INTRODUCTION  介紹 — 

Most symptomatic hemorrhoids are first treated conservatively with dietary or lifestyle changes and medications. Office-based procedures (eg, rubber band ligation) are then offered to those with persistent symptoms, while surgery is reserved for those who do not respond to office treatments or cannot tolerate them.
大多數有癥狀的痔瘡首先通過飲食或生活方式的改變和藥物進行保守治療。然後，為癥狀持續的患者提供基於辦公室的手術（例如，橡皮筋結紮術），而手術則保留給那些對辦公室治療沒有反應或不能耐受的患者。

This topic will review common surgical techniques used to treat hemorrhoids. The anatomy and clinical features of hemorrhoids, and nonsurgical treatment options, are discussed separately. (See "Hemorrhoids: Clinical manifestations and diagnosis" and "Home and office treatment of symptomatic hemorrhoids".)
本專題將總結治療痔瘡的常用手術技術。痔瘡的解剖結構和臨床特徵，以及非手術治療選擇詳見其他專題。（參見 “痔瘡的臨床表現和診斷” 和 “癥狀性痔瘡的家庭和辦公室治療”）

PREOPERATIVE PREPARATION  術前準備

●Anticoagulants and antiplatelet agents – Medications that increase the risk of bleeding (eg, warfarin, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) should be preferably held in the perioperative period depending on the urgency for treatment and risk of cessation. Perioperative management of anticoagulation is discussed separately. (See "Perioperative medication management", section on 'Medications affecting hemostasis' and "Perioperative management of patients receiving anticoagulants".)
抗凝劑和抗血小板藥物 –根據治療的緊迫性和停葯風險，最好在圍手術期服用增加出血風險的藥物（如華法林 、 阿司匹林 、 氯吡格雷 、非甾體抗炎藥）。抗凝的圍手術期治療詳見其他專題。（參見 “圍手術期用藥管理”，關於'影響止血的藥物'一節和 “接受抗凝治療的患者的圍手術期管理”）

●Bowel preparation – The patient usually undergoes a cleansing enema before the procedure. A full mechanical bowel preparation is not indicated and may be counterproductive.
腸道準備 – 患者通常在手術前進行清潔灌腸。不指徵全機械腸道準備，可能會適得其反。

●Prophylactic antibiotics – Based on limited data, prophylactic antibiotics are not beneficial before routine, elective hemorrhoid procedures, as the risk of infection is low [1,2]. Patients with underlying immunosuppression or extensive cellulitis may benefit from perioperative antibiotics (table 1).
預防性抗生素– 根據有限的數據，預防性抗生素在常規擇期痔瘡手術前無益，因為感染風險較低[1,2]。有基礎免疫抑制或廣泛蜂窩織炎的患者可能受益於圍手術期抗生素 （ 表 1）。

PATIENT POSITIONING  患者定位 — 

Either a prone, lithotomy, or lateral position can be used to perform hemorrhoid procedures as determined by surgeon preference and hemorrhoid location.
俯臥位、截石位或側位均可用於進行痔瘡手術，具體取決於外科醫生的偏好和痔瘡位置。

●Prone – Many colorectal surgeons prefer the prone jackknife position due to the superior view and exposure to the perianal region it affords. However, patients requiring airway control must first be intubated on the transport stretcher before being positioned prone on the operating room table.
俯臥 – 許多結直腸外科醫生更喜歡俯臥折刀姿勢，因為它提供了優越的視野和對肛周區域的暴露。然而，需要氣道控制的患者必須先在運輸擔架上插管，然後才能俯卧在手術室手術臺上。

●Lithotomy or lateral – For patients unable to tolerate the prone position because of concerns with airway control, the lithotomy or left-lateral positions are acceptable alternatives. However, visualization and access to the base of the hemorrhoid may be more difficult.
截石術或側向 – 對於因擔心氣道控制而無法耐受俯臥位的患者，截石術或左側臥位是可接受的替代方案。然而，痔瘡底部的可視化和進入可能更加困難。

In all cases, it is important to prevent undue pressure on the pelvis and genitalia and to pad all bony prominences, paying special attention to the legs when the lithotomy position is used. (See "Nerve injury associated with pelvic surgery", section on 'Avoid prolonged lithotomy position'.)
在所有情況下，重要的是要防止對骨盆和生殖器施加過度壓力並墊住所有骨突起，在使用截石位置時要特別注意腿部。（參見 “盆腔手術相關神經損傷”，關於'避免長時間截石位'一節 ）

ANESTHESIA  麻醉 — 

Hemorrhoid surgery can be performed under general, regional (spinal, epidural), or local anesthesia with or without conscious sedation [3-10]. Local anesthesia with intravenous sedation yields the best post-hemorrhoidectomy pain relief [11,12]. Surgeon preference guides the choice, although patient body habitus, airway, or respiratory status also matter.
痔瘡手術可在全身麻醉、區域麻醉（脊髓麻醉、硬膜外麻醉）或局部麻醉下進行，伴或不伴清注鎮靜[3-10]。局部麻醉和靜脈鎮靜可緩解痔瘡切除術后疼痛效果最佳[11,12]。外科醫生的偏好指導選擇，儘管患者的身體習慣、氣道或呼吸狀態也很重要。

Perianal blocks — Local anesthetic is typically administered in the perianal region during hemorrhoidectomy, except for patients undergoing spinal anesthesia. This infiltration significantly alleviates pain, whether used alone or in conjunction with other anesthesia methods [13].
肛周阻滯  —  痔切除術期間，局麻通常應用於肛周區域，脊髓麻醉患者除外。這種浸潤可顯著減輕疼痛，無論是單獨使用還是與其他麻醉方法聯合使用[13]。

The types of perianal blocks include anal block, pudendal nerve block, ischiorectal block, posterior perineal block, and local wound infiltration [14]. Among these, anal block is the most common.
肛周阻滯的類型包括肛門阻滯、神經阻滯、坐骨直腸阻滯、會陰后阻滯和局部傷口浸潤[14]。其中，肛門阻滯是最常見的。

During an anal block, local anesthetic, often with epinephrine, is injected into the ischiorectal fat surrounding the external sphincter [15]. Sodium bicarbonate (1 cc per 30 cc lidocaine) may be added to minimize local irritation if the patient remains awake.
在肛門阻滯過程中，局部麻醉劑（通常與腎上腺素一起）注射到外括約肌周圍的坐骨直腸脂肪中[15]。如果患者保持清醒，可以添加碳酸氫鈉 （每 30 cc 利多卡因 1 cc）以盡量減少局部刺激。

Longer-acting local anesthetics (eg, ropivacaine, bupivacaine, or liposomal bupivacaine) provide greater decrease in post-hemorrhoidectomy pain compared with short-acting agents (eg, lidocaine) [16,17] (table 2). The addition of triamcinolone to local anesthetics can reduce postoperative pain and narcotic requirements [18].
與短效藥物（如利多卡因 ）相比，長效局部麻醉劑（如羅哌卡因 、 布比卡因或脂質體布比卡因 ）可進一步減輕痔切除術后疼痛[16,17] （ 表 2）。在局部麻醉劑中加入曲安奈德可減輕術后疼痛和麻醉需求[18]。

EXTERNAL HEMORRHOIDECTOMY
外痔切除術 — 

External hemorrhoids generally do not require surgical management. Exceptions may include:
外痔一般不需要手術治療。例外情況可能包括：

●Thrombosed external hemorrhoids.
血栓形成的外痔。

●Large external hemorrhoids or skin tags that cause symptoms (eg, pain) or interfere with hygiene.
引起症狀（例如疼痛）或干擾衛生的大外痔或皮贅。

●External hemorrhoids combined with internal hemorrhoids (ie, mixed hemorrhoids) that cause symptoms (eg, bleeding).
外痔合併內痔（即混合性痔）引起癥狀（如出血）。

Thrombosed external hemorrhoids — Patients with a thrombosed external hemorrhoid present with an acutely painful purplish or blue mass in the perianal area (picture 1 and picture 2).
血栓性外痔  —  血栓性外痔患者肛周出現急性疼痛的紫色或藍色腫塊 （ 圖片 1 和 圖片 2）。

Nonoperative management — When the patient presents over three days after symptom onset, usually with symptoms already improving, surgery is not required [19]. After 48 to 72 hours, the thrombus organizes and contracts, lessening symptoms.
非手術治療  —  當患者在癥狀出現后 3 日以上就診，通常癥狀已經好轉時，無需手術[19]。48 至 72 小時後，血栓組織並收縮，癥狀減輕。

Occasionally, a thrombosed hemorrhoid will evacuate spontaneously, leaving a small ulcer with residual clot at the anal opening (picture 3). This will typically resolve on its own over a few weeks, leaving only a skin tag.
偶爾，血栓性痔瘡會自發排出，在肛門口留下一個小潰瘍，並殘留凝塊 （ 圖片 3）。這通常會在幾周內自行消退，只留下皮贅。

Excision — For patients who present in severe pain (typically within three days after symptoms onset) or significant bleeding, surgical intervention can provide immediate relief [20,21].
切除  —  對於出現劇烈疼痛（通常在癥狀出現后 3 日內）或大量出血的患者，手術干預可立即緩解[20,21]。

When surgery is needed, we suggest excision of the thrombosed hemorrhoid, rather than incision and evacuation of the clot [22,23]. However, if excision is not feasible, incising the hemorrhoid to remove the clot can also alleviate pain. (See 'Enucleation' below.)
當需要手術時，我們建議切除血栓性痔瘡，而不是切開和清除血栓[22,23]。但是，如果切除不可行，切開痔瘡去除血栓也可以減輕疼痛。（參見下文 '摘除術'）

Excision of the thrombosed external hemorrhoids has been shown to prevent recurrent thrombosis. The recurrence rate for a completely excised thrombosed hemorrhoid is 5 to 19 percent [22,23]. By comparison, simple incision and evacuation of the clot is associated with a 30 percent risk of reaccumulation and thrombosis, which may spread to adjacent hemorrhoidal columns [24].
切除血栓形成的外痔已被證明可以預防血栓復發。完全切除的血栓性痔瘡的復發率為 5%-19%[22,23]。相比之下，簡單切開和清除血凝塊與 30%的再蓄積和血栓形成風險相關，血栓形成可能擴散至鄰近痔柱[24]。

Excision of external hemorrhoids can be performed in the operating room, emergency room, or an appropriately equipped office in the following steps:
外痔切除可以在手術室、急診室或設備齊全的辦公室進行，步驟如下：

●The skin covering the hemorrhoid is prepped with povidone-iodine solution, and local anesthetic is injected around the base and into the overlying area. The authors also supplement this with an anal block for better analgesia. (See 'Perianal blocks' above.)
用聚維酮碘溶液準備覆蓋痔瘡的皮膚，並將局部麻醉劑注射到基部周圍和上覆區域。作者還用肛門阻滯來補充這一點，以獲得更好的鎮痛效果。（參見上文 '肛周阻滯'）

●An elliptical incision is made in the skin overlying the thrombosed hemorrhoid with a scalpel, scissors, or electrocautery pen (figure 1).
用手術刀、剪刀或電灼筆在血栓性痔瘡覆蓋的皮膚上做一個橢圓形切口 （ 圖 1）。

●The incision is carried around the hemorrhoid and dissected with care from the superficial fibers of the anal sphincter, making certain to avoid injury. The thrombosis and the resultant edematous tissue create a readily identifiable plane for dissection.
切口在痔瘡周圍進行，並小心地從肛門括約肌的淺層纖維中解剖，以確保避免受傷。血栓形成和由此產生的水腫組織形成了一個易於識別的解剖平面。

●The skin edges can be left open and allowed to drain or reapproximated with absorbable sutures, depending upon surgeon preference [25]. Following application of a topic antibiotic ointment, the wound is covered by a dressing to protect clothing from soilage. (See 'Postoperative care and follow-up' below.)
皮膚邊緣可以保持開放狀態，讓其引流或用可吸收縫合線重新近似，具體取決於外科醫生的偏好[25]。塗抹局部抗生素軟膏后，用敷料覆蓋傷口以保護衣服免受污染。（參見下文 '術後護理和隨訪'）

Patients with extensive thrombosis (picture 4) have a higher risk of injury if the perianal skin and anoderm are aggressively resected. The key to surgery in such patients is to remove the hemorrhoid while sparing the anoderm and allowing time for the inflammation to subside. Such patients are better treated in the operating room rather than the bedside. Multiple elliptical incisions can be used to limit excision of anoderm and perianal skin.
廣泛血栓形成患者 （ 圖片 4） 如果積極切除肛周皮膚和肛門，受傷的風險更高。此類患者手術的關鍵是切除痔瘡，同時保留肛門並留出炎症消退的時間。此類患者在手術室而不是床邊得到更好的治療。多個橢圓形切口可用於限制肛胚層和肛周皮膚的切除。

Enucleation — For clinicians who do not feel comfortable excising a thrombosed external hemorrhoid, an alternative, though not preferred, is to simply incise the overlying skin to evacuate thrombus from the hemorrhoid, which can produce immediate relief of pain.
摘除術  —  對於不習慣切除血栓的外痔的臨床醫生，另一種方法是簡單地切開上覆皮膚以排出痔瘡中的血栓，這可以立即緩解疼痛。

When incision is used instead of excision for hemorrhoids, a residual clot may occur if the incision is too small, leading to potential reaccumulation of blood and thrombosis. Thus, patients should be seen by a surgeon within 24 to 48 hours.
當痔瘡使用切口代替切除時，如果切口太小，可能會出現殘留凝塊，導致潛在的血液重新積聚和血栓形成。因此，患者應在 24 至 48 小時內就診。

Symptomatic external or mixed hemorrhoids — Symptomatic external or mixed external-internal hemorrhoids that are not thrombosed can only be removed. For these patients, excisional hemorrhoidectomy is required. (See 'Choosing a surgical treatment' below.)
有癥狀的外痔或混合  痔 —  有癥狀的外痔或未血栓形成的外-內混合痔只能切除。對於這些患者，需要切除痔瘡切除術。（參見下文 '選擇手術治療'）

INTERNAL HEMORRHOIDECTOMY
內痔切除術 — 

Because they lack sensory nerve innervation, internal hemorrhoids can be treated with one of several office-based procedures that do not require anesthesia (see "Home and office treatment of symptomatic hemorrhoids", section on 'Techniques'). Surgical treatment is only required in one of the following situations:
由於內痔缺乏感覺神經支配，因此可以使用幾種不需要麻醉的診室手術之一進行治療（參見 “癥狀性痔瘡的家庭和診室治療”，關於'技術'一節 ）。只有在以下情況之一的情況下才需要手術治療：

●Prolapsed internal hemorrhoids that require manual reduction (grade III) or are incarcerated (grade IV) (picture 2).
需要手動複位（III.級）或嵌頓（IV.級）的脫垂內痔（ 圖片 2）。

●Symptomatic internal hemorrhoids (eg, pain, bleeding) refractory to or intolerant of office-based procedures (See "Home and office treatment of symptomatic hemorrhoids", section on 'Office-based procedures for symptomatic hemorrhoids'.)
有癥狀的內痔（如疼痛、出血）對診室手術難治或不能耐受（參見 “癥狀性痔瘡的家庭和診室治療”，關於'癥狀性痔瘡的診室治療'一節 ）

Choosing a surgical treatment — There are three types of surgical treatments for hemorrhoids:
選擇手術治療  —  痔瘡的手術治療有 3 種類型：

●Excisional hemorrhoidectomy excises the hemorrhoidal tissue with a scalpel, monopolar electrocautery (conventional hemorrhoidectomy), or other advanced electrosurgical devices (eg, LigaSure hemorrhoidectomy, Harmonic hemorrhoidectomy).
切除痔切除術用手術刀、單極電灼術（常規痔切除術）或其他先進的電外科設備（如 LigaSure 痔切除術、諧波痔切除術）切除痔瘡組織。

●Stapled hemorrhoidopexy excises hemorrhoidal and redundant anal mucosal tissues with a circular stapler. The 2024 guidelines from the American Society of Colorectal Surgery did not recommend stapled hemorrhoidopexy as a first-line surgical treatment for internal hemorrhoids due to its marginal efficacy and significant risk profile [24].
吻合器痔固定術用圓形吻合器切除痔瘡和多餘的肛門粘膜組織。美國結直腸外科學會 2024 年指南不推薦將吻合器痔固定術作為內痔的一線手術治療，因為其療效有限且風險顯著 [24]。

●Hemorrhoidal arterial ligation (HAL) does not excise any tissue but ligates arteries that feed the hemorrhoids with ultrasound-guided precision. A mucopexy can be added to treat prolapse.
痔動脈結紮術 （HAL） 不切除任何組織，而是以超聲引導的精確度結紮為痔瘡供血的動脈。可以添加粘液固定術來治療脫垂。

Excisional hemorrhoidectomy can be used to treat both internal and external hemorrhoids. Stapled hemorrhoidopexy and HAL do not address external hemorrhoids. Thus, patients with external or combined internal and external hemorrhoids can only be treated with excisional hemorrhoidectomy.
切除痔切除術可用於治療內痔和外痔。吻合器痔固定術和 HAL 不適用於外痔。因此，外痔或內外痔合併的患者只能通過切除痔切除術進行治療。

A 2015 systematic review and network meta-analysis of 98 randomized trials compared clinical outcomes and effectiveness of various hemorrhoidectomy techniques used to treat grade III and IV internal hemorrhoids [26]. Results indicate that (table 3):
2015 年一項系統評價和網路 meta 分析納入了 98 項隨機試驗，比較了用於治療 III.級和 IV.級內痔的各種痔切除術技術的臨床結局和有效性[26]。結果表明（ 表 3）：

●Excisional hemorrhoidectomy using conventional instruments leads to the most postoperative pain and complications, resulting in extended hospital stays and recovery times. However, it's also linked to the lowest recurrence rate.
使用傳統器械切除痔瘡會導致術后疼痛和併發症最多，導致住院時間和恢復時間延長。然而，它也與最低的復發率有關。

●Compared with excisional hemorrhoidectomy performed with conventional instruments, LigaSure or Harmonic hemorrhoidectomy reduces operation time, blood loss, postoperative complications, and pain. (See 'Conventional instruments versus advanced energy devices' below.)
與使用傳統器械進行的切除痔切除術相比，LigaSure 或 Harmonic 痔切除術可減少手術時間、失血量、術后併發症和疼痛。（參見下文 '傳統儀器與先進能源設備'）

●Stapled hemorrhoidopexy has shorter operating times and less postoperative pain than excisional hemorrhoidectomy, allowing for a quicker return to normal activities and shorter hospital stays. However, its recurrence rate is higher than conventional excisional hemorrhoidectomy or LigaSure procedures. Stapled hemorrhoidopexy also carries more postoperative complications than Harmonic hemorrhoidectomy and a higher postoperative bleeding rate than HAL. (See 'Stapled hemorrhoidopexy' below.)
與切除痔切除術相比，吻合器痔固定術的手術時間更短，術后疼痛更少，可以更快地恢復正常活動並縮短住院時間。然而，其復發率高於傳統的痔切除術或 LigaSure 手術。吻合器痔固定術也比諧波痔切除術帶來更多的術后併發症，術後出血率也比 HAL 高。（參見下文 '吻合器痔固定術'）

●In the short term, HAL offers the most favorable outcomes among all procedures, with reduced operative and recovery time, decreased postoperative pain, bleeding, and complications, as well as fewer emergency reoperations. However, HAL also has the highest recurrence rate among all procedures. (See 'HAL' below.)
在短期內，HAL 在所有手術中提供了最有利的結果，減少了手術和恢復時間，減少了術后疼痛、出血和併發症，並減少了緊急再次手術。然而，HAL 在所有手術中復發率也是最高的。（參見下文 'HAL'）

Other randomized trials or meta-analyses of randomized trials that compared stapled hemorrhoidopexy versus excisional hemorrhoidectomy [27-30], HAL versus excisional hemorrhoidectomy [31-34], or HAL versus stapled hemorrhoidopexy [35,36] reached similar conclusions. Minor discrepancies arise from variations in excisional hemorrhoidectomy techniques, with some meta-analyses combining studies using both conventional and advanced instruments. (See 'Conventional instruments versus advanced energy devices' below.)
其他比較吻合器痔固定術與切除痔瘡切除術[27-30]、HAL 與切除痔切除術[31-34]或 HAL 與吻合器痔固定術[35,36]的隨機試驗或隨機試驗的 meta 分析也得出了類似的結論。切除痔切除術技術的變化導致了細微的差異，一些薈萃分析結合了使用傳統和先進儀器的研究。（參見下文 '傳統儀器與先進能源設備'）

Surgeons may limit their offering of hemorrhoid procedures due to differences in expertise and available equipment [24]. When multiple options are available, the decision should be guided by the patient's values and preferences. While excisional hemorrhoidectomy typically provides more lasting outcomes, stapled hemorrhoidopexy or HAL may be preferred by patients seeking to minimize postoperative pain and downtime.
由於專業知識和可用設備的差異，外科醫生可能會限制其痔瘡手術的提供[24]。當有多種選擇時，應根據患者的價值觀和偏好做出決定。雖然切除痔切除術通常可提供更持久的結果，但尋求盡量減少術后疼痛和停機時間的患者可能更喜歡吻合器痔固定術或 HAL。

Excisional hemorrhoidectomy — The goals of an excisional hemorrhoidectomy are to remove the redundant tissue, avoid damage to the sphincter, and avoid taking too much anoderm, which might lead to anal stenosis.
切除痔切除術  —  切除痔切除術的目標是去除多餘組織，避免損傷括約肌，並避免過多的肛門，這可能導致肛門狹窄。

When performing hemorrhoidectomy, all three hemorrhoidal columns are usually treated simultaneously. For those less experienced in performing a three-column hemorrhoidectomy or in patients with concern that this would result in anal stenosis, one- or two-column hemorrhoidectomy may be performed [37].
在進行痔切除術時，通常同時治療所有三個痔柱。對於對三柱痔切除術經驗不足的患者，或擔心肛門狹窄的患者，可進行單柱或雙柱痔切除術[37]。

Steps of excisional hemorrhoidectomy — Over the years, these basic steps of excisional hemorrhoidectomy remained the same, but technical details such as whether to close the mucosal defect or whether to use cold instruments or an energy source have evolved and diverged. (See 'Open versus closed hemorrhoidectomy' below and 'Conventional instruments versus advanced energy devices' below.)
痔切除  術的步驟 —  多年來，痔切除術的這些基本步驟保持不變，但技術細節（如是否閉合黏膜缺損或是否使用冷器械或能量源）已經發展和分化。（參見下文 '開放式痔切除術 vs 閉合式痔切除術' 和 '傳統器械 vs 先進能量設備'）

●The junction of the internal and external component of the hemorrhoid is grasped with a small clamp (eg, Allis, Babcock) to retract the hemorrhoid away from the sphincter muscles.
用小夾子（例如，Allis、Babcock）抓住痔瘡內部和外部元件的交界處，以將痔瘡縮回遠離括約肌。

●Using a scalpel or electrocautery pen, the rectal mucosa is scored in an elliptical or diamond shape around the hemorrhoidal bundle to delineate the plane for excision of the hemorrhoid.
使用手術刀或電灼筆，在痔束周圍將直腸黏膜劃成橢圓形或菱形，以勾勒出切除痔瘡的平面。

●The incision is carried deeper starting distally on the external hemorrhoidal tissue and extending proximally across the dentate line to the superior most extent of the hemorrhoidal column.
切口從外痔組織的遠端開始，向近端穿過齒狀線延伸至痔瘡的上端最深處。

●The hemorrhoid tissue is carefully dissected from the superficial internal and external sphincter muscles toward the main vascular pedicle in the anal canal. The base of the pedicle is suture ligated, and the hemorrhoidal tissue is removed.
將痔瘡組織從括約肌的淺表內外向肛管的主要血管蒂仔細解剖。椎弓根根部縫合結紮，切除痔瘡組織。

●The mucosal defect is then left open to heal by secondary intention or closed with a continuous 2-0 or 3-0 absorbable suture (eg, Vicryl). (See 'Open versus closed hemorrhoidectomy' below.)
然後將粘膜缺損保持開放以通過二次意圖癒合或用連續的 2-0 或 3-0 可吸收縫合線（例如，Vicryl）閉合。（參見下文 '開放性痔切除術 vs 閉合性痔切除術'）

●Care must be taken not to narrow the anal canal when multiple hemorrhoidal excisions are performed. Only the redundant anoderm associated with the hemorrhoidal tissue should be removed, preserving a minimum of 1 cm of anoderm between columns. A Hill-Ferguson retractor should be left in place until all suturing is complete.
進行多次痔瘡切除時，必須注意不要使肛管變窄。僅應去除與痔瘡組織相關的多餘陽極層，在柱之間保留至少 1 釐米的陽極層。Hill-Ferguson 牽開器應留在原位，直到所有縫合完成。

●Evidence suggests that lateral sphincterotomy or injection of botulinum toxin into internal anal sphincter (IAS) [38-41] can prevent IAS spasm and thus reduce postoperative pain after hemorrhoidectomy [42]. However, lateral sphincterotomy should not be routinely used due to the risk of incontinence. Only patients who have internal hemorrhoids that are associated with a high resting IAS pressure or concomitant fissure disease may benefit from supplemental sphincterotomy. (See "Anal fissure: Surgical management".)
有證據表明，外側括約肌切開術或向肛門內括約肌（intra anal sphincter， IAS）注射肉毒桿菌毒素[38-41]可預防 IAS 痙攣，從而減輕痔切除術后的術后疼痛[42]。然而，由於存在尿失禁的風險，不應常規使用側括約肌切開術。只有患有與高靜息 IAS 壓力或伴隨裂隙疾病相關的內痔的患者才能從補充括約肌切開術中受益。（參見 “肛裂的手術治療”）

Open versus closed hemorrhoidectomy — The two main types of excisional hemorrhoidectomy are the closed (Ferguson) hemorrhoidectomy and the open (Milligan-Morgan) hemorrhoidectomy (excision and ligation without mucosal closure).
開放性痔切除術  vs 閉合性痔切除術 —  切除性痔切除術的兩種主要類型是閉合痔切除術（Ferguson 痔切除術）和開放痔切除術（Milligan-Morgan 痔切除術）（切除和結紮不粘膜閉合）。

●Closed hemorrhoidectomy, or a modification of the technique, is the more commonly performed procedure for internal hemorrhoidectomy. This technique is successful in 95 percent of cases and has a low rate of wound infection [37]. The authors prefer a closed approach.
閉合痔切除術或技術的修改是內痔切除術中更常用的手術。該技術在 95%的病例中成功，傷口感染率較低[37]。作者更喜歡封閉的方法。

●Open hemorrhoidectomy is preferred for acute gangrenous hemorrhoids where tissue edema and necrosis prevent closure of the mucosa without undue tension [43]. In most other clinical settings, the handling of the mucosal wound is left to the discretion of the surgeon.
對於急性壞疽性痔瘡，開放性痔切除術是首選，因為組織水腫和壞死會阻止黏膜閉合而不會過度緊張[43]。在大多數其他臨床環境中，粘膜傷口的處理由外科醫生自行決定。

There is no definitive advantage between open and closed hemorrhoidectomy. Closed hemorrhoidectomy, according to a meta-analysis of 11 trials involving 1326 patients, led to less postoperative pain, faster wound healing, and reduced bleeding [44]. However, more patient-important outcomes such as complications and recurrences were similar. Thus, the choice between open or closed hemorrhoidectomy is at the discretion of the surgeon [45].
開放式痔切除術和閉合痔切除術之間沒有明確的優勢。一項 meta 分析納入了 11 項試驗，涉及 1326 例患者，閉合痔切除術可減輕術后疼痛，加快傷口癒合，減少出血[44]。然而，併發症和復發等對患者更重要的結局是相似的。因此，開放式痔切除術或閉合痔切除術的選擇由外科醫生自行決定[45]。

Conventional instruments versus advanced energy devices — A variety of devices, including surgical scalpels, scissors, or electrosurgical devices (eg, monopolar electrocautery, advanced bipolar sealing [LigaSure], ultrasonic desiccation [Harmonic scalpel], laser), can be used to make the incision and excise the hemorrhoidal tissue. (See "Overview of electrosurgery".)
傳統器械與先進能量器械  的比較 —  多種器械，包括手術刀、剪刀或電外科器械（如單極電灼術、高級雙極密封術、超聲乾燥術、鐳射），可用於切口和切除痔瘡組織。（參見 “電外科概述”）

Meta-analyses of mostly randomized trials reported that compared with cold surgical instruments and monopolar electrocautery, advanced energy devices resulted in shorter operating times and less postoperative pain [46-48]. There is no significant difference between various advanced energy devices [49]. However, these devices can be costly and there is no variance in longer-term patient-important outcomes. Thus, resource permitting, excisional hemorrhoidectomy can be performed with any instruments that the surgeon prefers. (See 'Choosing a surgical treatment' above.)
大多數隨機試驗的 meta 分析報告稱，與冷手術器械和單極電灼相比，先進的能量裝置可縮短手術時間，減輕術后疼痛[46-48]。各種先進能源器件之間沒有顯著差異[49]。然而，這些設備可能成本高昂，並且對患者重要的長期結果沒有差異。因此，在資源允許的情況下，可以使用外科醫生喜歡的任何器械進行切除痔切除術。（參見上文 '選擇手術治療'）

Stapled hemorrhoidopexy — Stapled hemorrhoidopexy is an alternative to excisional hemorrhoidectomy for internal hemorrhoids only. The technique uses a circular stapling device to excise a circumferential column of mucosa and submucosa from the upper anal canal, which reduces the hemorrhoidal tissue back into the anal canal and fixates them into position [50]. The device also interrupts part of the hemorrhoidal blood supply, thereby decreasing vascularity [51-53]. The need for a specialized device makes this procedure more expensive [54-57].
吻合器痔固定  術 —  吻合器痔固定術是切除痔切除術的替代方法，僅用於內痔。該技術使用圓形吻合裝置從上肛管切除一根周形粘膜和粘膜下層，將痔瘡組織縮小回肛管並固定到位[50]。該裝置還會中斷部分痔瘡血液供應，從而降低血管分佈[51-53]。由於需要專用設備，該手術費用更高[54-57]。

Steps of stapled hemorrhoidopexy
吻合器痔固定術的步驟

●An anal dilator and obturator provided with the surgical stapler is first inserted into the anus to dilate the anal canal (figure 2).
首先將手術吻合器隨附的肛門擴張器和閉孔器插入肛門以擴張肛管 （ 圖 2）。

●The most critical component of the procedure is the placement of the pursestring suture in the mucosa/submucosa approximately 4 cm from the dentate line. It is important that the pursestring suture be placed far enough proximal to avoid involving the sphincter muscles within the stapling device and to minimize other complications (eg, changes in continence, stricture, fistula).
該手術最關鍵的組成部分是將荷帶縫合線放置在距齒狀線約 4 釐米的粘膜/粘膜下層中。重要的是，荷包縫合線的近端位置應足夠遠，以避免累及吻合器內的括約肌，並盡量減少其他併發症（如，失禁、狹窄、瘺管的變化）。

●The circular stapling device is introduced into the anus, and the pursestring suture is tied to gather the mucosa/submucosa contents into the stapler.
將圓形吻合裝置引入肛門，並綁上荷包縫合線，將粘膜/粘膜下內容物收集到吻合器中。

●Before the stapler is engaged or fired, the posterior wall of the vagina should be assessed to ensure the stapler has not inadvertently engaged it. This can be noted by moving the stapler and seeing that the posterior vaginal wall does not tent or move with it.
在接合或發射吻合器之前，應評估陰道後壁，以確保訂書機沒有無意中接合它。這可以通過移動訂書機並看到陰道後壁沒有帳篷或隨之移動來注意到。

●When the stapler is fired, it creates a circular fixation of all tissues within the nonabsorbable circumferential pursestring suture to the rectal wall. In effect, it will draw up and suspend the prolapsed internal hemorrhoid tissue.
當訂書機被發射時，它會將不可吸收的環向荷包縫合線內的所有組織與直腸壁形成圓形固定。實際上，它會拉起並懸浮脫垂的內痔組織。

●The staple line should be fully evaluated and any bleeders should be suture ligated. The staple line is a source for early postoperative bleeding.
應全面評估釘線，並縫合任何出血器。釘線是術后早期出血的來源。

●Postprocedural tenesmus and reoperations are more prevalent among patients who undergo stapled hemorrhoidopexy [29]. One study suggested that defecatory symptoms may respond rapidly and completely to oral nifedipine [58].
術后裡急後重和再手術在吻合器痔固定術患者中更為普遍[29]。一項研究表明，排便癥狀可能對口服硝苯地平產生快速而完全的反應[58]。

Additionally, several unique and potentially serious complications have been associated with stapled hemorrhoidopexy [59]. These include rectal perforation, rectovaginal fistula, staple line bleeding, or stricture. Such complications are not commonly seen with excisional hemorrhoidectomy.
此外，還存在一些獨特且可能嚴重的併發症與吻合器痔固定術有關[59]。這些包括直腸穿孔、直腸陰道瘺、釘線出血或狹窄。這種併發症在切除痔切除術中並不常見。

HAL — Another alternative to excisional hemorrhoidectomy is Doppler-guided transanal HAL, also known as total hemorrhoidal dearterialization [60-64]. HAL uses a specially designed proctoscope housing a Doppler transducer to identify and ligate each hemorrhoidal arterial blood supply. A mucopexy procedure is added for patients with symptomatic prolapse.
HAL（ 痔切除術） —  痔切除術的另一種替代方法是多普勒引導下經肛門 HAL，也稱為全痔脫動脈術[60-64]。HAL 使用專門設計的直腸鏡，其中包含多普勒換能器來識別和結紮每個痔動脈血供應。為有癥狀的脫垂患者增加了粘液固定術。

Like stapled hemorrhoidopexy, HAL can only treat internal hemorrhoids. HAL does not excise any tissue; thus, it may have a role where excision is contraindicated (eg, patients on anticoagulation) [65].
與吻合器痔固定術一樣，HAL 只能治療內痔。HAL 不切除任何組織;因此，在禁忌切除的情況下，它可能起作用（如，接受抗凝治療的患者）[65]。

Steps of HAL  HAL 的步驟

●The specialized proctoscope is inserted and rotated so that the built-in Doppler probe can be used to identify the six trunks of hemorrhoidal arteries first proximally in the rectum, then followed distally to the apex of the internal hemorrhoids [66]. The spots are marked.
插入並旋轉專用直腸鏡，以便內置的多普勒探頭首先在直腸近端識別痔動脈的 6 個干，然後遠端追蹤到內痔頂點[66]。斑點被標記。

●If only dearterialization is required (ie, the patient has bleeding but no tissue prolapse), each artery is individually ligated with a Z-stitch.
如果只需要脫動脈（即患者有出血但沒有組織脫垂），則用 Z 型縫線單獨結紮每條動脈。

●For patients with prolapse, a running stitch is started higher up and ensured to incorporate a Z-stitch above and below the marked spot with the strongest Doppler signal, thus accomplishing both dearterialization and mucopexy.
對於脫垂患者，從更高的位置開始連續縫合，並確保在具有最強多普勒信號的標記點上方和下方合併 Z 形縫線，從而完成脫動脈和粘液固定術。

●The mucopexy suture ends just proximal to the apex of the internal hemorrhoid. Adequate distance should be reserved laterally between mucopexy sutures to avoid impeding venous return.
粘液固定縫合線在內痔頂端的近端結束。粘液固定縫合線之間應在橫向保留足夠的距離，以避免阻礙靜脈迴流。

HAL versus rubber band ligation — In a randomized trial of 337 patients with symptomatic grade II or III internal hemorrhoids, HAL is more effective but more painful and costly compared with a single rubber band ligation [67]. For patients with symptomatic grade II or III internal hemorrhoids, a course of rubber band ligation remains the first-line procedure of choice due to its low morbidity and cost. Patients who fail, refuse, or cannot tolerate rubber band ligation should be referred for one of the surgical hemorrhoidectomy procedures. (See 'Choosing a surgical treatment' above.)
HAL 與橡皮筋結紮  術的比較 —  一項隨機試驗納入了 337 例有癥狀的 II.級或 III.級內痔患者，發現與單次橡皮筋結紮術相比，HAL 更有效，但疼痛更大，費用更高[67]。對於有癥狀的 II 級或 III 級內痔患者，由於其發病率和費用低，橡皮筋結紮術仍然是首選的一線手術。失敗、拒絕或不能耐受橡皮筋結紮的患者應轉診進行其中一項外科痔切除術。（參見上文 '選擇手術治療'）

Rubber band ligation of internal hemorrhoids is discussed in detail in another topic. (See "Home and office treatment of symptomatic hemorrhoids", section on 'Rubber band ligation'.)
內痔的橡皮筋結紮術詳見另一個專題。（參見 “癥狀性痔瘡的家庭和診室治療”，關於'橡皮筋結紮'一節 ）

POSTOPERATIVE CARE AND FOLLOW-UP
術后護理和隨訪 — 

In the initial days after hemorrhoid surgery, patients often experience considerable pain and swelling. Supportive care typically involves warm sitz baths, stool softeners, and pain medications such as acetaminophen, anti-inflammatory drugs, or oral narcotics. The wound often opens after three to five days, with possible mucus drainage from the area. However, symptoms like high fever (>101°F), significant erythema or necrosis, or persistent pain should prompt further evaluation as they could indicate complications. (See 'Complications' below.)
在痔瘡手術後的最初幾天，患者通常會感到相當大的疼痛和腫脹。支援性護理通常包括溫水坐浴、大便軟化劑和止痛藥，如對乙醯氨基酚 、抗炎藥或口服麻醉劑。傷口通常在三到五天后打開，粘液可能會從該區域排出。然而，高燒 （>101°F）、明顯紅斑或壞死或持續疼痛等癥狀應促使進一步評估，因為它們可能表明存在併發症。（參見下文 '併發症'）

Pain management — Pain following hemorrhoid surgery is nearly universal and may in part be due to spasms of the internal sphincter. Perianal anesthetic infiltration with long-acting agents at the time of surgery is important for reducing postoperative pain. (See 'Perianal blocks' above.)
疼痛管理  —  痔瘡手術後的疼痛幾乎普遍存在，部分原因可能是內括約肌痙攣所致。手術時使用長效藥物進行肛周麻醉劑浸潤對於減輕術后疼痛很重要。（參見上文 '肛周阻滯'）

Initial pharmacologic treatment to control postoperative pain consists of topical analgesics (eg, topical lidocaine) and oral analgesics, such as nonsteroidal anti-inflammatory drugs and/or acetaminophen [13]. Opioids may be given if pain is not well controlled but carry the potential adverse effects of inducing constipation and possibly worsening the pain. (See "Approach to the management of acute pain in adults".)
控制術后疼痛的初始藥物治療包括局部鎮痛藥（如外用利多卡因 ）和口服鎮痛藥，如非甾體抗炎藥和/或對乙醯氨基酚 [13]。如果疼痛沒有得到很好的控制，但可能會引起便秘並可能加重疼痛的潛在不良反應，則可以給予阿片類藥物。（參見 “成人急性疼痛的處理方法”）

Other options to manage pain have been evaluated in randomized trials and meta-analyses:
其他控制疼痛的選擇已在隨機試驗和薈萃分析中進行了評估：

●Topical calcium channel blocker (eg, diltiazem) [68] or nitroglycerin [69] has been shown to reduce post-hemorrhoidectomy pain. The mechanism of benefit is presumably related to relaxation of the internal anal sphincter (IAS).
局部鈣通道阻滯劑（如地爾硫卓 ）[68]或硝酸甘油 [69]已被證明可減輕痔切除術后疼痛。獲益機制可能與肛門內括約肌 （IAS） 的鬆弛有關。

●Topical metronidazole (10%) has also been shown to decrease postoperative pain following hemorrhoidectomy as well as decrease post-defecation discomfort [70]. Oral metronidazole has also been shown to be beneficial for pain control [71], although the data are still mixed [72].
外用甲硝唑 （10%）也被證明可以減輕痔切除術后的術后疼痛，並減輕排便后不適[70]。口服甲硝唑也被證明有益於控制疼痛[71]，儘管數據仍然好壞參半[72]。

●Several other topical agents, including EMLA, aloe vera, and sucralfate, have been evaluated, but the results are inconclusive [73].
其他幾種外用藥物，包括 EMLA、蘆薈和硫糖鋁 ，也進行了評估，但結果尚無定論[73]。

Warm sitz bath — A sensation of "tightness" after the procedure can usually be alleviated with a warm sitz bath that can be performed as often as needed by the patient. Physiologic studies showed that anal resting pressure diminished significantly after a warm sitz bath (40°C) for 5 to 10 minutes [74]. The effects of warm water on the relaxation of the IAS could last up to 70 minutes after exiting the bath [75]. Of note, simple warm water is all that is required, and the addition of other bath or Epsom salts is not necessary.
溫水坐浴  —  手術后的“緊繃感”通常可以通過溫水坐浴來緩解，溫水坐浴可以根據患者的需要經常進行。生理研究表明，溫水坐浴（40°C）5-10 分鐘后，肛門靜息壓力顯著降低[74]。溫水對 IAS 鬆弛的影響在退出浴後可持續長達 70 分鐘[75]。值得注意的是，只需要簡單的溫水，不需要添加其他沐浴或瀉鹽。

Avoiding constipation — A bulk fiber supplement and/or increased dietary fiber and fluid intake will help reduce postoperative constipation and pain upon defecation. Fecal impaction after a hemorrhoidectomy is associated with postoperative pain and opiate use. Most surgeons recommend stimulant laxatives, stool softeners, and bulk fiber to prevent this problem. Should impaction develop, manual disimpaction under anesthesia may be required.
避免便秘  —  補充大量纖維和/或增加膳食纖維和液體攝入量將有助於減輕術后便秘和排便時疼痛。痔切除術后的糞便嵌塞與術后疼痛和阿片類藥物使用有關。大多數外科醫生建議使用刺激性瀉藥、大便軟化劑和散裝纖維來預防這個問題。如果發生嵌塞，可能需要在麻醉下手動脫嵌。

COMPLICATIONS  併發症 — 

The incidence of complications following hemorrhoidectomy is low overall. The nature of complications depends upon the type and extent of procedure.
痔切除術后併發症的發生率總體較低。併發症的性質取決於手術的類型和範圍。

●Following excision of a thrombosed external hemorrhoid, minor bleeding (<1 percent) and local swelling are common, and perianal abscess/fistula can also occur (approximately 2 percent). The most common complication is recurrent hemorrhoids that require another procedure (approximately 6 percent). Internal sphincter injury occurs infrequently (<1 percent) but has undesirable consequences [23].
切除血栓性外痔後，常見輕微出血（<1%）和局部腫脹，也可能發生肛周膿腫/瘺管（約 2%）。最常見的併發症是需要再次手術的復發性痔瘡（約 6%）。括約肌內損傷發生率較低（<1%），但會產生不良後果[23]。

●Following excision of internal hemorrhoids, the most common complications are bleeding and urinary retention [50]. Rare complications are rectal perforation and sepsis, rectovaginal fistula, minor changes in continence, and retroperitoneal and pelvic abscess [76].
切除內痔后，最常見的併發症是出血和尿潴留[50]。罕見的併發症是直腸穿孔和膿毒症、直腸陰道瘺、失禁輕微改變以及腹膜后膿腫和盆腔膿腫[76]。

Major complications following hemorrhoid surgery include urinary retention, urinary tract infection, fecal impaction, and delayed hemorrhage. Proper technique and adequate postoperative care can help prevent some of these complications. Other complications include sphincter damage (which is rare) and wound dehiscence (which is common but usually of no clinical consequence).
痔瘡手術後的主要併發症包括尿瀦留、尿路感染、糞便嵌塞和遲發性出血。正確的技術和充分的術后護理可以説明預防其中一些併發症。其他併發症包括括約肌損傷（很少見）和傷口裂開（常見但通常沒有臨床後果）。

Urinary retention — Urinary retention following hemorrhoidectomy is observed in as many as 30 percent of patients [77]. Spinal anesthesia tends to be associated with higher rates of urinary retention [3]. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study) [78]. Warm sitz baths and pain medication also may lessen the incidence of urinary retention and reduce the need for catheterization. Some patients will require urinary catheterization, although some remain relatively asymptomatic. (See "Acute urinary retention", section on 'Bladder decompression'.)
尿瀦留  —  多達 30%的患者在痔切除術后出現尿潴留[77]。脊髓麻醉往往與較高的尿瀦留率相關[3]。限制術后輸液可能會減少導尿插入術的需要（一項研究從 15%減少到不到 4%）[78]。溫水坐浴和止痛藥也可以降低尿瀦留的發生率並減少導尿的需要。一些患者需要導尿，儘管有些患者仍然相對無癥狀。（參見 “急性尿潴留”，關於'膀胱減壓'一節 ）

Urinary tract infection — Urinary tract infection develops in approximately 5 percent of patients after anorectal surgery [79], possibly secondary to occult urinary retention. (See "Catheter-associated urinary tract infection in adults".)
尿路感染  —  約 5%的患者在肛門直腸手術后發生尿路感染[79]，可能繼發於隱匿性尿瀦留。（參見 “成人導管相關尿路感染”）

Bleeding — Delayed hemorrhage, probably due to sloughing of the primary clot, develops in 1 to 2 percent of patients; it usually occurs 7 to 16 days postoperatively [79]. No specific treatment is effective for preventing this complication, which usually requires a return to the operating room for suture ligation.
出血  — 1%-2%的患者發生遲發性出血，可能是由於原發性血塊脫落所致;通常發生在術后 7-16 日[79]。沒有特定的治療方法可以有效預防這種併發症，這通常需要返回手術室進行縫合結紮。

Disturbance of bowel continence — In most cases, minor alterations in continence may be noted in the first few weeks following hemorrhoidectomy due to pain, anal spasm, and changes in sensation (ie, discriminating between liquid, solid stool, and gas). These patients typically get better with time, though bulking agents may help.
腸失禁  障礙 —  大多數病例在痔切除術后的最初幾周內，由於疼痛、肛門痙攣和感覺改變（即區分液體、固體糞便和氣體），可能會注意到輕微的尿失禁改變。這些患者通常會隨著時間的推移而好轉，但填充劑可能會有所説明。

Fecal incontinence can occur in approximately 2 to 10 percent of patients [80,81]. Management of fecal incontinence, including medical therapy and injectable materials, is reviewed separately. (See "Fecal incontinence in adults: Management".)
大便失禁可發生於約 2%-10%的患者[80,81]。大便失禁的治療，包括藥物治療和注射材料，詳見其他專題。（參見 “成人大便失禁的治療”）

Anal stricture — Anal stricture formation occurs in approximately 1 percent of patients and for internal hemorrhoidectomy is related to multiple-column hemorrhoidectomies where too much anoderm has been resected.
肛門狹窄  —  約 1%的患者發生肛門狹窄，內痔切除術與切除過多肛門的多柱痔切除術有關。

Infectious complications (rare) — Surgical site infection is uncommon after hemorrhoid surgery; however, submucosal abscess (<1 percent) and deep space infection can occur, although severe fasciitis or necrotizing infections are rare [76,79].
感染性併發症（罕見） —  痔瘡手術後手術部位感染不常見;然而，黏膜下膿腫（<1%）和深腔感染可發生，但重度筋膜炎或壞死性感染很少見[76,79]。

SOCIETY GUIDELINE LINKS  學會指南連結 — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hemorrhoids".)
來自世界各地選定國家和地區的社會和政府贊助指南的連結另行提供。（參見 “學會指南链接：痔瘡”）

INFORMATION FOR PATIENTS
患者教育 — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
UpToDate 提供兩種類型的患者教育材料，即“基礎”和“超越基礎”。基礎患者教育文章以通俗易懂的語言編寫，適合 5 ^{至 6 年級的}閱讀水準，它們回答了患者可能對特定疾病提出的四五個關鍵問題。這些文章最適合想要一般概述和喜歡簡短、易於閱讀材料的患者。Beyond the Basics 患者教育文章更長、更複雜、更詳細。這些文章是在 10 ^至 12 ^年級閱讀水準上寫的，最適合想要深入資訊並熟悉一些醫學術語的患者。

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
以下是與此主題相關的患者教育文章。我們鼓勵您將這些主題列印或通過電子郵件發送給您的患者。（您還可以透過搜索“患者資訊”和感興趣的關鍵字來找到有關各種主題的患者教育文章。

●Basics topics (see "Patient education: Hemorrhoids (The Basics)")
基礎篇（參見 “患者教育：痔瘡（基礎篇）”）

●Beyond the Basics topics (see "Patient education: Hemorrhoids (Beyond the Basics)")
基礎之外專題（參見 “患者教育：痔瘡（基礎之外）”）

SUMMARY AND RECOMMENDATIONS
總結與推薦

●Treatment of hemorrhoids – Most symptomatic hemorrhoids are first treated conservatively with dietary or lifestyle changes and medications. Office-based procedures (eg, rubber band ligation) are then offered to those with persistent symptoms, while surgery is reserved for those who do not respond to office treatments or cannot tolerate them. (See 'Introduction' above and "Home and office treatment of symptomatic hemorrhoids".)
痔瘡的治療 – 大多數有癥狀的痔瘡首先通過飲食或生活方式的改變和藥物進行保守治療。然後，為癥狀持續的患者提供基於辦公室的手術（例如，橡皮筋結紮術），而手術則保留給那些對辦公室治療沒有反應或不能耐受的患者。（參見上文 '引言' 和 “癥狀性痔瘡的家庭和辦公室治療”）

●External hemorrhoids – When patients present with a thrombosed external hemorrhoid over three days after symptom onset, usually with symptoms already improving, surgery is not required. After 48 to 72 hours, the thrombus organizes and contracts, lessening symptoms.
外痔 – 當患者在癥狀出現后三天內出現血栓性外痔時，通常癥狀已經好轉，則不需要手術。48 至 72 小時後，血栓組織並收縮，癥狀減輕。

For patients who present in severe pain (typically within three days after symptom onset) or significant bleeding, surgical intervention can provide immediate relief. For these patients, we suggest hemorrhoid excision rather than incision and evacuation of the clot (Grade 2C). Simple incision and evacuation of the clot is associated with a higher recurrence rate. (See 'External hemorrhoidectomy' above and 'Thrombosed external hemorrhoids' above.)
對於出現劇烈疼痛（通常在癥狀出現后三天內）或大量出血的患者，手術干預可以立即緩解。對於這些患者，我們建議進行痔瘡切除，而不是切開和清除凝塊（2C 級 ）。簡單的切開和清除凝塊與較高的復發率有關。（參見上文 '外痔切除術' 和 '血栓性外痔'）

Nonthrombosed, symptomatic (eg, pain, bleeding) external hemorrhoids or mixed external-internal hemorrhoids can only be treated with excisional hemorrhoidectomy. (See 'Symptomatic external or mixed hemorrhoids' above.)
無血栓、有癥狀（如疼痛、出血）的外痔或混合性外內痔只能通過切除痔切除術治療。（參見上文 '有癥狀的外痔或混合性痔瘡'）

●Internal hemorrhoids – There are three mainstream surgical treatments of internal hemorrhoids:
內痔 – 內痔的主流手術治療方法有三種：

•Excisional hemorrhoidectomy excises the hemorrhoidal tissue with a scalpel, monopolar electrocautery, or other advanced electrosurgical devices (eg, LigaSure, Harmonic scalpel). The wound can be closed (Ferguson) or left open (Milligan-Morgan). (See 'Excisional hemorrhoidectomy' above.)
切除痔切除術使用手術刀、單極電灼或其他先進的電外科設備（例如 LigaSure、Harmonic 手術刀）切除痔瘡組織。傷口可以閉合（弗格森）或保持開放（米利根-摩根）。（參見上文'痔切除術 '）

•Stapled hemorrhoidopexy excises hemorrhoidal and redundant anal mucosal tissues with a circular staple. (See 'Stapled hemorrhoidopexy' above.)
吻合器痔瘡固定術用圓形訂書釘切除痔瘡和多餘的肛門粘膜組織。（參見上文 '吻合器痔固定術'）

•Hemorrhoidal arterial ligation (HAL) does not excise any tissue but ligates arteries that feed the hemorrhoids with Doppler-guided precision. (See 'HAL' above.)
痔動脈結紮術 （HAL） 不切除任何組織，而是以多普勒引導的精度結紮為痔瘡供血的動脈。（參見上文 'HAL'）

The choice should be made based on available resources, surgeon preference, and the patient's values and preferences. While excisional hemorrhoidectomy typically provides more lasting outcomes, stapled hemorrhoidopexy or HAL may be preferred by patients seeking to minimize postoperative pain and downtime. (See 'Choosing a surgical treatment' above.)
應根據可用資源、外科醫生偏好以及患者的價值觀和偏好做出選擇。雖然切除痔切除術通常可提供更持久的結果，但尋求盡量減少術后疼痛和停機時間的患者可能更喜歡吻合器痔固定術或 HAL。（參見上文 '選擇手術治療'）

●Postoperative care – Following hemorrhoid surgery, the anal area is covered by a dressing to protect clothing. The wounds will generally heal within a couple of weeks. Pain is expected and can be controlled primarily using acetaminophen/nonsteroidal anti-inflammatory agents and warm sitz baths. Narcotic medications can be used if needed, but these may cause constipation. Patients are instructed to avoid constipation. (See 'Postoperative care and follow-up' above.)
術後護理 – 痔瘡手術後，肛門區域用敷料覆蓋以保護衣服。傷口通常會在幾周內癒合。疼痛是預期的，可以主要使用對乙醯氨基酚 /非甾體抗炎劑和溫水坐浴來控制。如果需要，可以使用麻醉藥物，但這些藥物可能會導致便秘。指導患者避免便秘。（參見上文 '術後護理和隨訪'）

●Complications – The incidence of complications following hemorrhoidectomy is low overall. The main complications following a conventional hemorrhoidectomy technique include urinary retention, urinary tract infection, fecal impaction, and delayed hemorrhage. (See 'Complications' above.)
併發症 – 痔切除術后併發症的發生率總體較低。傳統痔切除術后的主要併發症包括尿潴留、尿路感染、糞便嵌塞和遲發性出血。（參見上文 '併發症'）