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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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wound closure may lead to an abscess.
The surgical site is infiltrated with local anesthetic for postoperative pain
relief.
Postoperative Care
After surgery care includes:
Daily showers or baths to keep the surgical site clean
Analgesic medication
Time off from work
SUMMARY
Anal fissure is one of the most common ailments encountered by
colorectal surgeons. In 1951, Eisenhammer identified internal anal
sphincter contracture as a surgically correctable cause of chronic fissure
syndrome.
The internal anal sphincter is a continuation of the circular muscle of
the large bowel. It is therefore liable to a spastic contraction, the
greatest incidence appearing to exist in the anal canal. The structural
spastic changes have been referred to as chronic internal anal
contracture. The operation of internal anal sphincterotomy combined
with free dilatation appears to be a satisfactory method of correcting
this disability and restoring normal tone and expansibility to the anus.
This operation simplifies the surgery of the anal canal and especially
that for chronic fissure.
The percentage of sphincter necessary to be divided is not universally
agreed upon. Eisenhammer directed that “At least four-fifths of the
internal sphincter is divided.” Lesser degrees of division, “tailored
sphincterotomy,” in which the sphincterotomy is carried out only to the
apex of the fissure are used to reduce the rate of fecal incontinence.
Suggested Readings
Eisenhammer S. The surgical correction of chronic internal anal (sphincter-ic) contracture. S A Med J.
1951;25:486-489.
Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S. Operative procedures for fissure
in ano (review). Cochrane Database Syst Rev. 2011;(11):CD002199.
Nelson RL, Thomas K, Morgan J, Jones A. Non-surgical therapy for anal fissure. Cochrane Database
Syst Rev. 2012;(2):CD003431.
Perry WB, Dykes SL, Buie WD, Rafferty JF. Practice parameters for the management of anal fissures
(3rd revision). Dis Colon Rectum. 2010;53:1110-1115.
Stewart DB Sr, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SRT. Clinical Practice Guideline
for the management of anal fissures. Dis Colon Rectum. 2017;60:7-14.
Chapter 10
Anoplasty for Anal Stenosis
MICHAEL A. VALENTE
Perioperative Considerations
Anal stenosis is most often the result of iatrogenic injury from an over
aggressive hemorrhoidectomy, in which too much anoderm is removed
(Fig. 10-1).
FIGURE 10-1 Severe anal stenosis secondary to hemorrhoidectomy.
Other causes of stenosis may include idiopathic, neoplasm, inflammatory
(Crohn), trauma, infectious, or after radiation.
Anoplasty techniques may also be utilized for cases of ectropion, anal
ulcer, fissure, fistula-in-ano, and after the excision of
premalignant/malignant anal lesions (ie, Paget disease, anal
dysplasia/carcinoma).
Other indications include when the anoderm is absent and replaced by
scar, most often following excision of anoderm during an operation.
Multiple flap configurations exist, and each type should be used based on
the etiology, size/location of the scar, anatomy, and surgeon preference
and skill.
Establish the etiology of the stenosis, as this will dictate operative
approach.
Suitability/condition of the perianal/gluteal tissues must be assessed.
The presence of Crohn disease, history of radiotherapy, prior attempts at
repair, and quality of gluteal skin must also be addressed before repair.
Delineate the location(s) and the extent of the stenosis.
The decision to create a unilateral versus bilateral flap repair is based on
the abovementioned information.
Maintain good plastic surgical principles:
Sharp dissection; little to no cautery
Broad-based flap with adequate blood supply
Mobility maximized by releasing the tethering attachments under the
donor site rather than aggressive dissection under the flap skin itself
The principle of anoplasty is to remove the scar, allow the anus to
occupy its full length, and then cover the unepithelialized anus with
epithelium, in other words, skin.
Operative Preparation
A full cathartic bowel preparation may be given on a case-by-case basis
depending on surgeon preference. We prefer a bowel preparation to clear
the colon and rectal of stool and to defer stool during early healing.
If not receiving a full bowel preparation, patients will receive two-fleet
enemas the morning of the procedure.
Venous thromboembolism prophylaxis is achieved with sequential
compression device and subcutaneous anticoagulation agents.
Intravenous antibiotic prophylaxis is given 1 hour prior to incision and
includes ceftriaxone 2 g and metronidazole 500 mg.
Foley catheter drainage is recommended for most cases.
Patient Positioning
Patients routinely undergo general endotracheal anesthesia while in the
supine position.
Once the airway is secured, the patient is flipped into the prone jackknife
position.
A large Kraske roll is utilized by being placed under the iliac crests to
properly elevate the buttock and perianal regions.
Exposure to the anus is accomplished by securing the buttocks bilaterally
to the operating room table with tape; care is taken to ensure adequate
gluteal retraction and exposure, but also that the tape allows for proper
access to the soft tissue needed for reconstruction.
The entire perineal and buttock regions are sterilely prepped and widely
draped.
Approach and Equipment
Needle-tip Bovie electrocautery pen
Indelible marking pen
3-0 absorbable suture (Vicryl or polydioxanone)
Local anesthetic (lidocaine without epinephrine)
Kraske roll
3 in adhesive tape
Lighted Hill-Ferguson anoscopes
Betadine prep for anal mucosa; alcohol-based prep for gluteal skin
Techniques for Anal Stenosis
Various types of anoplasty exist, including the house, diamond, U, or V-Y.
These are the most commonly performed anoplasty techniques for anal
stenosis. The technique of S-plasty is usually reserved for the most severe
strictures with extensive loss of anoderm.
For scarring that is >50% circumference, bilateral flaps may be needed. In
general, performing one side is acceptable initially, followed by the
contralateral side only if needed.
The goal of making a flap is to provide viable tissue to fill the defect that
is created by stricture excision and also allows for prevention of recurrent
cicatrix and contracture.
Flap Preparation and Scar Release
The flap lines are drawn with indelible marking pen (Fig. 10-2).
FIGURE 10-2 House flap.
A longitudinal incision is made proximal to the dentate line with a scalpel
to the perianal skin for the length of the stenosis. In cases where a house
flap is being utilized for a sizeable stenosis (dentate line to perianal skin),
a radial incision is also created inside the anal canal and on the anoderm
where the scar ends, in conjunction with the longitudinal incision to
completely release the large cicatrix (Fig. 10-3).
FIGURE 10-3 Indelible ink to mark out a diamond flap.
This cicatrix must be excised/removed, and the underlying anal sphincter
muscles must be preserved. The length of this initial incision will roughly
correspond to the length of the flap (Fig. 10-4).
FIGURE 10-4 Total removal of the cicatrix is imperative to the success of the flap.
The assurance that the chronic cicatrix is fully excised is of the utmost
importance for flap success.
The ability to suture the flap edges to a well-vascularized, scar-free area is
critical. There can be no inflamed or hardened tissue where the sutures
will lie inside the anal canal. This will undoubtedly lead to flap dehiscence
and failure.
A partial lateral internal sphincterotomy may also be performed at this
time. Some surgeons routinely perform sphincterotomy, and others feel it
is unnecessary; depending on the etiology and size of the stricture, internal
sphincterotomy should be performed on a case-by-case basis.
Flap Creation: Basic Steps
Regardless of the style of flap utilized, dissection begins sharply with a
#15 blade to incise the skin down to the subcutaneous tissue.
The flap is incised along the marked lines and then down into the anal
canal until normal mucosa is found.
The flap attachments are released by undermining under the edges of the
donor site. The dissection should slant obliquely outward and not inward
(Fig. 10-5).
FIGURE 10-5 The flap attachments are released by undermining under the edges of
the donor site. The dissection should slant obliquely outward and not inward.
This oblique dissection allows for a broad fat pedicle for the flap, ensuring
adequate perfusion.
The use of the cut current on the electrocautery is advised. Scalpel may
also be used.
Aggressive coagulation with the electrocautery is strongly discouraged for
flap mobilization as this leads to tissue necrosis, breakdown, and resultant
infection.
Once the apex of the flap is released laterally on the buttock, the island of
tissue should very easily “fall into” the anoderm on its own (Fig. 10-6).
FIGURE 10-6 Flap easily advancing into the anal canal with minimal to no tension.
Care is taken of the wound edges at all times during the procedure.
There should be no tension when the flap slides into the anal canal.
Securing the Flap
The advanced pedicle is sewn into place. 3-0 absorbable suture in simple
interrupted manner about 2-3 cm apart is the preferred method for the anal
canal stitches (Fig. 10-7).
FIGURE 10-7 The flap is sewn into the anal canal with simple interrupted 3-0
absorbable suture.
The suture should be placed through the skin and subcuticular layer of the
flap and the full thickness of the donor skin to maintain a good blood
supply and to not tear the flap skin.
The donor site is closed with simple interrupted or horizontal mattress
sutures. The donor site is, therefore, closed in a linear manner (Fig. 10-8).
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