Introduction

Anal stenosis is a rare but serious condition which appears as fibrous constriction of the anal canal. Although the main cause is previous perianal surgery, especially hemorrhoidectomy (over 90%), it may develop due to radiotherapy, trauma, Crohn’s disease and tuberculosis [1]. Anal stenosis is classified into three groups—mild, moderate and severe—according to anal examination with Hill Ferguson (HF) retractor or index-small finger [2].

In this educational video, we demonstrate an advancement flap anoplasty in a patient who developed a severe anal stenosis after Milligan–Morgan hemorrhoidectomy.

Case report

The patient, a 57-year-old male, was admitted to the outpatient clinic with severe anal stenosis which did not allow the insertion of a finger (Fig. 1). A house advancement flap was performed (Fig. 2).

Fig. 1
figure 1

Severe anal stenosis

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Fig. 2
figure 2

House advancement flap anoplasty

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Postoperative care consisted of the administration of intravenous 1000 mg ceftriaxone and 500 mg metronidazole for 5 days and perianal wound care twice a day with sterile saline solution and chloramphenicol ointment. For pain control, tramadol hydrochloride was used for first 2 days and paracetamol for the following days.

The patient reported that his defecation had returned to normal, but he still had pain on postoperative day 15. At 6-month follow-up, there was no evidence of complications or recurrence and the patient no longer had pain.

House advancement flap is one of the surgical options to treat anal stenosis.

Alver et al. performed house advancement flap in 28 patients, eight of whom had anal stenosis. They reported that except for one patient who had surgery due to rectovaginal fistula and subsequently developed recurrence, the rest of the patients were satisfied with the procedure [3]. Three of the patients had minimal postoperative wound dehiscence.

Owen HA et al., in their study of 13 patients with benign anorectal disease who had house advancement flap, reported that the procedure failed in three patients (who had fistula surgery), while it was successful in the remaining patients [4].

In their study of 60 patients comparing the house advancement flap, rhomboid flap, and Y–V anoplasty, Farid M et al. showed that house advancement flap had the best outcomes in terms of postoperative complications, quality of life, and recurrence with the only disadvantage being a long operating time [5].

Especially in severe anal stenosis, house flap anoplasty provides reduced tension at the suture line and better blood supply to the flap, which makes it more reliable than other flap procedures.