To understand PPH surgery, we must first understand the two theories of how hemorrhoids occur. The earliest theory is that hemorrhoids are raised venous masses formed by tortuous and dilated peripheral veins in the lower rectum or anal canal; in 1975 Thomson first proposed the anal cushion theory, which states that in normal people there is a ring of fibrous connective tissue under the mucous membrane at the end of the anal canal and rectum, called the “anal cushion”, which together with the anal sphincter assists in the It assists in the closure of the anus and the control of defecation together with the anal sphincter. Later, in 1994, Lorder et al. proposed the theory of “downward migration of the anal cushion”, which suggests that under normal conditions, the anal cushion is loosely attached to the muscle wall of the rectoanal canal, but is pushed down by abdominal pressure during defecation and retracted into the anal canal after defecation by its own contraction function. When the anal cushion becomes congested, hypertrophy, relaxation or fracture, its elastic retraction is weakened, thus gradually moving down and prolapsing, and over time hemorrhoids are formed. In response to this new theory and doctrine, in 1998 Longo, Italy, proposed a new procedure for prolapse and hemorrhoids (PPH) by circumferential excision of the mucosa and submucosa of the lower rectal wall above the prolapsed internal hemorrhoid. The PPH procedure is performed by circumferentially removing the mucosa and submucosa of the lower rectal wall above the prolapsed internal hemorrhoid, and anastomosing the distal and proximal mucosa at the same time, so that the prolapsed internal hemorrhoid and mucosa are suspended and pulled upward to return to their normal anatomical position and not prolapse. At the same time, because the artery supplying the hemorrhoid from the superior rectal artery in the submucosa is cut off, the blood flow is reduced and the hemorrhoid nucleus gradually atrophies. So far, the two theories of hemorrhoids, namely the “varicose vein theory” and the “submigration of the anal cushion theory”, have their own valid reasons, and based on these two theories, two types of procedures were born, the classic “external hemorrhoidectomy and internal hemorrhoid Ligation” and later Longo’s invention of “anastomotic supra-hemorrhoidal mucosal circumcision —– or PPH surgery”. Only the pros and cons of PPH surgery are analyzed here. Because PPH surgery has strict surgical indications (i.e., it is most suitable for 3°-4° internal hemorrhoids with cricoid prolapse), it is not applicable to all hemorrhoids. The PPH surgery is only a supplement to the classic traditional hemorrhoid surgery and is far from being able to replace and overturn the traditional classic hemorrhoid surgery. At present, the domestic PPH surgery is almost universal at all levels of medical institutions, large and small, and can even be described as a flood. Many hospitals barely allow patients to choose, preferring PPH surgery, without strictly choosing the indications for PPH surgery, and without regard to the various post-operative complications that may result from PPH surgery. Many medical institutions promote PPH surgery as “painless” and “minimally invasive”, but is it really so? It is true that PPH alone is less painful than traditional classical surgery, but at present, most of the PPH surgeries in domestic medical institutions are not simple PPH surgeries. Because of the analysis of PPH principle, the anastomosis position is too high, which may lead to the recurrence of prolapse symptoms within a short period of time after surgery, so many PPH surgeries have to be combined with traditional classical ligation to ensure the efficacy and reputation of the surgery, which means that many domestic PPH surgeries actually do both PPH and traditional ligation. From this point of view, this combined PPH surgery is not the so-called “minimally invasive” and should be even more traumatic than the traditional ligation alone; nor is it the so-called “painless”, and the post-operative pain and anal swelling are even more intense. The height of the anastomosis of PPH surgery, there is a unified standard abroad initially, but the standard entered our country after “unconvincing”, according to the anastomosis height standard of PPH surgery, most of the patients after surgery within a short period of time external or internal hemorrhoids re-prolapse outside the anus. As a result, domestic anorectal experts began to improve the height of the anastomosis, such as lowering the height of the anastomosis or making a “double purse” anastomosis so that more of the rectal mucosa can be removed (I will not discuss here whether it is reasonable to excessively remove a normal section of rectal mucosa). However, so far, there is no uniform standard in various medical institutions in China, partly because of the variability of individual patients’ diseases. If the anastomosis position is too high, the long-term efficacy is poor and there is a possibility that the anal cushion may re-migrate; if the anastomosis position is too low, it may affect the function of sensation, stool control and defecation in the lower part of the anorectum. The local anatomy and severity of internal hemorrhoids vary from person to person, so the doctor’s grasp of some details of PPH surgery can determine the long-term efficacy of the procedure (e.g., judgment of anastomotic position, uniformity and integrity of the circumcised rectal mucosa, depth of anastomotic sutures). The anastomosis in PPH surgery is anastomosed with titanium staples (titanium metal), staggered inside and outside for a total of 2 turns, about 28-30 grains. Most of the titanium staples in the anastomosis of PPH are permanently left under the rectal mucosa. Of course, most people do not feel discomfort because of the residual titanium nail, but very few patients feel pain and swelling in the rectal canal due to the residual titanium nail, which is not only related to the low position of the anastomosis, but also related to the patient’s physical condition. Qualified titanium residue in the body generally does not affect the human body and does not affect MRI, but it also happens clinically that patients after PPH are affected when they receive lumbar spine and pelvic MRI years later, which may be related to the unqualified quality of some domestic anastomotic titanium nails. The incidence of anastomotic stenosis after PPH is around 30%, which is a problem that many primary surgeons will ignore. Therefore, it is very necessary to review the anastomosis 1 month after surgery. Early detection of anastomotic stricture can be treated by early anal dilation. Anal swelling is also common in the early post-operative period after PPH, which is reflected in frequent bowel movements and more frequent bowel movements, and will generally return to normal in 2-3 weeks. Very few patients have poorer bowel control than before surgery and can hold their bowels for a short time after surgery. In conclusion, domestic PPH surgery is neither overly advertised as “painless” nor “minimally invasive”, nor is it a one-size-fits-all key to all hemorrhoid treatment, and strict indications for surgery must be mastered. Before surgery, it is important to understand in detail the specific operating principles and various post-operative complications of various surgical procedures for hemorrhoids to avoid leaving patients and doctors with various physical pains and medical disputes.