Anterior Plication Postanal Repair and Total Pelvic Floor Repair

Anterior, postanal, and total pelvic floor repairs are not frequently performed and are no longer promoted as first line procedures in patients with incontinence. When the sphincter mechanism itself is anatomically intact but laxity in the pelvic floor or damage to pelvic innervation is implicated as the cause of fecal incontinence, the resulting dysfunction has been referred to as perineal descent syndrome, idiopathic incontinence, or neurogenic incontinence. If the symptoms are minimal, conservative treatment in the form of dietary modification or medical intervention is warranted. However, if symptoms are severe or the patient has pudendal neuropathy after an unsuccessful trial of sphincteroplasty, the postanal or total pelvic floor repair, sacral nerve stimulation, a neosphincter procedure, or a stoma all become options. Although postanal sphincter repairs have limited success, they demonstrate a low morbidity and remain a valuable option in patients with neurogenic incontinence for whom conservative measures have failed, are not candidates for sacral nerve stimulation (because of exclusion criteria), or neosphinc-ter procedures (stimulated graciloplasty or artificial bowel sphincter), and do not want a stoma.

Anterior plication (also called anterior reefing procedure) involves plication of the anterior perineal musculature. The procedure has been described with multiple variations but usually encompasses reapproximation of the anterior puborectalis with or without simultaneous approximation of the levators and S-shaped plication of the EAS. The theoretical outcome of this technique is a tightening of the anterior perineal musculature and, when employed, is used in combination with other procedures. In the early twentieth century, this technique was used as an alternative to reconstruction of thin or damaged sphincters. Although some studies have shown good initial results with this procedure, the long-term benefits significantly decrease over time. Consequently, this procedure is rarely used today in the current treatment of fecal incontinence.

Postanal repair (also called posterior sphincteroplasty or posterior plication) was devised by Parks et al.8 for the treatment of idiopathic and neurogenic incontinence. The goal of the procedure was to increase the length of the anal canal with the intent of restoring the anorectal angle. At our institution, after induction of general anesthesia, the patient is placed in the prone jackknife position on a Kraske roll and a curvilinear incision is made 5 cm posterior to the anus.9 An intersphincteric approach between the internal and EAS is used to expose Waldeyer's fascia and the levator ani muscle complex. Interrupted 2-0 polypropylene sutures are then placed from one side of the pelvis to the other through the two limbs of the iliococcygeus muscle. Because of the intervening distance, the two halves of the iliococcygeus muscle cannot be approximated, rather a lattice of suture is formed that supports the posterior rectal wall. Interrupted sutures are then placed in the pubococcygeus and puborectalis muscles in a similar manner (Figure 6-8.5). Plication of the EAS may also be performed before closing the skin in a V-Y manner. The theoretical outcome of approximating the levator ani muscles posteriorly behind the anorectal junction is to displace these muscles anteriorly and increase the angulation of the anorectal junction. Parks achieved the best results (>80% success) for this technique in his series. A review of several subsequent studies revealed a success rate of between 32% to 87%.2 Although this operation was designed to improve the anorectal angle and lengthen the anal canal, anatomic analysis has revealed no such results. In addition, correlation between successful outcome and reduction of this angle has not been proven and remains theoretical. Long-term results of this repair are poor because successful outcome ultimately decreases over time. The only predictor of adverse outcome is pudendal neuropathy, which, interestingly, is present in a majority of the patients considered candidates to undergo the repair.

Postanal repair was more popular in an era when routine EAUS was not available. Currently, it is rarely performed in the United States, but may be considered in select patients with no sphincter defect who have failed biofeedback and conservative measures or in whom an overlapping sphincter repair has achieved anatomic but not functional success. A study of this technique at our institution involved the analysis of results from 20 postanal repairs with a follow-up of 23 months.10 The success rate was 35% as indicated by a significant improvement in the inconti-

Pelvic Floor Repair

Figure 6-8.5. Postanal repair with dissection in the intersphincteric space (a) and posterior plication of the muscles of the pelvic floor (b). (Reprinted from Wexner SD, Beck DE. Fundamentals of Anorectal Surgery. 2nd ed.p 133-136, Copyright 2001 WB Saunders, with permission from Elsevier.)

nence score in 22 months of follow-up. The morbidity rate was minimal (5%) with no mortality. No clinical or physiologic variables were found to be predictors of success. Although the success rate of this operation is poor, it is relatively free of morbidity and remains an important option for those patients who may have few alternatives other than high-risk complicated operations (neosphincter procedures) or stomas. Nonetheless, it is rarely used by most surgeons because of its poor long-term success.

Total pelvic floor reconstruction refers to a combination of postanal repair, anterior levatorplasty, and can include sphincteroplasty. Indications include complicated injuries to the EAS and puborectalis in one or more sites with associated pudendal neuropathy. This approach was designed to provide a comprehensive repair, which also reinforces any perineal deficiency such as rectocele. It can be performed in stages or in one step with or without colostomy. This procedure also purportedly increases the angle of the anal canal and corrects the degree of pelvic floor descent at rest and during straining, but does not influence resting or squeeze anal canal pressures. As with postanal repair, studies have shown that clinical improvement did not correlate with change in the anorectal angle. Short-term results are encouraging, although long-term success is rare. This repair has not gained widespread popularity.

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