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Video of a secondary anal sphincter repair and perineal reconstruction following breakdown of a primary repair
IUGA Academy. Taithongchai A. Jun 30, 2018; 213277
Topic: Anal Incont - Fecal Urgency
Annika Taithongchai
Annika Taithongchai

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233

Video of a secondary anal sphincter repair and perineal reconstruction following breakdown of a primary repair

Taithongchai, A1; Abulafi, AM1; Thakar, R1

1: Croydon University Hospital

Introduction: The optimal management of obstetric anal sphincter injury (OASI) is immediate primary repair of the external anal sphincter (EAS) by overlap (if the full thickness is torn) or the end-to-end technique and separate repair of the internal anal sphincter (IAS) if disrupted1. However, occasionally patients may require a delayed sphincteroplasty either due to a missed OASI or a persisting defect with associated faecal incontinence despite a primary repair. During a secondary overlap sphincteroplasty, the IAS is not usually repaired separately from the EAS as it is considered technically difficult. Secondary sphincteroplasty has been shown to provide initial improvement in faecal incontinence symptoms2 but with deterioration over time3.

Objective: To demonstrate the technique of a secondary overlapping sphincteroplasty following OASI, with focus on the dissection and repair of the disrupted IAS.

Methods: This is the case of a 23-year-old who sustained an OASI during forceps delivery. Subsequently she had an infected breakdown of her wound and developed faecal incontinence, with complete disruption of the EAS on MRI. She underwent wound debridement and colostomy formation, as secondary repair at that time was not appropriate due to infection.

A tertiary referral was made to our unit. On examination she had a deficient perineal body of less than 1 cm and a Grade 1 rectocele. Anal manometry demonstrated an anal length of 3cm, maximum resting pressure of 48 mmHg and maximum squeeze pressure of 64 mmHg. Endoanal ultrasound showed the IAS to be thin with a full-length defect between 10 and 2 o’clock (figure 1). The EAS also had a full length and full thickness defect between 10 and 2 o’clock (figure 2). The patient consented to a secondary sphincteroplasty and perineal reconstruction.

We present a video of an overlap external anal sphincteroplasty with a Levatorplasty; demonstrating that the IAS can be repaired separately if a structured technique is followed.

Results: A literature review of primary and secondary repair results will be presented. Technique: A curved incision is made transversely on the perineum. The muscle complex and scar tissue are dissected from the rectum and vagina. The IAS is identified by rectal palpation and visualised using an Eisenhamer retractor. Following mobilisation, the ends opposed by two mattress PDS 2-0 sutures. The EAS ends were dissected at 10 and 2 o’clock, corresponding with the scan findings, and an overlap repair performed, forming a new sphincter complex. As she had a rectocele, a Levatorplasty was performed with perineal reconstruction; approximating the Bulbospongiosus and the Superficial Transverse Perineal muscles with Vicryl 1 sutures. The incision is closed in an inverted T fashion with interrupted sutures and a suction drain was inserted.

Conclusion: This video shows a secondary repair of the IAS and EAS, Levatorplasty and perineal reconstruction. It clearly demonstrates the feasibility of a delayed internal sphincter repair of the full length of the internal which hitherto has been considered unfeasible by most colorectal surgeons.

References: 1. Cochrane Database Syst Rev.2013 Dec 8;(12):CD002866 2. Int J Colorectal Dis. 2014;29(11):1377-83 3. Dis Colon Rectum. 2012;55(4):482-90

Figure 1 3D endoanal ultrasound scan demonstrating defect between 10 and 2 o’clock of the EAS (between the arrows) and IAS (hypoechoic ring medial to EAS).


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