Reconstructive Proctology: A Narrative Review of Flap-Based Anoplasty for Aesthetic and Functional Optimization in Grade Iv Hemorrhoidal Disease
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Abstract
Hemorrhoidal disease is one of the most ubiquitous benign anorectal conditions. While early disease is largely able to be controlled and treated in the office, Grade IV hemorrhoidal disease (i.e., permanently prolapsed and irreducible hemorrhoidal cushions) requires radical surgery. The gold standard for advanced disease is excisional hemorrhoidectomy. These extremely aggressive excisional procedures are very painful and can sacrifice much of the normal anoderm. The resultant healing by secondary intention often causes an iatrogenic anatomical anal stenosis. As a result, the field of contemporary reconstructive proctology has moved towards flap-based anoplasty. Pliable and well-vascularized perianal skin is brought into the anal canal by a set of techniques such as V-Y advancement, Diamond, and House flaps to restore the reconstructive principle of like with like. These techniques are used prophylactically during primary excisional hemorrhoidectomy and reactively to reconstruct the anal canal. The pathophysiology of Grade IV hemorrhoidal disease and postoperative anal stenosis, as well as geometric issues of modern flap anoplasty, are discussed in this review. The clinical outcome is compared with the more effective one by keeping the functional continence intact and the aesthetic satisfaction.
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References
I. Lacerda-Filho A, Silva L, et al. A New Classification for Hemorrhoidal Disease: The Creation of the BPRST Staging and Its Application in Clinical Practice. Ann Coloproctol. 2020;36(5):341-348.
II. Hawkins AT, Davis BR, Bhama AR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024;67(5):614-623.
III. van Tol RR, Kleijnen J, Watson AJM, et al. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Dis. 2020;22(6):650-662.
IV. Khan AA, Mahar T, Adnan MK, et al. Postoperative recovery; Stapled Hemorrhoidopexy versus Conventional haemorrhoidectomy. Prof Med J. 2020;27(1):166-171.
V. Jiang H, et al. Modified tissue-selecting therapy repair of anal pad combined with complete anal canal epithelial retention comparing with Milligan-Morgan surgery. Arq Bras Cir Dig. 2021;34(2):e1594.
VI. Leventoglu S, Mentes B, Balci B, Kebiz HC. New Techniques in Hemorrhoidal Disease but the Same Old Problem: Anal Stenosis. Medicina. 2022;58(3):362.
VII. Zakaria R, Metwalli AM, Hegab Y, Orban YA. Outcomes of V-Y Anoplasty Technique in The Management of Moderate to Sever Post Hemorrhoidectomy Anal Stenosis. J Coloproctol. 2025;45(3):1-7.
VIII. Salama A, et al. Diamond versus V-Y advancement flaps for management anal stenosis efficacy. SGO-IASGO. 2022.
IX. Sikakulya F, et al. House advancement flap anoplasty in anal stenosis post hemorrhoids surgery: A case report. Int J Surg Case Rep. 2023;102:107894.
X. Yabanoğlu H. Outcomes of Advancement Flaps Used in the Treatment of Anal Stenosis Developing After Hemorrhoid Surgery: One Center Experience. Turk J Colorectal Dis. 2018;28(3):125-128.
XI. Gallo G, et al. Anoplasty for anatomical anal stenosis: a systematic review and meta-analysis. Colorectal Dis. 2021.
XII. Elbanna H, et al. Role of simultaneous V-Y advancement flap during hemorrhoidectomy (Milligan-Morgan) in preventing anal stenosis. Zagazig Univ Med J. 2016.
XIII. Zheng Z, et al. Double-diamond-shaped flap anoplasty vs scar revision surgery for severe anal stenosis. World J Clin Cases. 2022;10(24):7698-7706.