Experience in clinical application of supramucosal hemorrhoidal circumcision (PPH): In 1975, Thomson put forward the anal cushion theory, denied the theory of internal hemorrhoidal vascular varicose and inflammation, and put forward the theory of anal cushion subsidence of internal hemorrhoids, i.e., it occurs due to the damage or rupture of the suspensory ligaments of the anal cushion, Treitz’s muscle and the ligament of Park, which leads to the prolapse and subsidence of anal caused by the fixed anal cushion. On the basis of this theory, Longo first reported the use of anastomosis for PPH in 1998. Because the procedure abandons the traditional surgical method, it can greatly reduce the postoperative pain, minimize the complications, and low recurrence rate; it can effectively treat severe prolapsed internal hemorrhoids, rectal mucosal intussusception, outlet obstruction constipation and rectal proptosis. PPH has been carried out in the domestic clinic for 13 years now, and its complications should not be ignored. In our hospital, 65 cases of PPH were carried out from January 2013 to December 2013, including 31 cases of circumferential mixed hemorrhoids, 23 cases of stage III internal hemorrhoids, 8 cases of rectal intramucosal prolapse, and 3 cases of rectal proptosis. In the application of PPH, we believe that the efficacy of the procedure is accurate, but also found that there are certain complications and need to pay attention to the steps, especially on the PPH technology for discussion and evaluation. The report is as follows: I. Surgical method 1.1 Preoperative preparation 20ml of cannabis oil was taken orally in the afternoon of the day before the surgery for the mechanical preparation of the intestinal tract. Colon hydrotherapy was performed once 12h before surgery to thoroughly clean the intestines. 1.2 Anesthesia choose intrathecal anesthesia. 1.3 Position selection of left lateral recumbent position or right lateral recumbent position. When the left or right lateral recumbent position is used, the patient’s knees are close to the abdomen, the assistant can fully assist in the operation, and the patient feels more comfortable in the awake state and can relax. 1.4 Surgical instruments choose anastomosis with large inner diameter. 1.5 The operation process routinely sterilizes the perineal skin and rectal cavity with aniline solution. After full dilation of the anus with the anal dilator, with the assistance of the assistant, slowly put in the transparent anal canal ring dilator, remove the inner bolus, generally visible dentate line just in the middle part of the transparent ring dilator, in the perineum at 1, 5, 7, 11 points each fixed with a needle, take out the inner core, will be anoscopic suture device placed. A purse-string suture was placed along the submucosa at 2-75px above the dentate line with 2-0 absorbable suture. Note that in female patients, the index finger of the left hand is inserted into the vagina during submucosal rectal suturing to prevent suturing into the vaginal mucosa. Withdraw the stapler, open the 850-px special anastomosis to its fullest extent, insert the head end over the purse-string suture, tighten the suture, and tie the knot. Use the matching thread carrier to pull out the suture through the side hole of the anastomosis, pull the ligature thread to the handle direction with force, so that the sutured and ligated mucosa and submucosa enter into the anastomotic casing, rotate the anastomosis in clockwise direction to tighten the anastomosis, turn on the safety device, and keep it in the closed state for 20~30 s after firing. rotate the anastomosis in anticlockwise direction for one week, and gently pull it out. Check the anastomosis site for active bleeding. For active bleeding, local hemostasis was performed with suture. 2.Results 2.1 The effective rate of retraction of the hemorrhoidal mass outside the anus was 100%, and the exfoliated hemorrhoidal masses of 54 patients were completely retracted. 2.2 Complications of recurrence of thrombosed external hemorrhoids 1 case, anastomotic stenosis 3 cases, 5 cases of intra-anal pain, intraoperative examination of the need for re-suture hemostasis of 18 cases, postoperative hemorrhage, bleeding rate of 14%. Anal pain required analgesic, fine bowel control disorder in 3 cases, given hemorrhoidal suppositories and potassium permanganate local symptomatic treatment. There was no perianal infection. There were 51 cases of postoperative urinary retention, but the rate of urinary retention was only 14% after recovery from anesthesia; there was no rectovaginal fistula. 2.3 The surgical anastomosis was successful in all cases, and the hemorrhoidal mass outside the anus was retracted into the anus in all cases. The anastomotic resection of the intestinal wall tissue for the circular bagel-like, width of 1.5 ~ 62.5px. microscopic examination showed that the mucosa and submucosal tissue in two cases in the ligation of the purse-string suture to the anastomosis in the pulling part of a small amount of muscle tissue can be seen. 3.1 Postoperative hemorrhage 3.1 Avoid repeatedly entering and exiting the needle when doing the purse-string suture to reduce the generation of hematoma; in the operation of the anastomosis, rotate and tighten the anastomosis as far as possible to the very end of the safety window until it can not be rotated; during the operation, keep the anastomosis closed for 30s, and then slowly release the handle; before removing the anastomosis, open the anastomotic head to the maximum extent, and then withdraw the anastomosis by gradually twisting it under the direct vision; postoperatively, the anastomosis examination is listed as a necessary part of surgery. Postoperative anastomotic examination is a necessary step in the procedure; if active bleeding is detected, sutures must be added to stop the bleeding. If a small amount of blood seepage, there is no need for too much suture, can be added iodoform gauze into the anus, removed after defecation, if necessary, can be filled with anal canal; anal canal hemostatic sutures can be used as much as possible absorptive thread, to the Vicodin line is more ideal. 3.2 Residual skin flap choose hemorrhoids at the larger site to start the needle; appropriate lowering of the suture position plane; purse-string suture, in the placement of anastomosis before the routine inspection of purse-string suture effect, the method of forefinger into the anus, close the purse-string suture, through the feeling of the depth of the suture line to determine the number of possible lifting of the mucosa. In the finger feeling suture shallow area, often lifting the rectal mucosa less than the need to excise the mucosa range of requirements, can not achieve PPH suspension and cut off the flow of effect, at this time, note the need to add suture mucosa at this point; for the larger residual skin or thrombosed hemorrhoids, can be simultaneous excision. 3.3 Postoperative pain disable rat-tooth clamping the skin at the anal verge. The purse-string suture is too deep, the anastomosis after removing too much muscle tissue, resulting in pain. 3.4 anastomotic stenosis generally does not appear stenosis, the author believes that the main reasons for stenosis are: ① loaded suture, the anastomotic incision is completely parallel to the dentate line, easy to lead to stenosis, while the suture plane is high in the front and low in the back, and the dentate line is not parallel to the main reason is not easy to stenosis. ② The anastomosis diameter chosen is small, which will lead to anastomotic stenosis, and it is generally more appropriate to use 34mm diameter. 3.5 The chance of urinary retention is 50%, due to anesthesia and postoperative anal stuffing, there will be different degrees of sphincter spasmodic pain, affecting the short-term postoperative urination, it is best to prophylactic catheterization. Avoid patients repeatedly getting out of bed and urinating with force after surgery, which may lead to anastomotic bleeding. In summary, PPH surgery for the treatment of severe hemorrhoidal prolapse efficacy is obvious, but must strictly grasp the indications for surgery, in the treatment of rectal mucosal intussusception and rectal anterior protrusion caused by outlet obstruction constipation efficacy to be observed.