Whitehead Deformity of Anus, S-Plasty Repair

.J.~.xlzs A. FERGUSOX, M.D.

DR. FERGUSON

Dr. MacKeigan, Dr. Sullivan, members and guests. I have often heard the remark that the Whitehead deformity is a misnomer, that it is a miscarriage of justice, that it is a perversion of an excellent surgical procedure at the hands of inept people, and I wel- comed the o p p o r t u n i t y to talk to Mr. Lockhar t - Mummery today, and others who are familiar with the British medical and surgical history because I had no firsthand knowledge of Walter Whitehead's pe r- formance. Mr. Lockhar t -Mummery tells me that this procedure was introduced early in the 20th century, let's say 1906, and that it was discredited in the fall of 1906. So my notions, though preconceived, seem to have been accurate. I do not want to derogate Dr. Whitehead, but nonetheless the defect that I am talk- ing about is the defect of ectropion or exteriorization of anal mucosa caused by a Whitehead type of am- putative hemorrhoidec tomy that could be caused by other things; t rauma probably, it has to be some phys- ical insult and it usually is surgical. I would like to point out, before I discuss this, that these patients are not incontinent. Thei r proprioceptive apparatus in the rectal ampulla is quite normal. They know when they want to have a bowel movement; they would be able to control it if they didn' t have a foreign body in the anus, namely the mucosal tube, and they have a mucosal secreting lesion of the skin surface of the body, namely at the anal outlet, which prevents that bowel from working satisfactorily, and even though it will pucker, and even though it tries to bite, it can't, because there is something in the way, namely the mucosal tube.

To orient you, this position is left lateral, posterior is at your left, anterior is at the right, right above, left below, so you can see this defect, this anal outlet that has mucosa at the anal verge; it is rigid, inelastic, can- not pucker, cannot bite; it has all the dynamic poten- tial of a knothole, and a wet knothole at that! The disability is that caused by chronic anal and perianal moisture. We don' t see these defects commonly; I don' t know of anybody that is doing a Whitehead type

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Ferguson Clbzic, Grand Rapids, Michigan

amputat ion anymore, but we will see maybe three or four of them per year. In the early '60's we had sev- eral such patients and realized that we just didn ' t have any adequate way to repair the deformity. T h e surgi- cal problem obviously is to get that mucosa out of the anal canal and get it relined with skin. Split thickness is not adequate nor is it dependable; at any rate, early in the '60's we invented and developed the flap-swing operation which has stood the test of time and which can be reliably expected to produce the effect that we want. Now it depends on a few raajor things. Y o u r local skin has to be good, healthy, elastic, thick, well- vascularized skin. If you try to do this procedure, or any other procedure as far as that goes, on perianal skin which is at tenuated, tissue-paperlike, you just won't succeed. You must have healthy skin; you must have healthy flaps and it should be ne ighborhood skin. As you see here, this ne ighborhood skin is quite good, and we therefore devised a system whereby we can rotate flaps into the anal canal after we have dis- sected out and amputa ted the mucosa which now cov- ers all of the internal sphincter. These are jus t pencil lines outlining the flaps and they encompass certain basic plastic surgical principles. You can see why it's called an s-plasty; what else, with that sort of config- uration? But the base of the flap on the right, which is here, and the base of the flap on the left, which is here, has to be somewhat longer than the alti tude of the flap, which is roughly here and roughly here. As you know, plastic surgically speaking, long narrow flaps are apt to die and you try to plan this so that the flaps will swing. It is an amazingly easy thing, once you get it laid out and once you get the hang of it. All right, we lay out the flaps early the first thing in the procedure because we want to have as much time in the operating room as possible to see if the flap dark- ens or is embarrassed in any way, and then having laid out the flaps, we circumcise the mucosa, expose the internal sphincter muscle, amputate the mucosa at the estimated anorectal line and then rotate or swing these flaps into the anal canal; the pivotal point for the left flap will be here, the pivotal point for the

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right flap will be here. These two points move very little. These points (this margin here and about that much of this margin) swing into the anal canal f rom the left and into the anal canal f rom the' right and I wilt show you how nicely it works. T h e flaps are being developed here; and, as I say, these flaps must be full thickness plus a mill imeter or two of fat in every at- tempt to obtain good viable flaps. Overzealous control of bleeding with ei ther cautery or suture material is to be avoided because it may cause little points of necro- sis unde r your flaps. We used, originally, chromic catgut; I think the new suture materials are b e t t e r - - Dexon, cotton, and silk are even very acceptable. You can use them in the anal canal; they cause very little reaction; they can be taken out as necessary.

You see here these flaps have been developed full thickness and tied back temporar i ly to the sur round- ing skin of the buttocks. We are starting to dissect the mucosa out of the anal canal. Here again your flaps are waiting to be swung, the mucosa is being taken out of the anal canal and here we have rotated the left- hand flap in like this; your flap is going to be along your est imated anorectal line right there. Fu r the r evidence of rotat ion of the lefthand flap and you get a semilunar defect of the skin f rom whence you have rotated the flap, but these ahnost inva~-iably can be closed loosely. T h e r e is a lef thand flap rotated in en- tirely. You see the pivotal point of the !ef thand flap and the swinging point of the r ighthand flap will meet each o ther and abut in the poster ior midline and the reverse is t rue in the anter ior midline. These can then be closed leisurely. When you talk about these things, you always talk like they are so easy, but they are not. Here we bring down the r ighthand flap. It will be sewn at the estimated anorectal line and then this line and this line, the pivotal point here and the leaning edge of the left flap, will be sewn in the anter ior mid- line. T h e resulting ellipses of skin of the buttocks can be closed, whichever way they go gracefully; the;,, can be left open if it is entirely necessary, but it really never is. You get this kind of a functional result with an anus which is lined with skin. T h e n we thought

originally, what about an anus lined with hair-bear ing skin? Would there be a lot of hang-ups there, you know, but, as it turns out, over the years, this hair- bear ing skin becomes smooth and hairless with use, and the results are excellent.

This is about 10 days postoperatively. I must admit to you that I switched patients on you here because I couldn ' t find the o ther slides on that one I've just shown to you, but anyway this is about 10 days post- operatively. It is intr iguing to look in there with a little anoscope and see how the tip of that flap is doing. Here you can see there was some death of skin along the poster ior edge, the leading edge of that r ight flap. This has occur red occasionally and we have lost as much as one third of the long dimension of a flap, however, the cor ium seems to be health,,' and a plane for re-epithelialization is there and it happens very rapidly. Now these are not pliant outlets in the first week. Th ey are a little bit rigid, naturally they would be; they are healing, but they do assume pliancy very quickly and it is amazing how closely the;,' imitate the normal anal canal; they are dry and they pucker and they' bite.

T h a n k you, Dr. MacKeigan.

DR. MAcKEIGAN

T h a n k you very much, Dr. Ferguson. I can assure you that not all of us can do it with the facilit;, that Dr. Ferguson can do it. T h e r e is much more involved in many aspects, I 'm sure; and there are going to be details that you people may want to know about and any o ther applications of the p rocedure ei ther for s tenosis or mucosa l p r o l a p s e o r any o t h e r cir- cumstance. So I invite you to start your questions. T h e r e will be people circulating in the aisles and we will move the questions forward and get them assem- bled for the panelists. Next we have Dr. Manuel Car- bonell, an associate of Dr. Larkin in Miami, who will be p r e s e n t i n g t h e i r e x p e r i e n c e wi th p o s t e r i o r proctotomy.