Since Longo, an Italian scholar, first reported the procedure for prolapse and hemorrhoids (PPH) for the treatment of prolapsed hemorrhoids in 1998, PPH has been widely used in the international arena because of its anatomical and physiological characteristics, simple operation, short operation time, less postoperative pain, and quick recovery of patients. PPH has been widely used in the world because of its anatomical and physiological conformation to the anus, simple operation, short operation time, less postoperative pain and quick recovery. PPH is indicated for internal hemorrhoids of circumferential prolapse of degree III and IV, and internal hemorrhoids of degree II with recurrent bleeding. PPH preoperative preparation Routine blood test, coagulation function, ECG if necessary. Take oral medication to cleanse the intestine the night before the operation, or enema in the morning of the operation. If intra-vertebral anesthesia or general anesthesia is used, abstain from eating and drinking on the morning of the operation. Anesthesia and position Local anesthesia, intralesional anesthesia or general anesthesia can be used, among which intralesional anesthesia is more effective for anal sphincter relaxation. Usually the folding knife position or truncal position is adopted. The main points of the operation are 1. Moderate dilation is necessary for the smooth introduction of the anal canal dilator (CAD33), and the CAD33 can be lubricated with liquid paraffin to prevent damage to the anal canal. 2.Fixation of CAD33 is one of the key steps in the operation of PPH, and a well-fixed CAD33 can fully expose the field of view and reveal the dentition line, which is convenient for the positioning of the bag and the next operation. It is usually fixed with sutures in the direction of 6 and 12 points. The optimal distance of the suture should be within 4 cm of the dentate line (2,5-4 cm), and the anastomosis should be 1,5-2,5 cm on the dentate line after the anastomosis. If the suture line is too high, the upward pulling and suspending effect of the anastomosis on the anal cushion will be weakened, which will affect the clinical efficacy. If the position is too low, the anal cushion will be easily damaged, and it will bleed easily after surgery because of the rich blood vessels in the anal cushion. If the skin of the dentary line or anal canal is damaged, it is easy to produce intractable postoperative pain, early anal canal sensory disorder, temporary fecal incontinence, etc. Depth: The depth of the purse-string suture is best in the submucosa, and should not be too deep or too shallow. If the suture is too shallow, mucosal tearing and hematoma will easily occur during anastomosis, and the anastomosis will not be easily fixed with the submucosal muscle layer, which will not eliminate the hemorrhoid symptoms well after surgery and affect the healing effect, resulting in long recovery time, painful infection or narrow anastomosis, and affecting defecation. If the suture is too deep, the muscle layer is easily injured, and even the perirectal tissues, such as the anterior vaginal wall, are damaged. The number of patients with prolapse of less than 3 cm can be closed with a single purse-section suture, but the uneven force between the pulling part of the single purse-section suture and the opposite side often leads to uneven width of the resected tissue and affects the efficacy of the treatment. According to the severity of prolapse, the distance between the two purses should be adjusted, the greater the distance, the more tissue should be removed. Note on the knotting of the purse string: When placing the anastomosis (HCS33) and tightening the purse string, it is important not to knot the purse string too tightly, but to leave some space for the purse to slide up and down the HCS33 center rod, so that more prolapsed mucosa can enter the cutting groove when pulling the purse string, making the cut mucosa wider and achieving better clinical efficacy. Otherwise, if the knot of the wire is too tight, the prolapsed mucosa can not be effectively drawn into the cutting groove, and it is not easy for the operator to control the width of the resected mucosa. 4.Closing and firing Before closing, the tail wire of the packet drawn from the lateral hole of HCS33 should be knotted or clamped to facilitate pulling, and at the same time, the HCS33 should be placed in the center of CAD33. During closure, the index finger is pulled moderately with one hand to bring the prolapsed mucosa into the cutting groove, and the anastomosis is tightened with the other hand. In the case of female patients, the assistant should cooperate with vaginal palpation when tightening the anastomosis to prevent damage to the vaginal wall. While tightening the anastomosis, the surgeon should observe the HCS33 scale indicator window and open the HCS33 safety before firing. Insufficient force is required to ensure complete excisional anastomosis, which may result in incomplete excisional anastomosis and difficult removal of the HCS33 from the anus. After the anastomosis, a crisp “click” sound can be heard. At this point, the anastomosis should be kept closed for about 30 seconds to stop the bleeding by compression. After removing the HCS33, the anastomosis should be carefully inspected and suture ligation should be performed if there is bleeding or suspected bleeding. 5. Postoperative observation The blood in the stool must be observed within a short period of time after surgery. Some postoperative cases of massive bleeding have been found both at home and abroad, which are related to incomplete intraoperative hemostasis on the one hand, and postoperative spasm of small artery diastole on the other hand, so postoperative observation should be done. If a small amount of bleeding can be applied hemostatic drugs and continue to observe, but for more serious bleeding should be decisive and timely surgery to stop the bleeding, in order to avoid delaying the disease.