Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 959 - файл

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This chapter presents the main surgical options that can be used in patients with FI.

The patient is positioned in the lithotomy position with the thighs exed, to expose the perineal region; intraoperative curarization is not required. Surgery begins with incision and mobilization of the gracilis muscle. The surgeon makes an incision on the medial inner aspect of the thigh, a few centimeters below the origin of the thigh, up to 10cm before the knee. Mobilization of the gracilis muscle must start from its central part to preserve the main neurovascular pedicle. The left index nger placed under the gracilis pulls the muscle out, allowing dissection of the nearby connective tissue and coagulation of additional secondary vascular pedicles. The middle nger of the surgeon’s left hand penetrates the distal tendon to the pes anserinus (at the level of the internal tibial tuberosity), where a small incision is made. The distal gracilis tendon must be interrupted at this level. The muscle is then tipped over on the perineum, and it is important to avoid twisting or compressing its neurovascular pedicle. At this point, the perineorectal area must be prepared by making two lateral incisions of 4–5cm each between the anal verge and ischium. To delineate the peri­neorectal area, a tunnel must be create between the origin of the thigh and the ipsi­lateral perineal incision. This tunnel must be large enough to allow the muscle to be laid without tension or obstruction, and special care must be taken to not twist the muscle. The gracilis muscle is rotated and passed through the perineorectal area to completely encircle the anal canal. It is important to avoid any contact between the muscle and the anal canal (because of the risk of ulceration) or excessive muscle tension (it must be possible to pass two ngers between the anal canal and the muscle). After checking for correct muscle tension, the distal tendon is xed to the contralateral (gamma-shaped loop) or ipsilateral (alpha-shaped loop) ischium with an orthopedic tendon clamp. During xation, the thigh must be positioned in full adduction to achieve adequate tightening and avoid secondary loosening. After hemostasis, the perineal incisions are closed without placing a drain. At this point,

two neurostimulation electrodes are positioned and inserted into the muscle, with the anode placed in the distal portion and the cathode in the proximal one. The elec­trodes are xed with nonabsorbable 4/0 Prolene sutures. Positioning of the elec­trodes connected to the external stimulator allows determination of the stimulation threshold and the maximum stimulation value. Placement of the neuromuscular pacemaker requires an incision in the ipsilateral iliac fossa of the harvested muscle to provide subcutaneous access from the origin of the thigh to the anterior abdomi­nal wall. Sheathed electrodes are then passed through this subcutaneous pathway to the rectus sheath and connected to the neuromuscular pacemaker. The pacemaker is placed in the subcutaneous space and secured to the fascia with a nonabsorbable suture. The procedure ends with closure of the thigh and cessation of electrical stimulation. A Redon suction drain is inserted into the thigh and drained through the tibial incision. After hemostasis, the subcutaneous tissue and muscular perimysium are approximated by a continuous suture layer of slowly absorbable material. The cutaneous plane is closed with a continuous non- absorbable suture. The stimulator is synchronized by telemetry with the stimulation parameters determined during electrode placement [11].

Currently, its use is largely limited to a small number of centers where sufcient patient volume and surgical experience ensure low morbidity and satisfactory func­tional outcomes.

The ring is implanted in the upper anal canal. The three elements are connected by a kink-resistant tube. The pressure-regulating reservoir, which controls the pres­sure exerted on the anal canal by the closure ring, is implanted in the subperitoneal space of Retzius, lateral to the bladder. The control pump is implanted in the scro­tum in males and in the labia majora in females and contains a resistor and a deac­tivation button in its upper part. The lower part of the pump consists of a piston that the patient squeezes to deliver the uid inside the implant [15, 17]. The ABS works semiautomatically [15]. The sphincter muscle automatically provides constant anal closure at low pressure approaching physiological levels; the pressure is transmitted to the closure cuff by the pressure-regulating pump. Emptying is actively controlled by the patient: the anus is opened by transferring the uid from the cuff to the pressure-regulating reservoir. Transfer is achieved by pressing the piston of the reg­ulating pump ve to ten times. Reclosure of the anus occurs automatically within minutes by gradually restoring the baseline pressure in the cuff.