Direct Apposition Sphincter Repair

The majority of fecal incontinence is attributed to anatomic defects in the EAS. This type of defect most often occurs as a result of midline perineal tears sustained during vaginal delivery. Overt sphincter rupture occurs during 5% of vaginal deliveries and increases to an incidence of 50% with the use of midline episiotomy and/or operative vaginal delivery.1 At the time of delivery, any documented trauma to the anal sphincter (third or fourth degree tear) should be given due regard. Even if waiting 12 to 18 hours is required, performing the repair in the operating room with adequate lights and instruments optimizes the repair, as judged by ultrasound after the repair has healed. The most common technique used in the acute setting is direct apposition of the sphincter ends in which the cut ends of the IAS and EAS are sutured together in layers. Direct apposition of the sphincters without tension in the acute setting has been reported to give satisfactory results in 47% to 100% of cases.2 Failures are attributed to tearing of the sutures through the tissue with resultant sphincter repair disruption. Hematoma formation, wound infection, technical considerations, and an unrecognized second sphincter injury also predispose to poor outcome requiring second repair in at least 5% of patients.1,3 In addition, in women with severe traumatic lacerations and significant perineal contamination, debridement and formation of a colostomy may be necessary until definitive sphincter repair can be performed. Secondary sphincter repairs should only be undertaken after all pelvic sepsis has resolved, contaminated perineal wounds have healed, the inflammation has completely resolved, and the tissues are soft and pliable. For most failed primary sphincter repairs, a period of waiting of at least 3 months before performing an overlapping sphincteroplasty is prudent. Overlapping sphincteroplasty is generally undertaken as the technique

Figure 6-8.1. Direct apposition sphincter repair. (Reprinted from Wexner SD, Beck DE. Fundamentals of Anorectal Surgery. 2nd ed. p 133-136, Copyright 2001 WB Saunders, with permission from Elsevier.)

for secondary repairs because, historically, direct apposition has demonstrated disappointing long-term results, although it yields good results in the acute setting (Figure 6-8.1).

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