This video demonstrate PPH stapled Piles Surgery step by step by Dr R K Mishra. PPH-stapler procedure for treatment of haemorrhoidal prolapse is an important improvement. Haemorrhoidal disease is the most frequent and ancient proctological pathology. Haemorrhoidectomy is always feared for intensive post-operative pain and complications. Stapled hemorrhoidopexy is good procedure but may be followed by severe postoperative complications of which haemorrhage is one of the most serious early events. Surgical techniques have advanced more and more with the aim of reducing the post-surgical complications and to help a faster recovery. “Open hemorrhoidectomy”, according to Milligan-Morgan procedure, has been the most used method in Europe, also in the “Ligasure” and “Ultracision” variants. “Closed hemorrhoidectomy”, according to Ferguson procedure, has been the most used method in the USA. Stapled hemorrhoidopexy (PPH-stapler) is an alternative method to conventional surgical procedures. It has many advantages such as less pain, faster recovery and a quicker return to normal activities. PPH stapler procedure for treatment of haemorrhoidal prolapse.

Hemorrhoidal disease (Piles) is one of the most common anorectal conditions worldwide, characterized by bleeding, prolapse, pain, and discomfort. Traditional hemorrhoidectomy techniques—like Milligan-Morgan and Ferguson—have been effective but often cause significant post-operative pain and prolonged recovery. 

In his detailed lecture on PPH stapler piles surgery, Dr. R. K. Mishra, a globally acclaimed laparoscopic and colorectal surgeon, explains the principles, operative steps, and clinical advantages of this minimally invasive approach, also known as Stapled Hemorrhoidopexy. 

What Is PPH Stapler Surgery?

PPH (Procedure for Prolapse and Hemorrhoids) is a minimally invasive stapled hemorrhoidopexy technique designed to treat prolapsed internal hemorrhoids. Rather than excising hemorrhoidal tissue externally, PPH uses a circular stapling device to remove a ring of rectal mucosa and submucosa above the hemorrhoids, lifting and repositioning the prolapsed hemorrhoidal cushions into their normal place. 

This reduces blood flow to the hemorrhoidal tissue, leading to shrinkage and symptomatic relief, with less postoperative pain and quicker recovery compared to conventional open techniques. 

Indications and Patient Selection

PPH stapler surgery is typically indicated for:

Symptomatic internal hemorrhoids — especially grades III and early IV with prolapse

Patients where less invasive surgery and faster recovery are priorities

Hemorrhoidal bleeding and prolapse not responding to conservative therapy

It is not usually recommended for isolated external hemorrhoids or extensive fibrotic tissue where repositioning alone is insufficient. 

Step-by-Step Surgical Technique

Below is an organized step-by-step overview of the PPH Stapler procedure as taught in Dr. Mishra’s lecture and standardized surgical protocols:

1. Preparation and Anesthesia

The patient is placed in the lithotomy position with appropriate sterility. Anesthesia may be spinal, epidural, or general depending on clinical needs. 

2. Anal Dilatation

A specialized anal dilator and anoscope are inserted to expose the operative field and facilitate instrument insertion. 
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3. Purse-String Suture Placement

A circumferential purse-string suture is placed in the rectal mucosa approximately 3–4 cm above the dentate line (just above the sensitive area inside the anus). This suture incorporates both the mucosa and submucosa layers. 

4. Placement of the Circular Stapler

The PPH stapling device (circular stapler) is introduced transanally. The purse-string suture threads are secured over the anvil of the stapler, and then gently tightened so that the redundant mucosa and hemorrhoidal tissue are pulled into the stapler’s chamber. 

5. Firing the Stapler

Once adequate tissue is drawn into the stapler and proper alignment confirmed, the device is fired. This step simultaneously:

Excises a circular segment of mucosa and submucosa

Staples the cut edges together to restore the rectal anatomy

The stapler is kept closed for a short period (e.g., 30 seconds) to enhance hemostasis. 

6. Inspection and Hemostasis

After firing, the staple line is carefully inspected for bleeding. Any minor bleeding points can be sutured. Final irrigation and cleanup are done before ending the procedure. 
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Advantages of the PPH Stapler Technique

Compared with traditional hemorrhoidectomy, PPH stapler surgery offers several clinical benefits:

Reduced postoperative pain (avoids sensitive anoderm wounds) 

Shorter hospital stay and quicker recovery 

Preservation of normal anal cushions and continence mechanisms 

Faster return to routine activities 

Postoperative Care and Recovery

Early ambulation is encouraged.

Analgesics and stool softeners help improve comfort.

Sitz baths and fiber-rich diet aid in smooth bowel movements.

Most patients resume normal activities faster than with conventional surgery. 

Potential Complications and Considerations

While generally safe, PPH stapler surgery can have rare complications:

Early postoperative bleeding

Staple line disruption

Stricture or incontinence (rare with experienced surgeons)

Recurrence if patient selection is inappropriate

Dr. Mishra emphasizes the importance of proper training, precise technique, and careful patient selection to minimize risks. 

Conclusion

The PPH stapler procedure represents a significant advance in the surgical treatment of prolapsing internal hemorrhoids. Through his step-by-step lecture, Dr. R. K. Mishra demonstrates how this technique combines surgical precision, patient comfort, and rapid recovery, making it a preferred option for suitable cases of hemorrhoidal disease.