Tech Coloproctol (2015) 19:53–56 DOI 10.1007/s10151-014-1221-1
THE LAST IMAGE
Anal sphincteroplasty and gracilis muscle transposition using transvaginal access in a patient with fecal incontinence A. N. Yu¨cesoy • M. Cifc¸i • S. Poc¸an
Received: 1 July 2014 / Accepted: 8 September 2014 / Published online: 30 October 2014 Ó Springer-Verlag Italia Srl 2014
We performed anal sphincteroplasty and gracilis muscle transposition operation using transvaginal access in a 32-year-old woman who with incontinence to solid stool after obstetric trauma (Fig. 1a). Rectal ultrasonography revealed a 25 % defect of the internal anal sphincter and a 40 % defect of the external anal sphincter ventrally. Surgery was performed in lithotomy position. The anal canal was mobilized circumferentially through and in the posterior vaginal wall (Fig. 2a, b). Repair of internal and external sphincters with No 0 vicryl U-sutures was performed (Fig. 3a). The gracilis muscle was isolated and
transposed to sublevator level via a subcutaneous tunnel (Fig. 3b). Anal canal was surrounded by gracilis muscle (Fig. 4a, b) which was sutured to itself with No 0 vicryl U-sutures, to subcutaneous external anal sphincter and ischial tuberosity bilaterally (Fig. 5). Vaginal and femoral incisions were closed after leaving a drain in the sublevator region (Fig. 1b). Postoperative course was uneventful. Pelvic MR imaging obtained at the third week postoperatively showed right gracilis muscle flap, surrounding the anal canal (Fig. 6a, b). The patient was followed up for 3 months and is fully continent to gas, liquids and solids.
A. N. Yu¨cesoy (&) General Surgery Department, Batı Bahat Hospital, Atatu¨rk mah. ˙Ikitelli cad. No:135 K.C¸ekmece, Istanbul, Turkey e-mail: [email protected] M. Cifc¸i Plastic Surgery Department, Batı Bahat Hospital, Istanbul, Turkey S. Poc¸an Radiodiagnostic Department, Batı Bahat Hospital, Istanbul, Turkey
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Fig. 1 a Preoperative and b postoperative view of the patient after anal sphincteroplasty and gracilis transposition using vaginal access
Fig. 2 Surgical exposure of the internal and external anal sphincters after transvaginal access (a posterior vaginal wall, b prolapsed rectal wall from ventral sphincteric defect and c ventrally ruptured external anal sphincter)
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Fig. 3 a Transvaginal sphincter repair (a posterior vaginal wall, b anal sphincteroplasty line and c penrose drain surrounding the anus). b The gracilis muscle transposition after preserving its
proximal pedicle (a transvaginally transposed gracilis muscle, b subcutaneous tunnel for gracilis transposition and c femoral incision for gracilis muscle isolation)
Fig. 4 a Transvaginal gracilis transposition (a anal sphincteroplasty line, b transposed gracilis muscle and c subcutaneous tunnel). b The transposition of the gracilis muscle around the repaired sphincters
(a anal sphincteroplasty line, b transposed gracilis muscle and c subcutaneous tunnel)
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Fig. 5 Completion of the transvaginal gracilis transposition (a posterior vaginal wall, b the gracilis muscle wrapped around the low rectum and c subcutaneous tunnel)
Fig. 6 Coronal and axial MR images of the transposed gracilis muscle in sublevator level (white arrows transposed gracilis muscle at sublevator level) Conflict of interest
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None.
THE LAST IMAGE
Anal sphincteroplasty and gracilis muscle transposition using transvaginal access in a patient with fecal incontinence A. N. Yu¨cesoy • M. Cifc¸i • S. Poc¸an
Received: 1 July 2014 / Accepted: 8 September 2014 / Published online: 30 October 2014 Ó Springer-Verlag Italia Srl 2014
We performed anal sphincteroplasty and gracilis muscle transposition operation using transvaginal access in a 32-year-old woman who with incontinence to solid stool after obstetric trauma (Fig. 1a). Rectal ultrasonography revealed a 25 % defect of the internal anal sphincter and a 40 % defect of the external anal sphincter ventrally. Surgery was performed in lithotomy position. The anal canal was mobilized circumferentially through and in the posterior vaginal wall (Fig. 2a, b). Repair of internal and external sphincters with No 0 vicryl U-sutures was performed (Fig. 3a). The gracilis muscle was isolated and
transposed to sublevator level via a subcutaneous tunnel (Fig. 3b). Anal canal was surrounded by gracilis muscle (Fig. 4a, b) which was sutured to itself with No 0 vicryl U-sutures, to subcutaneous external anal sphincter and ischial tuberosity bilaterally (Fig. 5). Vaginal and femoral incisions were closed after leaving a drain in the sublevator region (Fig. 1b). Postoperative course was uneventful. Pelvic MR imaging obtained at the third week postoperatively showed right gracilis muscle flap, surrounding the anal canal (Fig. 6a, b). The patient was followed up for 3 months and is fully continent to gas, liquids and solids.
A. N. Yu¨cesoy (&) General Surgery Department, Batı Bahat Hospital, Atatu¨rk mah. ˙Ikitelli cad. No:135 K.C¸ekmece, Istanbul, Turkey e-mail: [email protected] M. Cifc¸i Plastic Surgery Department, Batı Bahat Hospital, Istanbul, Turkey S. Poc¸an Radiodiagnostic Department, Batı Bahat Hospital, Istanbul, Turkey
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Tech Coloproctol (2015) 19:53–56
Fig. 1 a Preoperative and b postoperative view of the patient after anal sphincteroplasty and gracilis transposition using vaginal access
Fig. 2 Surgical exposure of the internal and external anal sphincters after transvaginal access (a posterior vaginal wall, b prolapsed rectal wall from ventral sphincteric defect and c ventrally ruptured external anal sphincter)
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Fig. 3 a Transvaginal sphincter repair (a posterior vaginal wall, b anal sphincteroplasty line and c penrose drain surrounding the anus). b The gracilis muscle transposition after preserving its
proximal pedicle (a transvaginally transposed gracilis muscle, b subcutaneous tunnel for gracilis transposition and c femoral incision for gracilis muscle isolation)
Fig. 4 a Transvaginal gracilis transposition (a anal sphincteroplasty line, b transposed gracilis muscle and c subcutaneous tunnel). b The transposition of the gracilis muscle around the repaired sphincters
(a anal sphincteroplasty line, b transposed gracilis muscle and c subcutaneous tunnel)
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Tech Coloproctol (2015) 19:53–56
Fig. 5 Completion of the transvaginal gracilis transposition (a posterior vaginal wall, b the gracilis muscle wrapped around the low rectum and c subcutaneous tunnel)
Fig. 6 Coronal and axial MR images of the transposed gracilis muscle in sublevator level (white arrows transposed gracilis muscle at sublevator level) Conflict of interest
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None.
