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294
a
b
c
d
e
Fig. 22.12 ( a ) This shows a recurrent Buschke-
Lowenstein tumour following previous radiotherapy that
required abdominoperineal excision (APE). The follow-
ing views show reconstruction to the defect using bilateral
inferior gluteal artery perforator fl aps. ( b ) The APE
defect. ( c ) Bilateral fl aps are planned to close the defect.
The right I-GAP fl ap has been elevated on its pedicle.
Note that the blue marks that identify the site of vascular
peforators identifi ed with a hand-held doppler prior to
elevation. The right I-GAP has been elevated and is shown
rotated on its pedicle. ( d ) Both fl aps are elevated and the
medial section of each fl ap medialised prior to advancing
the fl aps into the deep and wide defect. In this way, the
wound is closed and dead space controlled. ( e ) Stable and
well healed fl aps at 3 months post APE. Of note this
patient returned to cycling to work at this time
D. Ross and M. Dempsey
295
Anterolateral Thigh Flap
This fl ap was fi rst reported by Song et al. in 1984
[ 22 ]. Wang et al. described the use of the antero-
lateral thigh fl ap for perineal reconstructions, and
it has subsequently been used widely to recon-
struct defects both as a free and pedicled fl ap
[ 23 ]. The anterolateral thigh fl ap is versatile and
can provide a large, thin skin fl ap based on a sin-
gle suitable fasciocutaneous or musculocutane-
ous perforator. It is gaining in popularity due to
its excellent donor site that can, depending on the
size of the fl ap, be primarily closed.
Functioning Muscle Flaps
Efforts to reinforce the sphincter muscles in chil-
dren using the gluteus maximus muscle fl ap were
fi rst described over 100 years ago [ 24 ]. The
procedure was revised in the fi rst half of the last
century in an attempt to improve the outcome.
However, it was eventually superseded by the
graciloplasty. The use of the gracilis muscle fl ap
for anal sphincter reconstruction was fi rst
described in 1952 [ 25 ]. As opposed to the bulky
muscle belly of the gluteus requiring bilateral
transposition to encircle the anus, the gracilis is a
long, fl at muscle belly that allows unilateral
mobilisation to complete the wrap. In 1988 this
technique was further advanced by the connec-
tion of a pulse generator to a patient with subop-
timal function of the gracilis muscle transposition.
The result was a neo-sphincter with involuntary
resting tone [ 26 ]. This form of dynamic gracilo-
plasty can involve two or three phases and may
be dependent on the temporary use of a stoma;
however, it has proved to be an oncologically
sound procedure with an appreciable degree of
continence in most patients [ 27 ].
Microvascular Flaps
Microsurgery has increased the repertoire of fl aps
for reconstruction. As the number of options in
loco-regional and pedicled fl aps in perineal
reconstruction is large, the indications for micro-
surgical reconstructions are limited to repair very
large defects. These would tend to follow mas-
sive post-traumatic repair and following
hemipelvectomy.
Conclusion
Surgical excision of part or all of the anal
region can result in diffi cult wounds that may
be slow to heal, or indeed never do so, par-
ticularly following neo-adjuvant chemora-
diotherapy. As with optimal management of
all complex or malignant disease, teamwork
that brings together multiple disciplines can
only help the patient achieve a better overall
result.
Plastic surgeons have a signifi cant contri-
bution to make to the surgical care of both pri-
mary and post-surgical perineal and perianal
wounds and ideally should be involved at an
early stage in the decision and treatment path-
way. There are an extensive range of local and
regional fl aps that can be utilised to achieve
rapid healing of wounds and protection of
underlying vital structures. Skin resurfacing
can be achieved without recourse to a stoma
for partial resection, though will be required
for 3–6 months following larger anal resec-
tions and repair. Future challenges remain in
ensuring colorectal teams gain adequate plas-
tic surgical support, but the evidence suggests
this trend is changing as the benefi ts become
more evident and techniques evolve.
References
1. Mathes SJ, Hurwitz DJ. Repair of chronic radiation
wounds of the pelvis. World J Surg. 1986;10(2):
269–80.
2. del Carmen MG, Eisner B, Willet CG, Fuller AF.
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3. Stiernberg CM, Williams RM, Hokanson JA. Infl uence
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4. Mullen BM, Mattox DE, Von Hoff DD, Hearne EM.
The effect of preoperative adriamycin and dihydroxy-
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5. Niranjan N. Perforator fl aps for perineal reconstruc-
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6. Park JJ, Del Pino A, Orsay CP, Nelson RL, Pearl RK,
Cintron JR, Abcarian H. Stoma complications: the
Cook County Hospital experience. Dis Colon Rectum.
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7. Thorne C, Grabb WC, Smith JW. Grabb & Smith’s
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8. Hage JJ, Beurden M. Reconstruction of acquired peri-
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22(2):127–35.
11. El-Tawil S, Carapeti E. Use of a double rhomboid
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12. Yii NW, Niranjan NS. Lotus petal fl aps in vulvo-
vaginal reconstruction. Br J Plast Surg. 1996;49(8):
547–54.
13. Wee JT, Joseph VT. A new technique of vaginal
reconstruction using neurovascular pudendal-thigh
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14. Woods JE, Alter G, Meland B, Podratz K. Experience
with vaginal reconstruction utilizing the modifi ed
Singapore fl ap. Plast Reconstr Surg. 1992;90(2):270–4.
15. Taylor GI, Corlett RJ, Boyd JB. The versatile deep
inferior epigastric (inferior rectus abdominis) fl ap. Br
J Plast Surg. 1984;37(3):330–50.
16. Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA.
Outcomes of immediate vertical rectus abdominis
myocutaneous fl ap reconstruction for irradiated
abdominoperineal resection defects. J Am Coll Surg.
2008;206(4):694–703.
17. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J.
Extended abdominoperineal resection with gluteus
maximus fl ap reconstruction of the pelvic fl oor for
rectal cancer. Br J Surg. 2007;94(2):232–8.
18. Hainsworth A, Al Akash M, Roblin P, Mohanna P,
Ross D, George ML. Perineal reconstruction after
abdominoperineal excision using inferior gluteal
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584–8.
19. Hurst RD, Gottlieb LJ, Crucitti P, Melis M, Rubin M,
Michelassi F. Primary closure of complicated perineal
wounds with myocutaneous and fasciocutaneous fl aps
after proctectomy for Crohn’s disease. Surgery.
2001;130(4):767–72; discussion 772–63.
20. Fujii M, Terashi H, Hashikawa K, Tahara S. Functional
reconstruction of large anogenital defects with bilat-
eral V-Y advancement posterior thigh fasciocutaneous
fl aps. J Plast Reconstr Aesthet Surg. 2007;60(11):
1208–13.
21. Kishi K, Nakajima H, Imanishi N, Nakajima T. Anal
and perianal reconstruction after extramammary
Paget’s disease using a posterior thigh fl ap with a thin
square wing. J Plast Reconstr Aesthet Surg.
2010;63(8):1353–6.
22. Song YG, Chen GZ, Song YL. The free thigh fl ap: a
new free fl ap concept based on the septocutaneous
artery. Br J Plast Surg. 1984;37(2):149–59.
23. Friji MT, Suri MP, Shankhdhar VK, Ahmad QG,
Yadav PS. Pedicled anterolateral thigh fl ap: a versatile
fl ap for diffi cult regional soft tissue reconstruction.
Ann Plast Surg. 2010;64(4):458–61.
24. Chetwood CH. Plastic operation of the sphincter ani
with report of a case. Med Rec. 1902;61:529.
25. Pickrell KL, Broadbent TR, Masters FW, Metzger JT.
Construction of a rectal sphincter and restoration of
anal continence by transplanting the gracilis muscle; a
report of four cases in children. Ann Surg. 1952;
135(6):853–62.
26. Cera SM, Wexner SD. Muscle transposition: does it
still have a role? Clin Colon Rectal Surg. 2005;
18(1):46–54.
27. Dev VR, Gupta A. Plastic and reconstruc-
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anal cancer. Surg Oncol Clin N Am. 2004;13(2):
339–53.
D. Ross and M. Dempsey
297
R. Cohen, A. Windsor (eds.), Anus,
DOI 10.1007/978-1-84882-091-3, © Springer-Verlag London 2014
A
Abdominoperineal resection (APR) , 79, 84
Acrodermatitis enteropathica , 266
Acute anorectal abscesses , 240
Acute anorectal sepsis , 243–245
AES. See Anal endosonography (AES)
AJCC staging system , 72, 73
Allergic contact dermatitis , 258
Ambulatory manometry , 120
Anal adenocarcinoma
neoplasms , 81
prognosis , 82, 83
recurrence , 82–83
treatment , 82
Anal canal , 221–222
anal carcinoma , 9
anal endosonography , 7–8
anal fi stula , 9–11
anatomy and histology , 284
anorectal junction , 1
blood supply , 3
caudal hindgut , 1
cushions , 2
dentate (pectinate) line , 2
epithelium , 1, 2
external anal sphincter , 2, 3
longitudinal muscle layer , 2
lymphatic drainage , 4
muscularis propria layer , 1
pudendal nerve , 3
transitional zone epithelium , 1, 2
venous drainage , 3, 4
blood supply , 45–46
cancers ( see Squamous cell
carcinoma (SCC))
causes , 283
colorectal zone , 44
faecal incontinence , 11
glands and ducts , 45
lymphatic supply , 46
magnetic resonance imaging , 8–9
manual dilatation , 213
mucosa-associated lymphoid tissue , 45
musculature , 45
nerves supply , 46
physiology
defaecation , 5
gastrocolic refl ex , 5
internal anal sphincter functions , 4
liquid and solid stool , 4
rectal defaecatory refl ex , 5
rectum , 4, 5
resting and squeeze pressures , 4
resting tone , 6
sensory receptors , 7
vector volume manometry , 5, 6
water-perfused systems , 5
squamous zone , 45
structure , 43–44
transitional zone , 44–45
Anal cushions , 158–159
Anal endosonography (AES) , 233–234
anal canal , 7–8
anal carcinoma , 9
anal fi stula , 9–11
faecal incontinence , 11
Anal gland abscess , 244
Anal glands , 222–223
Anal intraepithelial neoplasia (AIN)
Bowen’s disease , 66–67
diagnosis , 64
grades , 62
human papillomavirus , 63
Paget’s disease , 66–67
screening , 64
treatment , 64
cidofovir cream , 65
electrocautery , 65
HPV vaccination , 65
imiquimod cream , 65
infrared coagulation , 64–65
photodiagnosis , 65
photodynamic therapy , 65
Anal manometry technique , 128
ambulatory manometry , 120
high-resolution anorectal manometry , 120
standard anal manometry
age and gender , 118
probes , 117
rectoanal inhibitory refl ex , 117, 119
Index
298
Anal manometry technique (cont.)
resting anal pressure , 117–120
squeeze pressure , 117–119
technique and measurements , 117
vector volume manometry , 120
Anal margin, squamous cell carcinoma
chemotherapy/radiation , 71, 72
conservation rates , 72
defi nition , 71
Anal melanoma
diagnosis , 84
histologic descriptions , 83
incidence of , 83
treatment
abdominoperineal resection , 84
chemotherapy , 84–85
prognosis , 85
radiation therapy , 85
recurrence , 85
Anal sensory testing , 121–122, 128
Anal stenosis , 264
Anoplasty , 56
Anorectal abscesses , 228
Anorectal dysfunction , 218–219
Anorectal physiology
constipation
causes , 14
classifi cation , 14
defi nition , 13
prevalence of , 13
Rome III criteria , 13
scoring and questionnaires , 14
examination
attempted defaecation , 17
balloon expulsion , 17
DRE , 16
inspection , 16
faecal incontinence
causes , 15
classifi cation , 14–15
defi nition , 14
scoring systems , 16
high-resolution manometry , 25
manometry ( see Manometric assessment,
anorectal physiology)
neurophysiology
EMG , 28–29
PNTMLs , 30
pelvic fl oor , 13
rectal compliance
barostat measurement , 27–28
impedance planimetry , 29
pathophysiology , 29
physiological factors , 29
reproducibility , 28–29
role of , 27
sigmoidal or triphasic curve , 28
smooth muscle , 27
sensory measurements
anorectal sensation , 26
rectal sensation , 25–26
vector volume manometry , 24–25
Anorectal sepsis
acute , 243–245
chronic anal fi stulas
clinical assessment , 245–246
treatment , 246
sphincter dividing techniques
chemical seton , 248
fi stulotomy , 246–247
staged fi stulotomy , 247
tight seton , 247–248
sphincter preserving techniques
advancement fl aps , 248–249
biological materials , 250–251
fi stulectomy , 248
loose drainage seton , 248
Anorectal tuberculosis , 200
Anterior Delorme’s procedure , 100
Anterolateral thigh fl ap , 295
Anti-motility agents , 134
Artifi cial bowel sphincter (ABS)
Acticon
®
Neosphincter , 143
outcomes , 144–145
technique , 144
Atopic dermatitis , 257
B
Baboon syndrome , 265
Balloon distension thresholds , 122–123
Balloon expulsion
anorectal physiology , 17
manometric assessment,
anorectal physiology , 21
Behçet’s disease , 264
Bipolar diathermy , 177
Blaisdell bar , 203
Botulinum toxin A (BTX) , 217–218
Bowen’s disease , 66–67
Bristol Stool Chart , 133
BTX. See Botulinum toxin A (BTX)
C
Capsaicin , 278–279
Cellulitis , 269
Cervarix , 65
Chemical seton , 248
Chemoradiation (CRT) , 74, 77, 78
Chemotherapy, anal melanoma , 84–85
Chronic anal fi ssure. See also Fissures
clinical assessment and investigation , 211–212
management , 218
pathophysiology , 212
sphincter-sparing
anorectal dysfunction , 218–219
chronic fi ssure fi brosis , 218
lateral internal sphincterotomy , 219
medical management , 215–218
surgical therapies
lateral internal sphincterotomy , 213–214
manual dilatation of anus , 213
sphincterotomy , 214
Index
299
Chronic anal fi stulas
clinical assessment , 245–246
treatment , 246
Chronic fi ssure fi brosis , 218
Cidofovir cream , 65
Circular haemorrhoidectomy , 183
Cloacal malformations , 52–53
Closed haemorrhoidectomy , 182
Combined modality therapy (CMT), squamous cell
carcinoma , 75–77
Congenital anorectal abnormalities
classifi cation , 50
clinical presentation , 54
colostomy formation , 56
Currarino triad , 49
diagnosis , 54
embryology , 49–50
female defects
cloacal malformations , 52–53
imperforate anus without fi stula , 53
rectoperineal fi stula , 52
rectovaginal fi stula , 53
rectovestibular fi stula , 52, 53
male defects
imperforate anus without fi stula , 51–52
rectal atresia/stenosis , 52
rectoperineal fi stula , 50–51
rectourethral fi stula , 51
rectovesical fi stula , 51, 52
outcomes , 59–60
phenotype ranges , 49
reconstruction techniques
anoplasty , 56
posterior sagittal anorectoplasty , 56–58
posterior sagittal anorectovaginourethroplasty , 59
treatment , 54–56
Constipation, anorectal physiology
causes , 14
classifi cation , 14
defi nition , 13
prevalence of , 13
Rome III criteria , 13
scoring and questionnaires , 14
Contact dermatitis
perianal skin , 257–258
pruritus ani , 277–278
Continence
anorectal inhibitory complex and sampling , 109–110
anorectal sensation , 109
fl ap-valve theory , 107–108
fl utter valve theory , 107
intact sphincters
anal fi ssure surgery , 111
anal fi stulas surgery , 111
external anal sphincter , 111
haemorrhoid surgery , 111
obstetric injuries , 111
resting pressure , 110, 111
slow wave frequency , 110
nerve supply , 110
rectal compliance , 108–109
sphincteric theories , 108
Crohn’s disease , 262–265
Cryotherapy , 175–176
Currarino triad , 49
D
Darier’s disease , 265–266
Deep anal fi ssures , 199
Defaecating proctography , 97
Defecating proctogram technique , 113
Dermatitis
allergic contact , 258
atopic , 257
contact , 257–258
irritant contact , 258
radiation , 265
seborrhoeic , 258–259
Diet therapy, fecal incontinence , 134
Digital rectal examination (DRE)
anorectal physiology , 16
incontinence , 112, 117
Dynamic Graciloplasty Therapy Study Group (DGTSG) ,
140–141
E
Ectoparasites , 269
Electric sensory thresholds , 122
Electrocautery , 65
Electromyography (EMG)
anorectal physiology , 28–29
incontinence , 113, 124
Electrophysiology
electromyography , 124
pudendal nerve terminal motor latency , 124
Endoanal ultrasound (EAUS). See also Ultrasound (US)
incontinence , 113, 124–125
squamous cell carcinoma , 73
Entamoeba histolytica , 270
Erythrasma , 270
European Organization for Research and Treatment of
Cancer (EORTC) studies , 75, 76
External anal sphincter (EAS) , 111
electromyography , 124
haemorrhoids , 162
resting pressure , 18, 19
squeeze pressure , 20
External haemorrhoids , 265
anatomy , 157, 158
history , 163–164
symptoms , 165
F
Faecal incontinence
aetiology , 112
algorithm , 126, 127
ambulatory manometry , 120
anal sensory testing , 128
clinical utility , 122
sensory modalities , 121
technique , 122
Index
300
Faecal incontinence (cont.)
anorectal physiology
causes , 15–16
classifi cation , 14–15
defi nition , 14
scoring systems , 16
balloon distension thresholds
clinical utility , 123
technique , 122
causes of , 115, 116
clinical history , 115–116, 118
defecating proctogram , 113
defi nition , 107
diagnosis , 112
digital rectal examination , 112
direct visualisation , 112
dynamic imaging studies , 126
electric sensory thresholds
clinical utility , 122
technique , 122
electromyography , 113
electrophysiology
electromyography , 124
pudendal nerve terminal motor latency , 124
endoanal ultrasound scans , 113
general and perineal examination , 116–118
high-resolution anorectal manometry , 120
history , 111
inspection of , 112
manometry , 113
MRI , 113
rectal balloon expulsion test , 124
rectal compliance , 113, 128
clinical utility , 123
technique , 123
recto-anal inhibitory refl ex , 128
clinical utility , 120–121
components of , 120, 121
technique and measurement , 120
severity assessment , 112
standard anal manometry
age and gender , 118
probes , 117
rectoanal inhibitory refl ex , 117, 119
resting anal pressure , 117–120
squeeze pressure , 117–119
technique and measurements , 117
static imaging studies
endoanal ultrasound , 124–125
magnetic resonance imaging , 125–126
stool-substitute retention test , 124
surgical treatment
artifi cial bowel sphincter , 142–145
conservative management , 133–134
injectables , 136, 138–139
postanal repair , 135–136
posterior tibial nerve stimulation , 151
radiofrequency therapy , 136–138
sacral nerve stimulation ( see Sacral nerve
stimulation (SNS))
sphincteroplasty , 134–135
stimulated graciloplasty , 140–143
unstimulated gluteoplasty , 139
unstimulated graciloplasty , 139–140
symptom scores and diaries , 116
vector volume manometry , 120
Fecal incontinence severity index (FISI) , 135
Female defects, congenital
anorectal abnormalities
cloacal malformations , 52–53
imperforate anus without fi stul , 53
rectoperineal fi stula , 52
rectovaginal fi stula , 53
rectovestibular fi stula , 52, 53
Fibromuscular elastic layer , 93
Fissurectomy , 218
Fissures
classifi cation of
high pressure vs. low pressure , 201–202
superfi cial vs. deep , 198–199
typical vs. atypical , 199–201
description , 197
incidence , 197
pathophysiology
constipation and diarrhoea , 205–206
fi ssures in pregnancy , 206
internal anal sphincter physiology , 202–203
pecten band , 203
perineal descent , 204–205
perpetuating factors , 206–208
Fistula-in-ano
AES , 233–234
aetiology
EUA , 232–233
internal opening , 231
ischioanal fossa , 232
surgical treatment , 232
imaging , 233
MRI
extrasphincteric , 236, 237
horseshoe extensions , 237, 238
intersphincteric , 235
ischioanal , 237
preoperative , 238–239
sphincteric , 236, 237
supralevator extensions , 237, 238
technique , 234–235
Fistulotomy , 246–247
Flaps
axial , 286–287
distant
anterolateral thigh , 295
functioning muscle , 295
gluteal perforator , 291–293
microvascular , 295
posterior thigh fasciocutaneous , 293, 294
rectus abdominis myocutaneous fl ap , 290
local , 288
perforator , 288, 290, 294
random
anal stenosis post-hemorroidectomy. , 288, 289
perianal defects , 288, 291–293
Index
301
rhomboid , 288, 290
V-Y fl ap , 288, 289
Flap-valve theory , 107–108
Flutter valve theory , 107
Folliculitis , 269
Fournier’s gangrene , 228
FSG. See Full-thickness skin grafts (FSG)
Full-thickness skin grafts (FSG) , 286
Functioning muscle fl ap , 295
G
Gardasil , 65
Gastrointestinal stromal tumour (GIST) , 85
Gluteal perforator fl ap , 291–293
Gluteoplasty, unstimulated , 139
Glyceryl trinitrate (GTN) cream , 20, 215, 217
Graciloplasty
stimulated , 140–143
unstimulated , 139–140
H
Haemorrhoidal artery ligation (HAL)
diagnostic instruments , 179–180
results , 179
technique , 178–179
Haemorrhoidal disease
ambulatory treatment
bipolar diathermy , 177
cryotherapy , 175–176
HAL , 178–180
monopolar diathermy , 176–177
outpatient treatment , 177–178
photocoagulation , 176
rubber band ligation , 173–175
sclerotherapy , 171–173
operative treatment
anal mucosa , 183, 184
circular , 183
closed , 182
open , 180–181
rectal mucosa , 183
rectoanal prolapse , 185–188
SH , 188–189, 191
smooth sphincter , 184
STARR , 190–192
submucosal , 182
rectal varices , 170
vascular hyperplasia , 170, 171
Haemorrhoidectomy , 111
circular , 183
closed , 182
open , 180–181
submucosal , 182
Haemorrhoids
abdominal examination , 165
anatomy
anal cushions , 158–159
blood supply , 159–160
classifi cation , 159
external and internal , 157, 158, 163–164
foetal development , 158
histological analysis , 159
innervation , 160
lymphatic drainage , 160
sphincter complex , 159
anorectum examination , 165–166
description , 157
external haemorrhoid symptoms , 165
functional abnormalities
anal and rectal sensation , 163
increased anal pressure , 162–163
slow and ultraslow waves , 163
history , 163–164
internal haemorrhoid symptoms
bleeding , 164
discharge , 165
pain , 165
prolapse , 164–165
pruritus and perineal hygiene , 165
pathogenesis
infection/infl ammation theory , 161
sliding anal lining theory , 161
varicose vein theory , 160
vascular hyperplasia theory , 160–161
predisposing factors
abdominal and pelvic causes , 162
defecatory position , 161
diet and stool consistency , 161
genetics , 161–162
symptoms , 161
Hailey-Hailey disease , 265
Herniation , 91, 97
Herpes simplex virus (HSV) , 267–268
Hidradenitis suppurativa , 261–264
High-resolution anorectal manometry , 120
High-resolution anoscopy (HRA)
colour , 62
contour , 62
surface confi guration , 62
vascular patterns , 62
High-resolution manometry , 25
Horseshoe abscess , 225, 227
Human immunodefi ciency virus (HIV)
perianal skin , 269
squamous cell carcinoma , 81
Human papilloma virus (HPV) , 267–268
anal intraepithelial neoplasia , 64, 65
Hypertensive anal cushions , 163
Hypertonia , 206–207
I
Iceberg syndrome , 92
Imaging techniques
endoanal ultrasound
anatomical variation , 37
EAS , 36, 37
high-frequency probes , 35
IAS , 36, 37
interface refl ection , 36, 37
Index
302
Imaging techniques (cont.)
longitudinal muscle , 36, 37
vs. MRI , 40
puborectalis , 37
subepithelium , 36
transducer , 35
MRI
anatomical variations , 40
atrophy , 39
coronal T2-weighted images , 39
endocoil , 38
hypointense signal structures , 39, 40
straight axial , 38
T2-weighted fast spin-echo recommendatons/
images , 38, 39
vs. ultrasound , 40
Imiquimod cream , 65
Imperforate anus without fi stula
female defects , 53
male defects , 51–52
Infection/infl ammation theory , 161
Infrared coagulation , 65–66
Intact sphincters , 110–111
Intensity-modulated radiation therapy (IMRT),
squamous cell carcinoma , 76, 77
Internal anal sphincter (IAS) , 18, 19
haemorrhoids , 162–163
hypertonia , 206–207
physiology , 202–203
Internal haemorrhoids
anatomy , 157, 158
history , 163–164
symptoms
bleeding , 164
discharge , 165
pain , 165
prolapse , 164–165
pruritus and perineal hygiene , 165
Internal sphincterotomy , 219
Intersphincteric fi stula , 235
Intradermal methylene blue injection
Botterill and Sagar report , 279–280
Mentes’ report , 280
Sutherland report , 280–281
Intrinsic myogenic tone , 202
Introitus aspect, in nulliparous and primiparous women ,
97, 98
Involuntary squeeze pressure , 21
Irritable bowel syndrome , 13
Ischaemia , 207
Ischioanal fossa , 232, 237, 238
Itch , 275–276
L
Laparoscopic ventral mesh rectopexy , 104
Laser haemorrhoidectomy , 181
Lateral internal sphincterotomy , 213–214, 219
Leiomyoma , 85–84
Leiomyosarcoma , 85–84
Lichen planus , 260–261
Lichen sclerosus , 260
Lichen simplex chronicus (LSC) , 259
LIFT technique , 250
Loose drainage seton , 248
Loperamide , 19
Lymphogranuloma venereum (LGV) , 267
M
Magnetic resonance imaging (MRI)
anal canal , 8–9
anal carcinoma , 9
anal fi stula , 9, 10
anatomical variations , 40
atrophy , 39
coronal T2-weighted images , 39
endocoil , 38
faecal incontinence , 11
hypointense signal structures , 39, 40
incontinence , 113, 125–126
squamous cell carcinoma , 73–74
straight axial , 38
T2-weighted fast spin-echo recommendatons/images ,
38, 39
vs. ultrasound , 40
Male defects, congenital anorectal abnormalities
imperforate anus without fi stula , 51–52
rectal atresia/stenosis , 52
rectoperineal fi stula , 50–51
rectourethral fi stula , 51
rectovesical fi stula , 51, 52
Manometric assessment, anorectal physiology
absolute pressure values , 18
endurance squeeze , 21
incontinence , 113
involuntary squeeze , 21
manoeuvres , 18
mechanical strength , 17
microballoon systems , 17
protocol , 18
rectoanal inhibitory refl ex , 23–24
resting pressure
external anal sphincter , 18, 19
glyceryl trinitrate cream , 20
high-pressure zone , 18
internal anal sphincter , 18, 19
intrinsic and extrinsic autonomic
innervation , 19
loperamide , 19
resting tone of , 19
slow waves , 19
ultraslow waves , 19
solid-state systems , 17
squeeze pressure , 20
straining/defaecatory manoeuvres
anatomical abnormalities , 22
balloon expulsion , 21
defaecation , 21, 22
physiological studies , 23
Index
303
rectal intussusception , 22
rectal prolapse , 22, 23
rectocele , 22
solitary rectal ulcer syndrome , 23
water-perfused systems , 17
Metastatic Crohn’s disease , 263
Microballoon systems , 17
Microvascular fl ap , 295
Mitomycin C (MMC) , 76
Molluscum , 268–269
Monopolar diathermy , 176–177
Mucosa-associated lymphoid tissue , 45
Muscle transposition
graciloplasty
stimulated , 140–142
unstimulated , 139–140
unstimulated gluteoplasty , 139
N
National Surgical Quality Improvement Program
(NSQIP) , 135
Neurophysiology, anorectum
EMG , 28–29
PNTMLs , 30
Nicorandil , 265
Non-adrenergic, non-cholinergic (NANC)
relaxation , 202
Normal fl ora , 254
O
Obstetric injury , 15, 16, 111
Obstructed defecation (OD) , 187, 188
Open haemorrhoidectomy
laser , 181
with ligasure , 181
technique , 180
P
Paget’s disease , 66–67
Park’s postanal repair , 136
Pelvic organ prolapse (POP) , 91
Pemphigus , 265
Perforator fl ap , 288, 291, 294
Perianal hematoma , 265
Perianal region
anatomy , 284
causes , 283
preoperative planning
anal reconstruction , 285–287
defects , 285, 287
faecal diversion , 285–287
fl aps , 286–288
skin grafts , 286
reconstruction
distant fl aps , 290–295
local fl aps , 288
perforator fl aps , 288, 291, 294
principles , 285
random pattern fl aps , 288–292
Perianal sepsis
anatomy
anal canal , 221–222
anal glands , 222–223
spaces , 223, 224
classifi cations , 228
clinical presentation , 227–228
diagnosis , 239–240
Fournier’s Gangrene , 228
immunocompromised host , 228
pathophysiology
aetiology , 223–225
bacteriology , 225
horseshoe abscess , 225, 227
spread of infection , 225, 226
Perianal skin
anatomy and function , 253–254
dermatology
examination and diagnosis , 256
history , 254–256
terminology , 254
treatment , 256
infectious
bacterial STIs , 266–267
viral STIs , 267–269
non-infectious
abscesses , 263
allergic contact dermatitis , 258
anal stenosis , 264
atopic dermatitis , 257
Behçet’s disease , 264
contact dermatitis , 257–258
Crohn’s disease , 262–265
dermatitis , 257
external haemorrhoids/ perianal hematoma , 265
fi ssures and fi stulae , 263
Hidradenitis suppurativa , 261–264
irritant contact dermatitis , 257–258
lichen planus , 260–261
lichen sclerosus , 260
LSC , 259
nicorandil , 265
perianal skin tag , 264–265
psoriasis , 259–260
pyoderma gangrenosum , 264
radiation dermatitis , 265
rarities , 265–266
seborrhoeic dermatitis , 258–259
skin pigmentation , 264
skin tags , 262–263
ulcers , 263
normal fl ora , 254
perianal infections
bacterial , 269–270
helminth , 271
protozoa , 270–271
viral and fungal , 270
STIs , 256–257
Index