00:00hello friends this is a case of PPH stapler that is also called stapled hemorrhoidopexy
00:08so we will perform this surgery this patient has second degree hemorrhoid and unfortunately
00:16he has taken the botox injection so there is some fibrosis but still bleeding and everything was
00:22there so these are the instrument which we are using for and we know that PPH stapler has the
00:29complete set of the instrument which comes in the complete packing so what are the instrument we
00:36will see here so this instrument is called no scope that is used to take the purse string suture this is
00:51obturator that will take V away from dentate line this is dilator that will go with the obturator
00:59here is a suture puller that we will use to pull the suture out after taking purse string and this
01:08is the main gun this is the main stapler it is available with the different company in by Lotus
01:15also by the you know ethic on Johnson and Johnson is also making many Chinese companies are also now
01:21making so we will see how to perform this surgery first step is that we to take little gilocaine and dilate
01:29the anus few times so that easily you can push the obturator and that will also make the mucosa little
01:39loose so after dilating you will go with the obturator and you will push it and then we have to suture it
01:49we have to fix it with the buttock so that it will not come out and will you fully introduce into the
01:59anus and that will make our all the purse string and a stapler line above the dented line
02:05these are just the sta suture at the end of surgery it has to cut out
02:30two two knot will be taken on either side of the buttock present should be in the either lithothrommi
02:58position or may be reverse jackknife position
03:28so this is the third knot here we are using number one silk
03:34so this is the third knot here we are using number one silk
03:49and now this is the last one
04:19after that we will introduce the anoscope and we will start our bite on the mucosa and
04:37sub mucosa at three o'clock position
04:53little bit cleaning so that any fecal matter or any we can see the hemorrhoids
05:00are visible and you have to go above this on the healthy mucosa
05:12so this is bite taken care should be taken that muscle should not come into
05:18your bite and only mucosa and submucosa should be taken here we are using only
05:24one hand because we have to record it we are recording with the laparoscopy
05:30telescope because recording of this area is very difficult so this is three
05:37o'clock now it will be anoscope will be rotated and then you will take five
05:42o'clock this is proline two zero proline you will use with the 22 number round
05:50but a needle and bite should must be taken above the pile's mass
05:59and this is five o'clock
06:05sometime if you feel that hemorrhoid can bleed then you can rotate and
06:10reintroduce now the third one is at seven o'clock
06:23if the hemorrhoid is there or not total seven bite we have to take all around
06:29persisting that is three o'clock five o'clock seven o'clock nine o'clock eleven o'clock
06:35one o'clock and again three and a half o'clock
06:42so this is nine o'clock
06:43after that this is one o'clock here it will be reverse bite taken
06:57so
07:04this is the one o'clock
07:06so
07:08so
07:10so
07:11so
07:15so
07:17so
07:19Now this is 1 o'clock and now 3.5
07:49So purse string is done. Now right side you have the two sutures. One is entry suture and another is exit suture. Now you will take one fresh needle and anoscope is reintroduced at 9 o'clock and then one simple bite will be taken at 9 o'clock at the same level where your first purse string has gone through.
08:19Purpose is that it should be bilateral symmetrical and when you will pull these sutures through the stapler then it will bring the doughnut in between anvil and gun. Now anvil will be fully opened.
08:43Two sutures right, two sutures left you have and slowly by a screwing movement you will introduce the anvil completely and this gun should go at least 4 cm inside.
08:57So that anvil will go above the pile's mass and after that you will pull little bit and then those sutures you can pull it through the hole which is in the stapler on either side.
09:14So this is the suture puller and you can pull the suture either side you can take it out. Some people they take half and some people they take one and half purse string.
09:31Some people they take half purse string above half below and then you pull the suture either side. Some people they take one and half. We take one complete 360 degree and one simple bite at 9 o'clock position.
09:44After that it will go up to 4 number 4 and then all the 4 sutures you can hold it with one artery forcep. So that you can pull it and you can give the consistent force.
09:58And simultaneously you will take care that it should be slowly slowly this gun has to be closed. So anvil will come near the gun and there is an indicator that indicator should be coming and then you will fire.
10:14Once you will fire then you should keep it pressed for minimum 40 second to 2 minute.
10:21After 2 minute you can open the gun and just rotate little bit into anti-clockwise direction.
10:46And then you will cut the purse string suture and slowly the gun and obturator will be taken out.
11:04So surgery is over.
11:08Now we can see here that this prolapse mucosa has pulled up.
11:15And hemorrhoid is cut.
11:18And mucosal mucosal anastomosis is performed.
11:21You should must take care that any bleeding is not there.
11:25We can see all has gone up.
11:28And then absolutely no bleeding is there.
11:31And it's a nice hemorrhoidoplexia is performed.
11:35You can inspect it by the finger.
11:38And once everything is fine then finally you can check for the donut.
11:45So you can see it is completely 360 degree donut.
11:49And it is cut.
11:51Now you will cut the donut at one end.
11:54And then you can inspect and send for biopsy.
11:58So thank you for watching this video.
12:01This was just a simple case of hemorrhoidoplexia.
12:05Thank you very much.
12:06Thank you very much.
12:07Thank you very much.
12:30I'll see you next time.
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