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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 17-9 Planned rotation of flap. A: Intraoperative photograph. B: Drawing
demonstrating the proper rotation.
Start with excising the specimen in a diamond shape. Carefully dissect and
watch for methylene blue staining of the underlying subcutaneous tissues.
The excision should be lateral to the blue tissue, and the blue tissue should
be included with the specimen (Fig. 17-10).
FIGURE 17-10 Dissection to include methylene blue–stained tissues.
Incise the skin to create the flap and carry the dissection down to the fascia
of the gluteus maximus.
Using 2-0 Vicryl suture, bring the deep corners of the flap to the corners
of the excision site (Fig. 17-11).
FIGURE 17-11 Rotation of flap. A: Initial rotation. B: Flap rotated and in place.
A second layer of 2-0 Vicryl suture should be used to close the dead space
between the subcutaneous fat.
A final layer of 3-0 monofilament permanent suture is used to close the
skin in a vertical mattress manner (Fig. 17-12).
FIGURE 17-12 Final flap after skin closure.
PEARLS AND PITFALLS
Avoid placing inferior corner of flap above the anus.
Inferior portion of the incision should be off the midline.
Ensure some undermining of the subcutaneous tissues in order to make
rotating the flap easier and decrease tension.
Minimize the depth of tissue excision.
Take only the amount of tissue necessary during the excision.
Bascom Flap (Cleft Lift)
Positioning and preparation are the same as the abovementioned steps.
Mark the safe zone of the gluteal cleft by opposing the buttocks and
marking where they touch (Fig. 17-13).
FIGURE 17-13 Marking of safety zone.
Identification of pits is the same as the abovementioned steps.
A scimitar-shaped incision should be made inferiorly in the skin to
encompass all the pits. Keep the incision just off the midline (Fig. 17-14).
FIGURE 17-14 Scimitar-shaped incision.
Carry the incision down toward the fascia. The incision does not have to
extend to the fascia, but it needs to be deep enough to excise the base of
the pit. Be careful not to wander laterally during the dissection and stay
close to the pit—this will ensure a smaller wound.
Raise a short flap on the side opposite of the incision (Fig. 17-15).
FIGURE 17-15 Dissection of cleft lift flap. A: Initial wound. B: After resection. C: Flap
closed.
Close wound in layers and dressing options are the same as the
abovementioned steps.
Final skin closure should result in an incision that is just off the midline.
PEARLS AND PITFALLS
Scimitar-shaped incision should point inferiorly to aid in perianal
reconstruction.
Flap can be raised using either electrocautery or sharply with scissors or
knife.
The area of the flap toward the anus should be thicker.
Central scarring can be “diced” with electrocautery to free the
contractures.
Obliterate dead space as much as possible with Vicryl suture.
May use a closed suction drain.
Postoperative Care
I&D can be packed for 24 hours to prevent bleeding, but then be treated
with a simple dressing for drainage.
In general, antibiotics are not required in the absence of underlying
comorbidities or excessive cellulitis.
A drain may be removed in 24-72 hours depending on the amount of
drainage (typically <30 mL), though there are a large variety of surgical
practice.
Stitches for flaps are commonly left in for several weeks prior to removal.
Activity should be restricted on all flaps for several weeks (no prolonged
sitting, exercising with pressure on the flap).
Suggested Reading
Johnson EK, Vogel JD, Cowan ML, Feingold DL, Steele SR; Clinical Practice Guidelines Committee
of the American Society of Colon and Rectal Surgeons. The American Society of Colon and
Rectal Surgeons’ Clinical Practice Guidelines for the Management of Pilonidal Disease. Dis
Colon Rectum. 2019;62(2):146-157.
Chapter 18
Anal Intraepithelial Neoplasia:
Performing High-Resolution Anoscopy
MICHELLE D. INKSTER
ERIC D. WILLIS
JAMES S. WU
Perioperative Considerations
Anal squamous intraepithelial lesion (SIL) precedes anal squamous cell
carcinoma. The causative agent is human papillomavirus (HPV) in the
majority of cases.
Anal squamous cell cancer arises between the anal verge and the anorectal
line (Fig. 18-1).
FIGURE 18-1 A. The epithelium at risk for anal SIL extends from the anal verge to the
anorectal line. B. The anorectal line defines the junction between the ATZ and the
columnar epithelium of the rectum. The ATZ, derived from the embryonic cloaca, extends
from the anorectal line to the dentate line. Distal to the dentate skin is the pecten that has
no or few sweat glands and extends from the dentate line to the anal verge. Distal to the
anal verge is the hair-bearing perianal skin or anal margin. C. Retroflexion with the scope
delineating the anatomy. A, anterior; ATZ, anal transitional zone; PEC, pecten; R, right;
Scope, endoscope; SIL, squamous intraepithelial lesion.
Although groups at high risk include HIV-positive individuals, especially
men who have sex with men; solid-organ transplant recipients; and those
with a history of cervical, vulvar, penile, or vaginal dysplasia, anal SIL
can occur in anyone.
Anal SIL detection, necessary for diagnosis and treatment, is facilitated by
inspection of at-risk epithelium with adequate lighting, magnification, and
chemical enhancement.
Diagnostic techniques used are derived from colposcopy described by
Hinselmann et al. in 1925.
In 1989, Scholefield et al. prospectively used a microscope to examine
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