Bilateral Gluteus Maximus Transposition for Anal Incontinence Russell K. Pearl, M.D., M. Leela Prasad, M.D., Richard L. Nelson, M.D., Charles P. Orsay, M.D., Herand Abcarian, M.D. From the Section of Colon and Rectal Surgery, Cook County Hospital, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois Pearl RK, Prasad ML, Nelson RL, Orsay CP, Abcarian H. Bilateral gluteus maximus transposition for anal incontinence. Dis Colon Rectum 1991;34:478-481.
Seven patients (five men and two women) ranging in age from 26 to 65 years (5~-- 44) underwent bilateral gluteus maximus transposition for complete anal incontinence. The indications for operation were sphincter destruction secondary to multiple fistulotomies (n = 4), bilateral pudendal nerve damage (n = 2), and high imperforate anus (n --- 1). The procedure is performed without the use of a diverting colostomy. The inferior portion of the origin of each gluteus maximus is detached from the sacrum and coccyx, bifurcated, and tunneled subcutaneously to encircle the anus. The ends are then sutured together to form two opposing slings of voluntary muscle. Postoperatively, six patients regained continence to solid stool, two to liquid stool as well, and only one patient in this group was able to control flatus. Although resting pressures remained unchanged, voluntary squeeze pressures were restored by this operation. In addition, rectal sensation was markedly improved, which helps make this a worthwhile procedure for properly selected patients. [Key words: Fecal incontinence; Gluteus maximus; Anal encirclement; Muscle transfer] ecal i n c o n t i n e n c e is a distressing condition that may result from a variety of causes including trauma, surgery, and n e u r o l o g i c disorders. W h e n the anal sphincter has b e e n d e n e r v a t e d or d a m a g e d b e y o n d the scope of direct repair, sphincter reconstruction, using healthy, adjacent muscle, may be warranted in p r o p e r l y s e l e c t e d patients. The gluteus maximus muscle has often b e e n used to accomplish this goal, most likely because of its proximity to the anus and a m p l e b l o o d supply. Several clever operations have b e e n devised using various portions of this muscle to restore fecal c o n t i n e n c e since the b e g i n n i n g of the century. 1-6 This report describes our e x p e r i e n c e with bilateral gluteus maximus transposition in seven c o m p l e t e l y incontinent patients.
Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990. Address reprint requests to Dr. Pearl: Section of Colon and Rectal Surgery, Cook County Hospital, 1835 W. Harrison St., Chicago, Illinois 60612. 478
This operation was p e r f o r m e d on five m e n and two w o m e n ranging in age from 26 to 65 years (mean, 44 years). In four of these patients, the indication for muscle transposition was sphincter destruction because of multiple fistulotomies. Two other patients had bilateral p u d e n d a l nerve damage, o n e because of an obstetric injury and o n e s e c o n d a r y to diabetic neuropathy. The remaining patient was a y o u n g man w h o was b o r n with a high imperforate anus for which he u n d e r w e n t a pullthrough operation as an infant; however, he never r e g a i n e d fecal continence. In the majority of patients, Preoperative evaluation i n c l u d e d anorectal physiologic studies such as anal m a n o m e t r y , electromyography, and dynamic proctography. The majority of the m a n o m e t r i c studies were p e r f o r m e d using a water perfusion system and the Synectics Polygraph (Synetics Medical, Inc., Irving, TX). In addition, psychiatric assessment was o b t a i n e d w h e n d e e m e d necessary.
All patients r e c e i v e d a standard mechanical and oral antibiotic b o w e l preparation as for elective colorectal surgery, which was s u p p l e m e n t e d by perioperative administration of a parenteral s e c o n d or third g e n e r a t i o n cephalosporin. N o n e of these patients had colostomies at the time o f operation. Regional or general anesthesia was_ used; :and the p r o c e d u r e was p e r f o r m e d with the .pat~ients in the prone-jackknife position with the buttocks taped apart to facilitate exposure. Two mirror image incisions are made. The u p p e r incisions overlie and parallel the course of the caudal portion of the gluteus maximus m u s c l e (Fig. 1). A pair of lateral circumanal incisions, allow for suturing the bifurcated ends of the transposed muscle t o g e t h e r to form the o p p o s i n g slings (Fig. 2).
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Figure 1. The patient is placed in the prone-jackknife position. The lower 4-5 cm of the origin of the gluteus maximus muscle including a margin of periosteum is detached from the sacrum and coccyx. The dashed lines indicate placement of the incisions.
Figure 2. A. detached gluteus maximus muscle is bifurcated, rotated inferiorly, and then tunneled subcutaneously to encircle the anus;:.The ends of each of the bifurcated limbs from the same side are sutured together to form two opposing voluntary muscle slings. B. Overview of the completed operation. Note the location of the neurovascular bundles (arrow). When the body of the gluteus maximus muscle contracts, the anal canal is pulled posteriorly. C. Suction drains are placed subcutaneously to evacuate the dead space created by the skin flaps in the postoperative period.
The lower 4-5 cm of the origin of the gluteus maximus muscle (including a margin of periosteum) is detached from the lower portion of the sacrum and coccyx. The muscle bundle is dissected
from the main body of the gluteus maximus and the underlying sacrotuberous ligament, taking care not to injure its neurovascular supply. When the muscle flaps have been mobilized sufficiently to
PEARL E T AL
reach beyond the anus, they are bifurcated longitudinally, rotated inferiorly, and tunneled subcutaneously to encircle the anus at the level of the deep postanal space. The two ends of each transposed muscle bundle and its adjacent periosteum are then joined to each other in an overlapping fashion using interrupted 2-0 polyglactin sutures to form two opposing muscular slings. Suction drains are placed in the subcutaneous space and the incisions are closed. On the first postoperative day, the patients are started on a clear liquid diet that is continued for the next 2-3 days. No other special bowel confinement routine is employed. In addition, patients are instructed not to sit for 2 weeks to avoid compromising the muscle repair. RESULTS Within 3 months after this procedure, continence to solid stool was restored in six of the seven patients. Of these six, two patients were able to sense and control the passage of liquid stool whereas only one was totally continent for gas. Subjectively, four patients judged their clinical result as good, two as fair, and there was one failure. Of particular note, in all six continent patients rectal sensation was improved dramatically after this operation. Preoperative and postoperative anal manometry was performed in four of the seven patients. However, because of changes in equipment over the follow-up period, it was not possible to collectively quantify these results accurately. Despite this shortcoming, preoperative resting pressures appeared uniformly low, often less than 25 mm Hg. This parameter was unchanged by the operation. In contrast, voluntary squeeze pressure was markedly increased by this procedure in those patients with a successful outcome. Interestingly, the greatest pressures were generated on the anterior wall of the anal canal (Fig. 3). There were no deaths associated with this operation. Three of seven patients (43 percent) developed wound infections that required prolonged hospitalization and intensive local wound care. However, none of these three patients required a colostomy to control sepsis. DISCUSSION Muscle transposition procedures may be indicated for primary central cord disorders, sphincter
Dis Colon Rectum, June 1991
Figure 3. Representative preoperative and postoperative voluntary squeeze pressures in the anterior quadrant. injury not amenable to direct repair, or efferent nerve damage. The gluteus maximus muscle has been used to reconstruct the anal sphincter mechanism since Chetwood's report in 1902.1 This series is patterned after the operation described by Hentz 5 in 1982, and we believe it is the largest experience with this procedure to date. The gluteus maximus muscle is a strong thigh extensor and lateral rotator of the hip. It originates from the upper part of the ilium, back of the sacrum, coccyx, and sacrotuberous ligament, and inserts on the femur and iliotibial tract. It has a generous blood supply from the superior and inferior gluteal arteries supplemented by branches of the medial and lateral femoral circumflex arteries. Motor innervation is via the inferior gluteal nerve (L5, S-l, S-2). This factor must be considered when the cause of sphincter dysfunction is secondary to spina bifida or myelomeningocele, which may warrant the use of a more proximally innervated donor muscle such as the gracilis (L2-4). Factors necessary to maintain fecal continence include a compliant reservoir (rectum), an intact sensory system, and a functional sphincter mechanism, which is what this operation attempts to reconstruct. If the rectum is nondistensible as a result of extensive injury or chronic inflammation, encirclement of the anal outlet will not improve control. The fact that only three of the seven patients in this report regained continence to gas or liquid stool in the postoperative period underscores the importance of the internal sphincter in sensing and regulating anorectal contents. Each of the four patients whose incontinence resulted from multiple
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fistulotomies incurred irreparable damage to their internal as well as external sphincters. In addition, as this operation does not reconstruct the internal sphincter, postoperative resting pressures remain unchanged. Of interest, almost all of these patients regained rectal sensation after the procedure. It is postulated that because preoperatively there was no mechanism to occlude the anus, fecal matter would pass through a flaccid rectum without distending it. Encircling the anus with voluntary muscle allows the rectum to distend, which is perceived by the patients and enables them to evacuate in a controlled fashion. We believe that this is the only anal encirclement procedure that restores voluntary squeeze pressure. This is in contrast to Thiersch operations, which function as adynamic loops. Some authors contend that patients are able to actively regulate the caliber of the anal opening after gracilis muscle transposition. 7'8 In this procedure, which was popularized by Pickrell e t a l . 8 in 1952, the long tendon of the gracilis muscle is detached and mobilized to surround the anus, and the end is then fixed to the opposite ischial tuberosity. It has been our experience that the relatively avascular tendon eventually behaves more like a living Thiersch wire than a dynamic sphincter mechanism. Postoperative anal manometry showed that the greatest pressures were directed against the anterior wall of the anal canal. This observation can be explained by studying the configuration of the completed gluteal wrap. When the gluteus maximus contracts, the two muscular slings that are in continuity with the main body of this muscle pull the anus posteriorly. This action simulates the directional squeeze of the main portion of the intact
external anal sphincter, and may contribute to fecal continence by kinking the anal canal. CONCLUSIONS Bilateral gluteus maximus transposition appears to be the only anal encirclement procedure that restores voluntary squeeze pressure. Although it has no effect on resting pressure, it markedly improves sensation most likely because it effectively occludes the anus, allowing for rectal distention. Despite being a technically demanding procedure with a significant morbidity, we believe bilateral gluteus maximus transposition is a worthwhile operation for properly selected patients.
REFERENCES 1. Chetwood CH. Plastic operation for restoration of the sphincter ani, with report of a case. Med Rec 1902;61:529. 2. Wreden RR. A method of reconstructing a voluntary sphincter ani. Arch Surg 1929;18:841-4. 3. Stone HB. Plastic operation for anal incontinence. Arch Surg 1929;18:845-51. 4. Bistrom O. Plastischer ersatz des m sphincter ani. Acta Chit Scand 1944;90:431-48. 5. Hentz VR. Construction of a rectal sphincter using the origin of the gluteus maximus muscle. Plast Reconstr Surg 1982;70:82-5. 6. Orgel MS, KucanJO. A double-split gluteus maximus muscle flap for reconstruction of the rectal sphincter. Plast Reconstr Surg 1985;75:62-7. 7. Raffensperger J. The gracilis sling for fecal incontinence. J Pediatr Surg 1979;14:794-7. 8. Pickrell KL, Broadbent TR, Masters FW, Metzger JT. Construction of a rectal sphincter and restoration of anal continence by transplanting the gracilis muscle. Ann Surg 1952;135:853-62.