540 Gut and Liver, Vol. 5, No. 4, December 2011 scheduled. Following re-hospitalization in the eighth postoperative week, a phosphate enema a day before surgery and antibiotic prophy- laxis (Cefuroxime 1.5 g, Metronidazole 500 mg) at anesthesia induction were administered to the patient. After the adminis- tration of general anesthesia and the placement of an epidural catheter for pain control, the patient was prepared, placed in a lithotomy position and a Foley catheter was placed. Stapled mucosectomy was performed using a 33-mm circular stapler kit (PPH; Ethicon Endo-Surgery, Cincinatti, OH, USA). First, the anal canal was lubricated and the obturator piece of the instrument was used for mild anal dilatation. Then, the obtura- Fig. 1. Visualization of the anal canal with an operating anoscope (arrow and arrowhead point to the dentate line and the ileal mucosa, respectively). tor was removed and an operating anoscope was placed for the exposure of the anal canal. The dentate line was identified (Fig. 1). The gap in the anoscope was rotated in the anus for the ap- plication of a 2/0 monocryl purse-string suture with a 25-mm curved needle. Every bite included mucosal and submucosal layers of the rectum 1 cm above the dentate line. The distance between the purse-string suture and the dentate line was kept the same over the entire circumference. Each bite of the purse- string suture was taken 2 to 3 mm behind the exit point of the preceding bite in order to prevent sliding of the purse-string. Then, the anoscope was removed and the lubricated open cir- cular stapler was inserted with its anvil beyond the purse-string suture. The purse-string was firmly tied on the shaft and its free ends were pulled through the lateral ports of the stapler device with a suture grasper. The tails of the purse-string were pulled as the jaws of the circular stapler were closed. The stapler was fired and it was then gently withdrawn from the anal canal. Following the withdrawal of the stapler, the excised tissue was checked for complete cylindrical doughnut. At the end of this procedure, the staple line was inspected by rotating the dilator. There were no bleeding points, and the lumen above the den- tate line was seen to be free of the rectal mucosa (Fig. 2). The excised tissue was sent for histopathologic analysis. Afterwards, the ileostomy was closed in the usual fashion with hand-sewn sutures. The operation was terminated with no intraoperative complications. After surgery, pain control was provided by epidural analge- sia and nonsteroidal anti-inflammatory agents as required. The patient was allowed to take clear oral fluids on the fourth post- operative day. Histopathologic examination of the excised tissue Fig. 2. Schematic illustration of the anatomy of the anal canal before (A) and after (B) the stapled mucosectomy procedure.