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

After spinal/local anesthesia [18], with the patient in the lithotomy position, small (2mm) skin incisions are performed at 12, 3, 6, and 9 o’clock or at 1, 3, 5, 7, 9, and 11 o’clock in the intersphincteric groove to allow implantation of four or six pros­theses by using a specically designed delivery system, which is functionally simi­lar whether GK or SK prostheses are being implanted; in the latter case, up to ten small skin incisions can be used. Under digital guidance, the introducer is inserted into the intersphincteric space through a short subcutaneous tunnel and pushed up to reach the upper part of the anal canal. The introducer is placed in the upper third of the anal canal, at the level of the puborectalis muscle. Once in place, the gun is red resulting in retraction of the cannula and deployment of the prosthesis. When the proximal part of the prosthesis reaches the tip of the cannula, the whole cannula retracts completely inside the delivery system and the prosthesis is released in place in the desired position within the intersphincteric space. The delivery device is then withdrawn. The implants are distributed equally around the anal canal, as it is believed that the actual position does not inuence the outcome, even in the pres­ence of EAS or IAS tears. The prostheses are placed in the same position in all patients, irrespective of the location of possible EAS/IAS lesions. Beginning from the very rst reports of GK implantation, the prostheses were placed at 3, 6, 9 and 12 o’clock positions for convenience but it is likely that, provided the implants are inserted correctly and distributed equally around the anal canal, the actual position does not inuence the outcome. As for the number of prostheses implanted, it has been recently demonstrated that the greater the number of the prostheses, the better the clinical outcome [19]. Some authors [8] perform skin incisions about 2cm away from the anal verge to minimize the risk of wound contamination during bowel movements. Nonlinear tunneling through the soft subcutaneous tissues to reach the intersphincteric plane from the skin incision is thought to avoid possible prosthesis extrusion along the track. In our procedure [18], all of the steps are veried by pal­pation and direct vision using the Eisenhammer anal speculum. However, prosthesis placement can also be performed under EAUS guidance to monitor the procedure step by step and ensure correct positioning of the prostheses, but this is not manda­tory and simple digital palpations by an expert physician can be enough to guaran­tee proper positioning of the prostheses. When performed, EAUS is used to conrm the position of the prosthesis, which appears as a hyperechoic dot with a hypoechoic shadow behind it. Three-dimensional EAUS (3D-EAUS) was used by some groups and showed a continuous hyperechoic line after implantation [9]. Finally, the skin wounds are sutured with resorbable material. Patients are usually discharged on the same day and instructed to avoid any trauma or sexual practice during the rst 48h after implantation. Bed rest is usually recommended and aims at decreasing the risk