Always operate on a paralysed patient; it is easy to insert the CAD33 obturator. Secure the obturator with silk sutures tied around the four internal bridges (keeps the obturator within the sphincter complex). Flex and abduct the hips as much as possible. Hydraulic styrups are ideal. Lithotomy tends to make things difficult.
Using fingers, ensure that the EAS is pushed over the inside edge of the obturator. Check the degree of prolapse using a small swab placed inside then removed from the rectum. When there is lots of prolapse simply insert the 2/0 prolene purse string (no need for the anoscope). Counter pressure against the obturator ring facilitates this.
If you need the anoscope, remove it completely before turning/reinserting for the next stitch. Use a Rampleys’ forceps to secure it to the obturator (saves on an assistant).
Don’t worry how deep you place the purse string, but how far it is from the dentate line (3cm is optimum). If you place it at 5cm you run the risk of inducing a stricture.
Always open the stapler to the maximum position. Gently push the stapler as counter traction is applied to the purse string. Check that the posterior vaginal wall moves on the rectum.
Release with one turn of the knob as soon as fired i.e. you want to see any arterial bleeding now! Secure with 3/0 monocryl. It should look like this.
If there is any residual prolapse, rpt the process by placing a suture through the apex of the prolapse, tie it before pulling through a new pph (03) gun.
In 4th degree piles, evert the anus with clips on the apex of the haemorrhoids. Insert the purse string followed by the open PPH gun with obturator. Insert the obturator, close and fire the gun. It is seldom necessary to remove any skin tags.
Infiltrate bupivicain around the EAS and perform a pudendal nerve block.