RECONSTRUCTION
OF THE PERINEAL BODY AS TREATMENT FOR ANAL INCONTINENCE By LARS HAKELIUS,
M.D.
Department of Plastic Surgery, University Hospital, Uppsala, Sweden
THE sphincter system of the anus is considered to be composed of 3 muscles : the smooth internal sphincter, the striated external sphincter and the puborectalis muscle. Physiological investigations show that the internal sphincter contributes to the tonic closure of the anus at rest. It plays no part in maintaining continence when the rectum is distended with faeces (Gaston, 1948; Frenckner and v. Euler, 1975). The external sphincter contracts when rectal pressure increases but can maintain contraction for no more than about I minute (Duthie and Bennet, 1963); it functions therefore as an emergency muscle contracting on sudden increase of intrarectal or intra-abdominal pressure. The inability of the external sphincter to maintain strong contraction for a longer time indicates that it plays a relatively minor part in the mechanism of continence. In the work of Stephens (1953) the dominant role of the puborectalis muscle The muscle is a LJ-shaped sling arising in maintaining continence was established. at the back of the pubic bone near the symphysis and corresponding fibres from both sides unite to form a sling behind the rectum at the anorectal junction (Fig. I). The
PIG.
I.
Schematic
illustration
of the normal
relations between muscle.
the anal canal,
vagina
and the puborectalih
BRITISH
246
JOURNAL
OF
PLASTIC
SURGERY
puborectalis contracts as soon as increased intrarectal pressure endangers continence (Scharli and Kiesewetter, 1970). The shortening of the muscle sling pushes the anorectal junction forward and upward making the angle between the rectum and the anal canal more acute thereby preventing passage of the contents. Stephens (1963) has demonstrated that after surgery for imperforate anus continence could be achieved by use of the puborectalis muscle alone. Recent reports on anatomical dissections of the sphincter region (Shtik, 1975a) show that the deeper part of the external sphincter and the puborectalis are fused together and cannot be differentiated either morphologically or histologically. Probably the deeper part of the external sphincter also acts physiologically as a part of the puborectalis muscle. The intermediate portion of the external sphincter forms a distinct bundle of muscle fibres surrounding the middle part of the anal canal (Shafik, 1975a). This ring of muscle is attached to the coccyx dorsally. The intermediate portion of the external sphincter and the hiatal ligament which is a more condensed and thicker part of the pelvic fascia running in the space between the medial borders of the pubococcygeal muscle at the level of the anorectal junction, compose the anatomical structures in the perineum that keep the anal canal in a backward position (Shafik, 1975b). It appears therefore that the most important factor in maintaining continence is a functioning puborectalis muscle. An injury to the anal region can disturb the physiological function of the puborectalis sling in 2 ways (Fig. 2) : the continuity of the muscle is interrupted and the torn ends retract; the anus and anal canal are displaced ventrally, following destruction of the perineum, the muscle sling then becomes relatively too long, and it cannot make the anorectal angle more acute on contraction. If the muscle is ruptured it must be repaired or replaced with a free muscle graft (Hakelius, 1975; Hakelius et al., 1978). In the case of a deficient perineum with an intact but incompetent puborectalis, the logical approach would be to reconstruct the perineum thereby pushing the anal canal backwards and making the incompetent muscle competent. For a third degree tear of the perineum at delivery a primary muscle repair is often successful (Ingraham et al., 1949). Sometimes a secondary perineorrhaphy is necessary and in that case there are many variations in operative technique (Warren, 1882; Martius, 1954; Miller and Brown, 1937). However, all of these procedures have as their main purpose to reconstruct the superficial part of the external sphincter and deal less with the reconstruction of a firm perineum with adequate cutaneous covering.
A FIG. 2. Diagram of the puborectalis because of rupture of the muscle
B muscle from below. A. Norma1 conditions. C. Disturbed function because of ventrally
C B. Disturbed funcrton displaced anal canal.
A
% 2
35
30
29
7
8
9
Tear at delivery Tear at delivery Tear at delivery Excision of cystic tumour of vagina complicated by rectovaginal fistula
13 t4 15
12
at delivery
at delivery
at delivery
at delivery
at delivery
Tear
Tear
Tear
Tear
Tear
II
30
62
6
IO
at delivery
Tear
29
5
at delivery
at delivery at delivery
Tear Tear
;z
:
Tear
at delivery
Tear
28
anal fistula
2
Operated
26
Aetiology
I
Patient
Age at operation
J; 7
14
4
9
I
I
4
35
12
18
21
2
I
Years between injury and operation
Perineorrhaphy after injury Perineorrhaphy times 3
3 yr
Rerineorrhdphy 3 months after injury -
5 failed operations for rectovaginal fistula: colostomy Perineorrhaphy 112 yr after injury -
:
ST ST
ST
ST
ST
ST
ST
T Colostomy
ST
T T
T
T
Attempt to close a rectovaginal fistula twice Perineorrhaphy IO yr after injury -
Degree of incontinence
Previous reconstructive surgery mm high
ro mm cutaneous, no muscular Cloaca Cloaca Cloaca Cloaca
Cloaca
2 mm high
Cloaca
Cloaca
Cloaca
Cloaca to mm cutaneous, no muscular Cloaca
5 mm high
2
Perineal status preoperatively
-
Hirschsprung’s disease operated infancy -
Crohn’s disease resection of ileum -
in
Anal atresia op. in infancy Prolapse of uterus complicated by rectovaginal fistula -
-
Crohn’s disease colectomy Rectovaginal fistula
Complicating disease or injury
Preoperative data of 15 patients treated with perineal reconstruction for anal incontinence. In the column “Degree of incontinence” T = total incontinence for faeces and flatus. ST L uncontrolled passage of flatus and liquid stools but possibility to hold back faeces of normal consistence up to one minute.
TABLE I
248
BRITISH JOURNAL
OF PLASTIC
SURGERY
MATERIAL
Fifteen patients suffering from anal incontinence, due to injury of the muscular perineum, have been operated on with reconstruction of the muscular and cutaneous perineum; all were female. At the time of operation they were between 26 and 66 years old (average 39.5 years). The main clinical details are shown in Table I. The main complaints of the patients were of course the incontinence and the hygienic and social difficulties it caused. All of them had to use napkins. Many of them also complained of sexual difficulties because of the missing perineum and recurring urinary infections. The dominant aetiology was a tear of the perineum at delivery (13 cases). In the younger patients the incontinence was a direct consequence of the perineal injury. In some of the older ones (4, 6 and 14) there was a history of incontinence in connection with delivery. After a few months the incontinence had decreased and the patients experienced relatively little discomfort until they reached the menopause when the problems reappeared. In the cases complicated by Crohn’s disease the chronic diarrhoea accentuated the insufficiency of the anal sphincter mechanism. In all the patients the superficial part of the external anal sphincter was ruptured and retracted from the perineal circumference of the anus. Because of that and damage to the deeper part of the perineal body the perineum was very low or quite missing (Table I). The function of the puborectalis muscle was tested preoperatively by palpating it during contraction. In most of the cases the contractibility and strength of the puborectalis sling was estimated to be very good. A compensatory hypertrophy of the muscle was also observed in some cases, but because of the displaced anal canal the muscle could not affect the anorectal angle. METHOD
Preoperative. For 2 days prior to surgery the patients receive only liquid nourishment. The colon is emptied with 3 water clysters during these 2 days. No preoperative antibiotics are used. Operative techniques. Under epidural anaesthesia and with the patient in the lithotomy position, the operation starts with a horizontal 5 cm long incision in the thin plate of the damaged perineal tissue (Fig. 3). After careful dissection in this plate of scar tissue between the anal canal and the vagina the lower margin of the puborectalis muscle is identified on both sides of the midline at 3 to 5 cm depth. At this level in the midline the scar tissue is found to be replaced by normal connective tissue. Normally in this plane, muscle fibres are crossing the perineum from one side to the other, but in these cases there is a defect in the muscle layer. The defect is bounded by the puborectalis muscle laterally, the vagina in front and the anorectal angle behind. After dissecting through the scar tissue the anal canal can be moved backwards to its original position. The next step is to reconstruct the muscular perineum to a height of about 3 cm and a depth of 3 cm. To make a muscular perineum of that depth it is not enough to join the puborectalis strands in the midline. The dissection is therefore continued through the muscular defect in the perineum up along the inner surface of the funnelshaped muscular floor of the pelvis for about 3 cm. This dissection uncovers the inner surface of the pubococcygeus muscle. The lower parts of this muscle on each side are then coapted to each other in the midline with 2 rows of I/O Vicryl absorbable sutures (Fig. 4). To complete the reconstruction of the muscular perineum a third line of sutures brings together the medial strands of the puborectalis muscle in the midline
RECONSTRUCTION
OF
THE
PERINEAL
BODY
249
FIG. 3.
Incision line.
FIG. 4.
The lower parts of the pubococcygeus muscle coapted to each other.
FIG. 5.
Note the low perineum.
Reconstruction of the muscular of the perineum completed.
part
(Fig. 5). No attempt to restore the circular continuity of the superficial part of the external anal sphincter is made. The reconstruction of the muscular perineum has displayed the deficit of fat and skin between vulva and anus. To replace this defect the soft tissue lateral to the perineum is undermined and moved medially, transforming the horizontal skin incision into a vertical one. In order to bring additional skin to the perineum and to break the vertical scar a Z-plasty is incorporated (Fig. 6). The skin is sutured with 3/o Dexon (Fig. 7). The operative field is covered with Nobecutane. The urinary bladder is drained by a urethral catheter. Postoperative. The patient is kept strictly in bed for 7 days with the urethral catheter in place. The low bulk diet is continued and opium by mouth is added for 7 days. These precautions prevent, as a rule, evacuation of the bowel during the first postoperative week. The bladder drainage and the bed rest make optimal relaxation of the pelvic floor possible during the first critical healing period. On the 8th day the
BRITISH
250
FIG. 6.
The
horizontal
JOURNAL
incision transformed
FIG. 7.
OF
PLASTIC
gyk~dvertical
SURGERY
one and incision lines for the Z-plasty
The operation completed.
urethral catheter is removed, and the low bulk diet and bed rest are discontinued. Ordinarily the first postoperative movements of the bowel occur 2 days later.
RESULTS
The stay in hospital after surgery was between 27 and II days (average 14.7 days). In II cases the early postoperative period elapsed without any complications. Three cases (9, 12 and 14) had superficial necrosis of the tip of I of the flaps of the Z-plasty. All of them healed spontaneously without infection. In I case (6) an abscess in the perineum developed and drained spontaneously to the rectum on the 12th postoperative day. The rest of the postoperative period was uneventful and no fistula formed. At follow-up 3 to 38 months after repair (average 14.7 months) 12 patients claimed that the anal continence for faeces as well as flatus was totally restored to normal. This group included case 6, who had a colostomy made 2 years previously because of severe incontinence combined with a rectovaginal fistula. Nine months after the perineal reconstruction the colostomy was closed and the patient is now totally continent. The remaining 3 cases (I, 4 and 5) are markedly improved; they have no social problems because of their incontinence and they are able to control flatus fairly well, but have difliculties in holding back stools for longer than 15 to 20 minutes. They occasionally have problems with soiling of the underwear, especially after defaecation. The 3 patients in this group included I patient with active Crohn’s disease (I) and I earlier operated on for anal atresia (5). Case I had an anal fistula 8 months after operation apparently as a consequence of her Crohn’s disease. All the patients were happy with the results of the operation and none of them had to use napkins any more. As a consequence of the separation of anus from vulva by the perineal reconstruction several of the patients who previously had recurring urinary infections were without symptoms or signs of infection of the urine after operation.
RECONSTRUCTIONOF THE PERINEAL BODY
251
DISCUSSION At present a number of surgical techniques are being used for the correction of anal This may indicate that the ideal treatment for this disabling state does incontinence. not exist. One essential reason for unsatisfactory results in this field is that our Thus most of knowledge of the physiology of anal continence has been fragmentary. the existing methods are directed towards the repair or replacement of the superficial circular part of the external sphincter (Blaisdell, 1940; Pickrell et al., 1952). A great step forward in understanding the mechanism of anal continence was made when the importance of the puborectalis function was established by Stephens (1953). As a consequence of this knowledge the analysis of the cause of the missing puborectalis function is important in each case, since the operative treatment of an interrupted puborectalis muscle apparently should be different from that of a muscle insufficient because of a ventrally displaced anal canal. The differential diagnosis is best made by palpation and inspection. In the first case the aim of the operation must be to reconstruct the puborectalis sling. In my hands free muscle transplantation has given good results (Hakelius, 1975; Hakelius et al., 1978). In the second case the most important point must be the reconstruction of a firm deep and high perineum which will neutralise the tendency to displace the anal canal ventrally on puborectalis contraction. The expanding knowledge of the anatomy and physiology of the sphincteric apparatus has made it possible to make a differential diagnosis in cases of anal incontinence. The reconstructive efforts can then be directed towards the particular part of the sphincter mechanism that has been damaged. On the whole the results in this series, consisting of cases selected according to the principles recounted above, are good. It is my sincere hope that in the future plastic surgeons will take a more active interest in patients with anal incontinence and, with plastic surgical techniques, make it possible for them to return to a socially decent life. SUMMARY The report presents 15 cases of anal incontinence after injury of the perineum operated on with a technique stressing the reconstruction of a firm and high perineal body. The aim of the operation is to push the anal canal backwards thereby making an insufficient puborectalis muscle sufficient. The perineal body is covered by skin flaps designed to minimise scar contraction between anus and vulva. At follow-up 3 to 38 months after operation (average 14.7 months) 12 patients claimed that the anal continence was totally restored to normal. The remaining 3 cases were much improved and had no social problems because of their incontinence.
REFERENCES Repair of the incontinent sphincter ani. Surger_y, Gynecology and BLAISDELL, P. C. (1940). Obstetrics, 70, 692. DUTHIE, H. L. and BENNET, R. C. (1963). The relation of sensation in the anal canal to the functional anal sphincter: a possible factor in anal continence. Gut, 4, 179. FRENCKNER,B. and v. EULER, C. (1975). Influence of pudendal block on the function of the anal sphincters. Gut, 16, 482. The physiology of fecal continence. Surgery, Gynecology and GASTON, E. A. (1948). Obstetrics, 87, 208. Free autogenous muscle transplantation in two cases of total anal HAKELIUS, L. (1975). incontinence. Acta Chirwgica Scandinavica, 141, 69. HAKELIUS, L., GIERUP, J. and GROTTE, G. (1978). A new treatment of anal incontinence in children: free autogenous muscle transplantation. Journal of Pediatric Surgery, 13, 77.
252
BRITISH
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SURGERY
INGRAHAM,H. A., GARDNER, M. M. and HEUS, E. G. (1949). A report on 159 third degree lacerations. American Journal of Obstetrzcs and Gynecology, 57, 730. hhRTIUS, H. (1954). Die gyn&ologischen Operationen. Stuttgart: Georg Thieme Verlag. MILLER, N. F. and BROWN, W. (1937). The surgical treatment of complete perineal tears in the female. Amel-ican Journal of Obstetrics and Gynecology, 34, 196. PICKRELL, K., BROADBENT, T., MASTERS, F. W. and METZGER, J. T. (1952). Construction of a rectal sphincter and restoration of anal continence by transplanting the gracilis muscle. Annals of Surgery, 135, 853. Defecation and continence: some new SCHARLI. A. F. and KIESFWETTER. W. B. (1970. concepts. Diseases of Colon a& Rectu&*i3, 81. SHAFIK, A. (1975a). A new concept of the anatomy of the anal sphincter mechanism and The external anal sphincter: a triple-loop system. the physiology of defecation. Investigative Urology, 12, 412. SHAFIK, A. (1975b). A new concept of the anatomy of the anal sphincter mechanism and the uhvsiologv of defecation. II. Anatomv of the levator ani muscle with soecial reference io pubot&alis. Znvestigative urology; 13, 175. STEPHENS, F. D. (1953). Congenital imperforate rectum, recta-urethral and recta-vaginal fish&e. AustraZian and New Zealand Journal of Surgery, 22, 161. STEPHENS, F. D. (1963). Congenital malformations of the rectum, anus and genito-urinary tracts. Edinburgh: E. & S. Livingstone Ltd. WARREN. T. C. (1882). A new method of ooeration for the relief of ruuture of the perineum of the Amhrican Gynecological through the sbhincter and rectum. _ Transactions Society.
OF THE PERINEAL BODY AS TREATMENT FOR ANAL INCONTINENCE By LARS HAKELIUS,
M.D.
Department of Plastic Surgery, University Hospital, Uppsala, Sweden
THE sphincter system of the anus is considered to be composed of 3 muscles : the smooth internal sphincter, the striated external sphincter and the puborectalis muscle. Physiological investigations show that the internal sphincter contributes to the tonic closure of the anus at rest. It plays no part in maintaining continence when the rectum is distended with faeces (Gaston, 1948; Frenckner and v. Euler, 1975). The external sphincter contracts when rectal pressure increases but can maintain contraction for no more than about I minute (Duthie and Bennet, 1963); it functions therefore as an emergency muscle contracting on sudden increase of intrarectal or intra-abdominal pressure. The inability of the external sphincter to maintain strong contraction for a longer time indicates that it plays a relatively minor part in the mechanism of continence. In the work of Stephens (1953) the dominant role of the puborectalis muscle The muscle is a LJ-shaped sling arising in maintaining continence was established. at the back of the pubic bone near the symphysis and corresponding fibres from both sides unite to form a sling behind the rectum at the anorectal junction (Fig. I). The
PIG.
I.
Schematic
illustration
of the normal
relations between muscle.
the anal canal,
vagina
and the puborectalih
BRITISH
246
JOURNAL
OF
PLASTIC
SURGERY
puborectalis contracts as soon as increased intrarectal pressure endangers continence (Scharli and Kiesewetter, 1970). The shortening of the muscle sling pushes the anorectal junction forward and upward making the angle between the rectum and the anal canal more acute thereby preventing passage of the contents. Stephens (1963) has demonstrated that after surgery for imperforate anus continence could be achieved by use of the puborectalis muscle alone. Recent reports on anatomical dissections of the sphincter region (Shtik, 1975a) show that the deeper part of the external sphincter and the puborectalis are fused together and cannot be differentiated either morphologically or histologically. Probably the deeper part of the external sphincter also acts physiologically as a part of the puborectalis muscle. The intermediate portion of the external sphincter forms a distinct bundle of muscle fibres surrounding the middle part of the anal canal (Shafik, 1975a). This ring of muscle is attached to the coccyx dorsally. The intermediate portion of the external sphincter and the hiatal ligament which is a more condensed and thicker part of the pelvic fascia running in the space between the medial borders of the pubococcygeal muscle at the level of the anorectal junction, compose the anatomical structures in the perineum that keep the anal canal in a backward position (Shafik, 1975b). It appears therefore that the most important factor in maintaining continence is a functioning puborectalis muscle. An injury to the anal region can disturb the physiological function of the puborectalis sling in 2 ways (Fig. 2) : the continuity of the muscle is interrupted and the torn ends retract; the anus and anal canal are displaced ventrally, following destruction of the perineum, the muscle sling then becomes relatively too long, and it cannot make the anorectal angle more acute on contraction. If the muscle is ruptured it must be repaired or replaced with a free muscle graft (Hakelius, 1975; Hakelius et al., 1978). In the case of a deficient perineum with an intact but incompetent puborectalis, the logical approach would be to reconstruct the perineum thereby pushing the anal canal backwards and making the incompetent muscle competent. For a third degree tear of the perineum at delivery a primary muscle repair is often successful (Ingraham et al., 1949). Sometimes a secondary perineorrhaphy is necessary and in that case there are many variations in operative technique (Warren, 1882; Martius, 1954; Miller and Brown, 1937). However, all of these procedures have as their main purpose to reconstruct the superficial part of the external sphincter and deal less with the reconstruction of a firm perineum with adequate cutaneous covering.
A FIG. 2. Diagram of the puborectalis because of rupture of the muscle
B muscle from below. A. Norma1 conditions. C. Disturbed function because of ventrally
C B. Disturbed funcrton displaced anal canal.
A
% 2
35
30
29
7
8
9
Tear at delivery Tear at delivery Tear at delivery Excision of cystic tumour of vagina complicated by rectovaginal fistula
13 t4 15
12
at delivery
at delivery
at delivery
at delivery
at delivery
Tear
Tear
Tear
Tear
Tear
II
30
62
6
IO
at delivery
Tear
29
5
at delivery
at delivery at delivery
Tear Tear
;z
:
Tear
at delivery
Tear
28
anal fistula
2
Operated
26
Aetiology
I
Patient
Age at operation
J; 7
14
4
9
I
I
4
35
12
18
21
2
I
Years between injury and operation
Perineorrhaphy after injury Perineorrhaphy times 3
3 yr
Rerineorrhdphy 3 months after injury -
5 failed operations for rectovaginal fistula: colostomy Perineorrhaphy 112 yr after injury -
:
ST ST
ST
ST
ST
ST
ST
T Colostomy
ST
T T
T
T
Attempt to close a rectovaginal fistula twice Perineorrhaphy IO yr after injury -
Degree of incontinence
Previous reconstructive surgery mm high
ro mm cutaneous, no muscular Cloaca Cloaca Cloaca Cloaca
Cloaca
2 mm high
Cloaca
Cloaca
Cloaca
Cloaca to mm cutaneous, no muscular Cloaca
5 mm high
2
Perineal status preoperatively
-
Hirschsprung’s disease operated infancy -
Crohn’s disease resection of ileum -
in
Anal atresia op. in infancy Prolapse of uterus complicated by rectovaginal fistula -
-
Crohn’s disease colectomy Rectovaginal fistula
Complicating disease or injury
Preoperative data of 15 patients treated with perineal reconstruction for anal incontinence. In the column “Degree of incontinence” T = total incontinence for faeces and flatus. ST L uncontrolled passage of flatus and liquid stools but possibility to hold back faeces of normal consistence up to one minute.
TABLE I
248
BRITISH JOURNAL
OF PLASTIC
SURGERY
MATERIAL
Fifteen patients suffering from anal incontinence, due to injury of the muscular perineum, have been operated on with reconstruction of the muscular and cutaneous perineum; all were female. At the time of operation they were between 26 and 66 years old (average 39.5 years). The main clinical details are shown in Table I. The main complaints of the patients were of course the incontinence and the hygienic and social difficulties it caused. All of them had to use napkins. Many of them also complained of sexual difficulties because of the missing perineum and recurring urinary infections. The dominant aetiology was a tear of the perineum at delivery (13 cases). In the younger patients the incontinence was a direct consequence of the perineal injury. In some of the older ones (4, 6 and 14) there was a history of incontinence in connection with delivery. After a few months the incontinence had decreased and the patients experienced relatively little discomfort until they reached the menopause when the problems reappeared. In the cases complicated by Crohn’s disease the chronic diarrhoea accentuated the insufficiency of the anal sphincter mechanism. In all the patients the superficial part of the external anal sphincter was ruptured and retracted from the perineal circumference of the anus. Because of that and damage to the deeper part of the perineal body the perineum was very low or quite missing (Table I). The function of the puborectalis muscle was tested preoperatively by palpating it during contraction. In most of the cases the contractibility and strength of the puborectalis sling was estimated to be very good. A compensatory hypertrophy of the muscle was also observed in some cases, but because of the displaced anal canal the muscle could not affect the anorectal angle. METHOD
Preoperative. For 2 days prior to surgery the patients receive only liquid nourishment. The colon is emptied with 3 water clysters during these 2 days. No preoperative antibiotics are used. Operative techniques. Under epidural anaesthesia and with the patient in the lithotomy position, the operation starts with a horizontal 5 cm long incision in the thin plate of the damaged perineal tissue (Fig. 3). After careful dissection in this plate of scar tissue between the anal canal and the vagina the lower margin of the puborectalis muscle is identified on both sides of the midline at 3 to 5 cm depth. At this level in the midline the scar tissue is found to be replaced by normal connective tissue. Normally in this plane, muscle fibres are crossing the perineum from one side to the other, but in these cases there is a defect in the muscle layer. The defect is bounded by the puborectalis muscle laterally, the vagina in front and the anorectal angle behind. After dissecting through the scar tissue the anal canal can be moved backwards to its original position. The next step is to reconstruct the muscular perineum to a height of about 3 cm and a depth of 3 cm. To make a muscular perineum of that depth it is not enough to join the puborectalis strands in the midline. The dissection is therefore continued through the muscular defect in the perineum up along the inner surface of the funnelshaped muscular floor of the pelvis for about 3 cm. This dissection uncovers the inner surface of the pubococcygeus muscle. The lower parts of this muscle on each side are then coapted to each other in the midline with 2 rows of I/O Vicryl absorbable sutures (Fig. 4). To complete the reconstruction of the muscular perineum a third line of sutures brings together the medial strands of the puborectalis muscle in the midline
RECONSTRUCTION
OF
THE
PERINEAL
BODY
249
FIG. 3.
Incision line.
FIG. 4.
The lower parts of the pubococcygeus muscle coapted to each other.
FIG. 5.
Note the low perineum.
Reconstruction of the muscular of the perineum completed.
part
(Fig. 5). No attempt to restore the circular continuity of the superficial part of the external anal sphincter is made. The reconstruction of the muscular perineum has displayed the deficit of fat and skin between vulva and anus. To replace this defect the soft tissue lateral to the perineum is undermined and moved medially, transforming the horizontal skin incision into a vertical one. In order to bring additional skin to the perineum and to break the vertical scar a Z-plasty is incorporated (Fig. 6). The skin is sutured with 3/o Dexon (Fig. 7). The operative field is covered with Nobecutane. The urinary bladder is drained by a urethral catheter. Postoperative. The patient is kept strictly in bed for 7 days with the urethral catheter in place. The low bulk diet is continued and opium by mouth is added for 7 days. These precautions prevent, as a rule, evacuation of the bowel during the first postoperative week. The bladder drainage and the bed rest make optimal relaxation of the pelvic floor possible during the first critical healing period. On the 8th day the
BRITISH
250
FIG. 6.
The
horizontal
JOURNAL
incision transformed
FIG. 7.
OF
PLASTIC
gyk~dvertical
SURGERY
one and incision lines for the Z-plasty
The operation completed.
urethral catheter is removed, and the low bulk diet and bed rest are discontinued. Ordinarily the first postoperative movements of the bowel occur 2 days later.
RESULTS
The stay in hospital after surgery was between 27 and II days (average 14.7 days). In II cases the early postoperative period elapsed without any complications. Three cases (9, 12 and 14) had superficial necrosis of the tip of I of the flaps of the Z-plasty. All of them healed spontaneously without infection. In I case (6) an abscess in the perineum developed and drained spontaneously to the rectum on the 12th postoperative day. The rest of the postoperative period was uneventful and no fistula formed. At follow-up 3 to 38 months after repair (average 14.7 months) 12 patients claimed that the anal continence for faeces as well as flatus was totally restored to normal. This group included case 6, who had a colostomy made 2 years previously because of severe incontinence combined with a rectovaginal fistula. Nine months after the perineal reconstruction the colostomy was closed and the patient is now totally continent. The remaining 3 cases (I, 4 and 5) are markedly improved; they have no social problems because of their incontinence and they are able to control flatus fairly well, but have difliculties in holding back stools for longer than 15 to 20 minutes. They occasionally have problems with soiling of the underwear, especially after defaecation. The 3 patients in this group included I patient with active Crohn’s disease (I) and I earlier operated on for anal atresia (5). Case I had an anal fistula 8 months after operation apparently as a consequence of her Crohn’s disease. All the patients were happy with the results of the operation and none of them had to use napkins any more. As a consequence of the separation of anus from vulva by the perineal reconstruction several of the patients who previously had recurring urinary infections were without symptoms or signs of infection of the urine after operation.
RECONSTRUCTIONOF THE PERINEAL BODY
251
DISCUSSION At present a number of surgical techniques are being used for the correction of anal This may indicate that the ideal treatment for this disabling state does incontinence. not exist. One essential reason for unsatisfactory results in this field is that our Thus most of knowledge of the physiology of anal continence has been fragmentary. the existing methods are directed towards the repair or replacement of the superficial circular part of the external sphincter (Blaisdell, 1940; Pickrell et al., 1952). A great step forward in understanding the mechanism of anal continence was made when the importance of the puborectalis function was established by Stephens (1953). As a consequence of this knowledge the analysis of the cause of the missing puborectalis function is important in each case, since the operative treatment of an interrupted puborectalis muscle apparently should be different from that of a muscle insufficient because of a ventrally displaced anal canal. The differential diagnosis is best made by palpation and inspection. In the first case the aim of the operation must be to reconstruct the puborectalis sling. In my hands free muscle transplantation has given good results (Hakelius, 1975; Hakelius et al., 1978). In the second case the most important point must be the reconstruction of a firm deep and high perineum which will neutralise the tendency to displace the anal canal ventrally on puborectalis contraction. The expanding knowledge of the anatomy and physiology of the sphincteric apparatus has made it possible to make a differential diagnosis in cases of anal incontinence. The reconstructive efforts can then be directed towards the particular part of the sphincter mechanism that has been damaged. On the whole the results in this series, consisting of cases selected according to the principles recounted above, are good. It is my sincere hope that in the future plastic surgeons will take a more active interest in patients with anal incontinence and, with plastic surgical techniques, make it possible for them to return to a socially decent life. SUMMARY The report presents 15 cases of anal incontinence after injury of the perineum operated on with a technique stressing the reconstruction of a firm and high perineal body. The aim of the operation is to push the anal canal backwards thereby making an insufficient puborectalis muscle sufficient. The perineal body is covered by skin flaps designed to minimise scar contraction between anus and vulva. At follow-up 3 to 38 months after operation (average 14.7 months) 12 patients claimed that the anal continence was totally restored to normal. The remaining 3 cases were much improved and had no social problems because of their incontinence.
REFERENCES Repair of the incontinent sphincter ani. Surger_y, Gynecology and BLAISDELL, P. C. (1940). Obstetrics, 70, 692. DUTHIE, H. L. and BENNET, R. C. (1963). The relation of sensation in the anal canal to the functional anal sphincter: a possible factor in anal continence. Gut, 4, 179. FRENCKNER,B. and v. EULER, C. (1975). Influence of pudendal block on the function of the anal sphincters. Gut, 16, 482. The physiology of fecal continence. Surgery, Gynecology and GASTON, E. A. (1948). Obstetrics, 87, 208. Free autogenous muscle transplantation in two cases of total anal HAKELIUS, L. (1975). incontinence. Acta Chirwgica Scandinavica, 141, 69. HAKELIUS, L., GIERUP, J. and GROTTE, G. (1978). A new treatment of anal incontinence in children: free autogenous muscle transplantation. Journal of Pediatric Surgery, 13, 77.
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