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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 16-19

A new modification of limberg flap for correction of severe anal stenosis


Department of Plastic Surgery, S. L. Raheja/Fortis Hospital, Mumbai, Maharashtra, India

Date of Submission28-Oct-2019
Date of Acceptance25-Apr-2020
Date of Web Publication30-May-2020

Correspondence Address:
Ajitkumar Shripad Borkar
40/B, Shankar Smruti. Sir Bhalchandra Road, Dadar (East), Mumbai - 400 014, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_4_19

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  Abstract 


This case presents two new concepts. First, a new modification of Limberg flap is introduced where the flap is raised by extending the long axis of the rhombic defect. It is particularly useful for correction of contracture with the vector of release lying along the short axis. Second, we are introducing a novel method for surgical treatment of moderate or severe anal stenosis. This flap brings an ample amount of skin with excellent blood supply and mobility with the least amount of tension at the suture line. It also allows the excision of the cicatrix and can avoid internal sphincterotomy. Donor site closure scar does not add to the vector of contracture.

Keywords: Anal stenosis, anoplasty, Limberg flap, rhombic flap


How to cite this article:
Borkar AS, Kulkarni UY. A new modification of limberg flap for correction of severe anal stenosis. Indian J Colo-Rectal Surg 2019;2:16-9

How to cite this URL:
Borkar AS, Kulkarni UY. A new modification of limberg flap for correction of severe anal stenosis. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2020 Sep 29];2:16-9. Available from: http://www.ijcrsonweb.org/text.asp?2019/2/1/16/285425




  Introduction Top


Traditionally, a Limberg flap is used to cover a rhombic-shaped defect by making the use of adjacent skin laxity at right angle to the short axis of defect. We are introducing a modification where the skin laxity at right angle to the long axis is utilized. This in effect rotates the rhombic through 90° so that the axes get interchanged, the difference in their lengths providing additional release along the direction of the short axis [Figure 1] and [Figure 2]. This modification makes the flap particularly suitable for contractures where you expect more release later because of the gradual stretching of underlying tissue such as muscle or ligament.

Anal stenosis provides a perfect example of such a contracture where you can preserve the tight sphincteric muscle during the contracture release and stretch it later with dilatation. Surgical intervention in the form of anoplasty, internal sphincterotomy, or both is advocated for moderate or severe grade anal stenosis. Sphincter preservation is advisable as sphincterotomy can result in anal incontinence. Most of the anoplasty methods, for example, house flap, diamond flap, and V-Y plasty, are dependent on and limited by subcutaneous tissue for mobility and blood supply. Our modification of Limberg flap maintains a skin pedicle which is superior in both. It provides ample healthy skin without tension at the suture lines, thus avoiding wound dehiscence and providing for future stretching of the sphincter. It is easy to learn and execute. We suggest it as a mainstay of surgical treatment for anal stenosis.
Figure 1: Diagrammatic representation of flap planning

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Figure 2: Diagrammatic representation of flap insetting

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  Case Report Top


A 44-year-old male presented with complaints of painful defecation, hard stools, recurrent constipation, and bleeding while passing stools. The symptoms developed after hemorrhoidectomy which he had undergone 3 years back. On examination, he was found to have a very tight anal opening which did not allow digital examination. Under anesthesia with relief from anal spasm, still, it was not possible to do a digital examination. Anal opening was dilated with Hagar's dilators till a pediatric size proctoscope could be introduced [Figure 3]. It revealed a severe diffuse tubular anal canal stenosis extending above the dentate line. The patient was planned for anoplasty with or without internal sphincterotomy.
Figure 3: Preoperative evaluation of anal stenosis

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The patient was put in a lithotomy position. Anal region and perineum were prepared and draped. Incisions were marked along the longitudinal axis of the anal canal at 3 o'clock and 9 o'clock positions. They extended from healthy anoderm to about 1 cm above the dentate line. The circumferential contracture was released carefully from distal to proximal till supple base was reached [Figure 4]. The sphincteric muscle was found to be quite pliable and was left alone. The adequacy of the release was confirmed by easy passage of adult size proctoscope.
Figure 4: Release of anal stenosis at 3 and 9 o'clock positions

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The release of contracture left a rhombic defect ABCD with the long-axis AC lying along the longitudinal axis of the anal canal. The long-axis AC was extended up to E so that CE equaled any side of the rhombic. A line EF was drawn parallel and equal in length to BC [Figure 1] and [Figure 5]. A rhombic flap BCEF was raised and inset in the defect so that points F and C and points E and D were approximated and the donor defect was closed primarily [Figure 2] and [Figure 6]. The release of anal stenosis was reconfirmed with the easy passage of adult size proctoscope.
Figure 5: Planning of the flaps

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Figure 6: Insetting of the flaps

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Postoperatively, the patient was given laxatives and stool softeners. Sutures were removed after 2 weeks. Anal diameter was confirmed every week with the passage of adult size proctoscope for 6 weeks and then twice a month for 6 months [Figure 7]. The patient did not suffer from either constipation or anal incontinence.
Figure 7: Postoperative result after 6 months

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  Discussion Top


Limberg flap was first described by Prof. A. A. Limberg of Leningrad in 1928. It was introduced in English in 1963.[1] A classic Limberg flap involves a rhombic transposition flap with angles of 60° and 120° and sides of equal length. It is planned by extending the short axis of the rhombic defect it is meant to cover. The variations of Limberg flap by Dufourmentel or Webster are also designed near the short axis of the defect, and all of them use the laxity along the long axis to close the donor defect primarily.[2],[3] If the vector of contracture was to lie along the short axis of the defect, then the scar of donor site closure in these flaps would actually add on to the tendency to contract as in anal stenosis.

The modification of Limberg flap that we suggest is planned along the long axis of the defect which is extended equally to a side of the rhombic defect. A line parallel to side of defect is dropped from the end, again equal in length. It gives a transposition flap with sides equal to the sides of defect but with an obtuse angle of 150° and an acute angle of 30° for a classic Limberg defect (120° and 60°). This flap uses the laxity along the short axis of the defect for primary closure, the scar of donor site closure being at right angle to the vector of contracture in anal stenosis. In effect, this flap brings a lot of skin for the contracture release.

Anal stenosis is a rare, incapacitating condition. Ninety percent of anal stenoses follow overzealous hemorrhoidectomy.[4] It was more common after whitehead hemorrhoidectomy as compared to Milligan-–Morgan or stapled rectal mucosectomy.[5] The patient presents with complaints of painful defecation, bleeding, constipation, and narrow string-like stools. Examination under anesthesia eliminates the “functional” stenosis caused by sphincteric spasm and reveals “anatomic” or “cicatricial” stenosis. It is then graded as per Milson and Mazier classification[6] as follows:

  • Mild: Digital examination possible
  • Moderate: Prior mechanical dilatation required for digital examination
  • Severe: Digital rectal examination is not possible.


The best treatment for postsurgical anal stenosis is prevention. Mild stenosis is managed with stool softeners, fiber supplements, and dilatations. Moderate and severe stenoses require surgical intervention, either internal sphincterotomy or anoplasty or both. Various methods of anoplasty have been described using anal mucosa or anoderm such as mucosal advancement flaps, Y-V plasty, V-Y plasty, U-flap, C-flap, house flap, diamond flap, and rhomboid advancement flap.[7],[8] Almost all of these flaps are dependent on the limited mobility and vascularity provided by subcutaneous base. It causes tension, necrosis, and dehiscence at suture line with resultant recurrence of stenosis. A Limberg flap has certain distinct advantages:

  • It is easy to learn and execute
  • It brings pliant, healthy, and highly vascular skin into defect
  • Donor site laxity is used to avoid tension at the suture line where it matters
  • Less chances of suture line dehiscence
  • Less morbidity and hospital stay
  • It can be used bilaterally.


The modification we have suggested by raising the flap along the long axis of the rhombic defect has additional advantages:

  • It brings substantial additional skin along the direction of contracture release
  • It allows for future stretching of tight sphincter with dilatation, thus giving the option of avoiding sphincterotomy and possible anal incontinence
  • The donor site scar does not add on to the vector of contracture.


We strongly recommend it as a primary method of choice for moderate or severe postsurgical anal stenosis. In short, this modification of Limberg flap is ideal for contractures released along the short axis of the rhombic defect where you expect further lengthening in the future of the tight base formed by tissues such as muscle, tendon, ligament, or capsule.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank Miss Priyanka Borkar for technical assistance and artwork creation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gibson T, editor. Modern trends in plastic surgery. London: Butterworths; 1964.  Back to cited text no. 1
    
2.
Lister GD, Gibson T. Closure of rhomboid skin defects: The flaps of Limberg and Dufourmentel. Br J Plast Surg 1972;25:300-14.  Back to cited text no. 2
    
3.
Webster RC, Davidson TM, Smith RC. The thirty degree transposition flap. Laryngoscope 1978;(1 Pt 1):85-94.  Back to cited text no. 3
    
4.
Brisinda G. How to treat haemorrhoids. Prevention is best; haemorrhoidectomy needs skilled operators. BMJ 2000;321:582-3.  Back to cited text no. 4
    
5.
Wolff BG, Culp CE. The Whitehead haemorrhoidectomy. An unjustly maligned procedure. Dis Colon Rectum 1988;31:587-90.  Back to cited text no. 5
    
6.
Milson JW, Mazier WP. Classification and management of postsurgical anal stenosis. Surg Gyne Obst 1986;163:60-4.  Back to cited text no. 6
    
7.
Brisinda G, Vanella S, Cadeddu F, Marniga G, Mazzeo P, Brandara F, et al. Surgical treatment of anal stenosis. World J Gastroenterol 2009;15:1921-8.  Back to cited text no. 7
    
8.
Sloane JA, Zahid A, Young CJ. Rhomboid-shaped advancement flap anoplasty to treat anal stenosis. Tech Coloproctol 2017;21:159-61.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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