fixation by means of suturing as a part of surgery was used in case of prolapsed segment longer than 15.0 mm or more than 25.0 mm. As in case of internal hemorrhoids welding, the most effective were modes LL-5, DA-3 and DA-5. Wound edges were approximated by application of interrupted sutures or they were left untouched. Morphologic investigation showed coagulative changes in the walls of welded arteries and veins with the formation of homogeneous junction at the place of electrodes application. Outside of this area dystrophic changes of the vascular wall were observed not far than 1 mm aside. Conclusions. 1. To cut the skin hypoderm and highly dense superficial fascia the mode HL-1 is preferable. In case of significant destruction of the superficial fascia, a grape-like varicose dilation of hemorrhoidal piles and their dense filling with blood surgery on a dry field and good identification of all anatomic structures may be achieved by using of LL mode. 2. By using LL-5 mode well-controlled and bloodless mobilization of the external and the internal hemorrhoids of all sizes and localization was possible to perform, except the transient zone, where considering minimal thermal damage, the use of LL-3 mode is reasonable. 3. DA-3 mode appeared to be effective for transmucous welding of a hemorrhoidal pile of II degree, up to 8.0 mm in diameter, a pile without visible supplying vessels in its projection over the serratus line, and in case of fixation of a prolapsed segment of the anal and rectal mucosa up to 20.0 mm in length. 4. DA-5 mode makes it possible to perform transmucous welding of hemorrhoids of II-III stages, submucous coagulation with simultaneous fixation of a prolapsed segment of the anal and rectal mucosa more than 20.0 mm long.