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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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FIGURE 10-8 The donor site is, therefore, closed in a linear manner with simple
interrupted 3-0 absorbable suture.
SPECIFIC FLAP CONFIGURATIONS
Y-V or V-Y Flap
The Y-V or V-V anoplasties have been classically used for replacement of
anoderm for a short segment stenosis at and below the dentate line with
associated mucosal ectropion. They can be performed in any quadrant and
are usually performed unilaterally, but also can be done in a bilateral
manner.
Y-V: After an anatomy is created over the stricture, the incision is then
carried into the perianal sin/buttock in a Y shape for 5-8 cm for both limbs
(Fig. 10-9). The resultant V flap is advanced into the anal canal; the tip of
the flap is sutured to the anorectal mucosa (dentate line) and internal
sphincter muscle.
FIGURE 10-9 Y-V flap.
V-Y: An alternative to Y-V, the advanced portion is wider and may have
less ischemia and necrosis (Fig. 10-10).
FIGURE 10-10 V-Y flap.
The Y-V and V-Y varieties of anoplasty flaps are not ideal for stenosis
that is proximal to dentate line, due to the limited mobility that they offer.
In order to bring the flaps more proximal to the dente line, a high degree
of tension will ensue. Additionally, the Y-V has a narrow proximal
component that is prone to ischemia.
House Flap
The house flap is utilized for moderate-to-long anal stenosis and can
accommodate proximal and distal stenosis in any all quadrants, including
circumferential involvement (Fig. 10-2).
Additionally, the house flap increases the anal canal diameter and
advances very easily into the proximal anal canal. The house flap has a
broad base, which avoids the pitfall of having a narrow apex, which may
lead to ischemia/necrosis.
The donor site is closed primarily, helping the flap to stay in the anal canal
without tension.
Diamond Flap
The diamond flap is ideally suited for moderate-to-severe stenosis, which
is mostly intra-anal and above the dentate line.
After incising the scar, a diamond defect is left behind (Fig. 10-11).
Bilateral flaps may be utilized based on the severity of the stenosis.
FIGURE 10-11 Diamond flap.
Similar to the house flap, the donor site is closed in a linear manner,
helping the flap to keep in the anal canal without undue tension.
Limited undermining of the diamond flap will preserve the vascular
integrity of the flap.
U Flap
The U flap is similar to the abovementioned flaps, but the donor site is left
open to granulate in secondarily (Fig. 10-12).
FIGURE 10-12 U flap.
This flap is especially valuable when there is a large amount of mucosal
ectropion to be excised among with the stenosis.
Rotational S Flap
The S flap is reserved for the most severe stenosis, which is usually
located high in the anorectum and circumferentially located onto the
perianal skin.
When there is a large amount of anoderm removed, as in a Whitehead
deformity after an injudicious hemorrhoidectomy, this flap is well suited.
After the scar is circumferentially excised, full-thickness S-shaped flaps
are made in the perianal skin, with the size of the base as great as its
length.
Incision starts from the dentate line to about 8-10 cm long (Fig. 10-13).
The flaps are rotated and sutured to the normal anal mucosa.
FIGURE 10-13 Rotational S-plasty. Point A should be brought to A’ and B to B’ during
closure.
This is a complex technique with associated high morbidity and longer
hospital stay.
PEARLS AND PITFALLS
Always draw the flap out larger than one may think is necessary. The
flap may look bulky at first, but they shrink in size considerably after
mobilization. It is easier to work with a flap that may be a few
centimeters too big than a few centimeters too small. If the flap is too
small, the stenosis will not be corrected and bilateral flaps will most
likely be needed.
Do not undermine the flap; always slant in an outward direction while
mobilizing.
Tension will cause the flap to become ischemic and necrotic and
potentially fail.
The scar must be excised entirely if a flap is going to be sutured in its
place.
Most often, unilateral approach is the initial step in correction of the
stenosis; bilateral flaps should be reserved for the most severe stenosis
and/or for failures.
A medium Hill-Ferguson anoscope should be easily placed into the anus
at the completion of the anosplasty; if this cannot be achieved, strong
consideration should be made for a bilateral flap (Fig. 10-14).
FIGURE 10-14 A medium Hill-Ferguson anoscope should be easily placed into the
anus at the completion of the anosplasty; if this cannot be achieved, strong
consideration should be made for a bilateral flap.
Postoperative Care
Limit the activity and direct pressure on the flap for at least 1 week after
surgery.
Many patients can have outpatient surgery, but some will need at least 1-2
days in the hospital.
Oral antibiotics should be given for up to 1 week postoperatively to
decrease the risk of infection.
Infection and separation of the flap is not uncommon; antibiotics may help
reduce this risk.
Timely examination under anesthesia may be required for debridement of
affected tissues in the early postoperative period if infection is present.
Donor site separation is common and should be allowed to granulate in
with secondary intention.
Patients should be followed in the office after the operation until full
healing is achieved.
Diabetics, smokers, and previous radiation portend the worst outcomes in
terms of wound healing and overall success.
Suggested Readings
Feingold DL, Lee-Kong SA. Anal fissure and anal stenosis. In: Beck DE, Steele SR, Wexner SD, eds.
Fundamentals of Anorectal Surgery. 3rd ed. Philadelphia, PA: Springer Publishers; 2019:241-
255.
Lagares-Garcia JA, Nogueras JJ. Anal stenosis and mucosal ectropion. Surg Clin North Am.
2002;82(6):1225-1231.
Milsom JW, MAzier WP. Classification and management of postsurgical anal stenosis. Surg Gynecol
Obstet. 1986;163(1):60-64.
Chapter 11
Anorectal Abscess
VLADIMIR BOLSHINSKY
JOSEPH TRUNZO
Perioperative Considerations
Principles of Dealing with Perianal Sepsis
Irrespective of the complexity of perianal sepsis and potential associated
fistula tracts, the initial step in the management of all patients is the same.
After obtaining a history and performing examination, either in the office
or emergency setting, the patient is required to undergo an examination
under anesthesia (EUA).
In the elective setting, a magnetic resonance imaging (MRI) of the
perineum is sometimes helpful to further delineate the site of pelvic sepsis
in cases with complex and multiple tracts. We prefer MRI to endoanal
ultrasound due to its quality and interpretation that are more reproducible.
In the acute setting, most anorectal sepsis can be recognized on clinical
examination, though a computed tomography (CT) can be useful to aid in
deep space abscesses preoperatively. Acute abscesses most often simply
need drainage, often done in the office under local anesthesia, with no
MRI or added imaging at all.
Multiple EUAs may be required to adequately gain source control.
Half of perianal abscesses become fistulas. Classically, in a case of a
simple cryptoglandular anorectal abscess, there is one abscess and one
tract leading to a single internal opening. Goodsall rule (Fig 11-1) can be
used to predict the internal opening and trajectory of the fistula tract based
on the location of the external opening.
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