Thenextkeystepistoplacethemucosalcircumferentialpurse-string. Havingclearlyidentifiedthedentateline,thesiteofwherethepurse­stringistobeplacedisidentified.Placementcanbeawkwardbecausethe prolapsinghemorrhoidaltissuemaycontinuouslyobscurethesurgeons’ viewofthedentatelineandthesegment3–5cmabovethedentateline wherethepurse-stringshouldbeplaced.Thisstepisfacilitatedbytheuse ofthepackagedwingedanoscope(Fig.3-6).Thesuturematerialshould beplacedinastepwisefashion.Eachsequentialbiteshouldincludethe mucosaandnottherectalmuscle.Theneedleshouldbeinserted coincidenttothelaststitches’exitsite.Thisensuresthatthesutureis buriedinthesubmucosalplane.Thesurgeonshouldensurethateachbite continuesinacircumferentialmannerwithoutanydeviation,and equidistantfromthedentatelinethesutureshouldprogress circumferentially.Thisensuresthatauniversalsizedcuffoftissueis includedintheresectedspecimen.Theanvilofthestapleristhenplaced proximaltothepurse-string,andthesutureisthentiedaroundtheshaft ofthestapler,whichisthenbroughtintoaclosejuxtapositionwiththe anvilinpreparationforfiringthestapler.Thematedanvilandgunare leftatthatsettingforatleast15–30secondstoensurethattheresidual tissueedemaencompassedinthestapledsegmentdiminishesbefore completingthefiring.