Anal Sphincter Repair
Original Editor - Khloud Shreif
Top Contributors - Khloud Shreif and Vidya Acharya
Description
Fecal incontinence is a condition that affects a person’s daily life. It leads to emotional distress, social embarrassment, and physical discomfort. People with FI feel anxious about leaving their homes and attending social events. Over time, this can lead to isolation, loss of confidence, and low self-esteem, and may even contribute to depression.
Procedures
There were different surgical procedures developed to correct external anal sphincter (EAS) where the original sphincter cannot be fully restored. The procedure depends on the degree of damage to the sphincter.
Crossed Flap Puborectalis Muscle Reconstruction (CFPRM )
During this procedure, a flap from the puborectalis is dissected from the symphysis pubis anteriorly to keep the innervation to the muscle to be able to work properly as a sphincter, and then the flap is sutured to the tip of the remaining part of the original EAS.
Puborectalis is used in this surgery as it shares the same nerve supply as EAS, hence, the contraction and relaxation will be synchronous.
This procedure can be carried in cases of when sphincter defect does not allow an end-to-end or overlap reconstruction, can be used in patients with rectovaginal fistula and rectovaginal cloaca and not indicated in cases with nerve damage or atrophied puborectalis muscle[1].
Graciloplasty
The gracilis muscle (as one of the adductors ) used in this procedure, rich in neurovascular supply proximally and has enough length to make it easy to overlap around the anus. This procedure was divided into two types:
Adynamic/ unstimulated Graciloplasty
A single incision was made 2cm below the landmark surface of adductor longus on the medial aspect of the thigh, then the insertion end was cut and the muscle pulled up proximally until its blood supply (terminal branch of medial circumflex femoral artery) was seen. A tunnel between the perianal incision and the proximal thigh incision will be created to pass the muscle and wrap it around the anus. At the end, the free end of the muscle was inserted into the ischial tuberosity with stitches, allowing for only one finger to pass gently. It was first described in 1952 when they attempted to restore continence function in four children[2].
Dynamic Graciloplasty
Unlike adynamic graciloplasty two incision sites are made, the stimulator electrode is attached to the muscle and stimulation test is carried intra-operation, when the best contraction is achieved the stimulator unit will be fixed in a subcutaneous pocket that is usually in the ipsilateral site of thigh[3].
One of the disadvantages and challenges with gracilis, it contains mainly type II, fast-twitch muscle fibers, which explains the long-term failure of muscle and learning patients to contract it is hard as it has nothing in common with PFM. This is overcome by the surgeon by tightening the muscle wrap around the anus to reduce the required power of contraction. They thought the morbidity rate of the limb after transplantation was rare, unlike gluteoplasty[3]. However, the distal end of the gracilis muscle has a poor blood supply and is prone to ischemic injury then become fibrotic more than contractile muscle[4].
Gluteoplasty (Gluteus Maximus Plasty)
It was the first muscle flap performed for augmenting the anal sphincter reported in 1902, where the gluteus muscle were detached from the femur insertion and wrapped around the anus in a scissor-like configuration, later on in 1982 another technique was described by Hentz, whereby the gluteus muscles were detached from their origin at sacral and coccygeal and wrapped around the anus.
Gluteus maximus works in synchronization with EAS to help with defecation, and in some normal people, they use its contraction to prevent continence and leakage in urgent situations. In addition, because of its functional position to help keep the erect position, its fibers have characteristics similar to muscles type 1 muscle fiber which is fatigue resistant.
Adynamic/ unstimulated gluteoplasty
The innervation to the gluteus maximus (inferior gluteal nerve) divides into three branches: upper, middle, and lower to supply the muscle before entering. This enables harvesting the lower third of the muscle while keeping the intact of the neurovascular bundle.
Mostly one incision is made at one side of the gluteus, the first one at the lower third of the muscle, and another one on the opposite side over the anus and near the ischial tuberosity. The lower third of the transposed muscle is split and wrapped around the anal canal, then attached to the ischial tuberosity of the other side to form a tight muscular cuff. The bulk of the muscle helps maintain the compression around the anal canal[4].
Gluteus maximus is easier for the patient to retrain, form a true muscle bulk around the anus, not a tendon, and it is the best and last-choice option, designated for cases of end-stage incontinence, destroyed EAS can not be repaired. Young patients with severe sphincter defects are the best candidates for this surgery.
Indications
- Obstetric trauma (vaginal birth labour)
- Anal malformation in children
- Anorectal surgery
- Rectoanal fistula
- Rectovaginal fistula
- External rectal prolapse[1]
- Neurogenic causes
Diagnostic Tests
- Rectal manometry
- Pudendal nerve terminal motor latency
- Three-dimensional endoanal ultrasound
- Pelvic magnetic resonance imaging
- X-ray cine defecography
Post-operative Management
- Early ambulation after 24 hours is recommended.
- Caring of wound and scar of incision to avoid infection.
- Advise patients to avoid heavy lifting, straining, vigorous physical activity for about 6 weeks post-surgery.
- From day 10 post-operative: advise patients to start exercising the gluteus maximus contraction to simulate the control maneuvers.
Pelvic floor training
Pelvic floor muscle rehabilitation program:
- Gradual pelvic floor muscle training (fast and slow contractions)[5][6], patient can start with 4 sets of 10 squeezes per session, 3 times daily[7].
- Biofeedback training can be added for patients who can not contract/ squeeze or sustain contraction of the muscle[4] and can be started from the fourth week post surgery[8].
- Electrical muscle stimulation to stimulate and enhance muscle strength and endurance[9], tibial nerve stimulatation[10] [11]
Resources
Japanese Practice Guidelines for Fecal Incontinence
NHS: Physiotherapy, Obstetric Anal Sphincter Injury
References
- ↑ 1.0 1.1 Longo A. Reconstruction of Wide Anal Sphincter Defects by Crossing Flaps of Puborectalis Muscle. InAnal Incontinence: Clinical Management and Surgical Techniques 2022 Oct 10 (pp. 197-204). Cham: Springer International Publishing.
- ↑ Gohil AJ, Gupta AK, Jesudason MR, Nayak S. Graciloplasty for anal incontinence—is electrical stimulation necessary?. Annals of Plastic Surgery. 2019 Jun 1;82(6):671-8.
- ↑ 3.0 3.1 Barišić G, Krivokapić Z. Adynamic and dynamic muscle transposition techniques for anal incontinence. Gastroenterology report. 2014 May 1;2(2):98-105.
- ↑ 4.0 4.1 4.2 Balakrishnan TM, Yanamadala S, Janardhanam J. Unstimulated Gluteus Maximus Sphincteroplasty for Bowel Incontinence. Indian Journal of Plastic Surgery. 2023 Feb;56(01):022-30.
- ↑ Mathé M, Valancogne G, Atallah A, Sciard C, Doret M, Gaucherand P, Beaufils E. Early pelvic floor muscle training after obstetrical anal sphincter injuries for the reduction of anal incontinence. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2016 Apr 1;199:201-6.
- ↑ Pucciani F, Ringressi MN, Redditi S, Masi A, Giani I. Rehabilitation of fecal incontinence after sphincter-saving surgery for rectal cancer: encouraging results. Diseases of the colon & rectum. 2008 Oct 1;51(10):1552-8.
- ↑ Ofluoglu CB, Aydin IC, Altuntas YE, Cetin K, Inan R, Ilhan N, Mulkut F, Kucuk HF. Impact of pelvic floor muscle training on sphincter function and quality-of-life in patients who underwent low anterior resection: A comparative evaluation. Northern Clinics of Istanbul. 2024 Jul 30;11(4):336.
- ↑ Farid M, Moneim HA, Mahdy T, Omar W. Augmented unilateral gluteoplasty with fascia lata graft in fecal incontinence. Techniques in Coloproctology. 2003 Apr;7(1):23-8.
- ↑ Aziz DE, Rizkalla NF, Naguib MT, Habib EK, Bekheet EA. A Study of the Effect of Cutaneous Electric Stimulation on the Structure of The Anal Sphincter of Rat After Induction of Anal Muscle Injury. The Egyptian Journal of Anatomy. 2024 Apr 1;43(2):412-27.
- ↑ Jin Q, Zhu Y, Yin P, Li X. Tibial nerve electrical stimulation for fecal incontinence: a systematic review and meta-analysis. Updates in Surgery. 2023 Aug;75(5):1059-70.
- ↑ Hosker G, Cody JD, Norton CC. Electrical stimulation for faecal incontinence in adults. Cochrane database of systematic reviews. 2007(3).