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withthoseintheRAFgroup.
TissueInterposition
ThesuccessrateofMartiusflapvariesfrom60%to94%;however,ina largeseriesof23patientswhounderwentaMartiusflap,thesuccessrate was65%asreportedbyPiteletal.(2011).

CONCLUSIONS

RVFisadevastatingproblemofheterogeneousetiology.ManagingRVF requiresknowledgeoftheetiology,definitionoftheanatomyofthe fistula,ensuranceofsphincterintegrity,optimizationofhealthy surroundingtissues,andresolutionofinfection/inflammation.Variable clinicalpresentation,multitudeofavailablesurgicalprocedures, individualsurgeonpreferences,andlackofrandomizedtrialshave resultedinlackofconsistentsurgicalmanagement.However,surgeons shouldbeawareofavailableprocedurestobeabletotailortheproper techniquefortheappropriatecandidate.
RECOMMENDEDREFERENCESAND READINGS
EllisCN.Outcomesafterrepairofrectovaginalfistulasusingbioprosthetics.DisColonRectum
2008;51:1084–8. EllisCN.Rectovaginalfistula.SeminColonRectalSurg2009;20:58–62. HullTL,BartusC,BastJ,FlorutaC,LopezR.Multimediaarticle.Successofepisioproctotomyfor
cloacaandrectovaginalfistula.DisColonRectum2007;50(1):97–101. HullTL,El-GazzazG,GurlandB,ChurchJ,ZutshiM.Surgeonsshouldnothesitatetoperform
episioproctotomyforrectovaginalfistulasecondarytocryptoglandularorobstetricalorigin.Dis
ColonRectum2011;54:54–9. HullTL,FazioVW.SurgicalapproachestolowanovaginalfistulainCrohn’sdisease.AmJSurg
1997;173(2):95–8. HullTL.Anorectalvaginalfistula.In:HullTL,ed.PosteriorPelvicFloorAbnormality.
Philadelphia,PA:ElsevierSaunders,2011:69–79. JooJS,WeissEG,NoguerasJJ,WexnerSD.EndorectaladvancementflapinperianalCrohn’s
disease.AmSurg1998;64:147–50. JoyceMR,HullTL.Endoanaladvancementflapsinthemanagementofcomplexanorectal
fistulas.SeminColonRectalSurg2009;20:24–31. LowryAC,ThorsonAG,RothenbergerDA,GoldbergSM.Repairofsimplerectovaginalfistulas.
Influenceofpreviousrepair.DisColonRectum1988;31:676–8. MarchesaP,HullTL,FazioVW.Advancementsleeveflapsfortreatmentofsevereperianal
Crohn’sdisease.BrJSurg1998;85(12):1695–8. PitelS,LefevreJH,ParcY,etal.Martiusadvancementflapforlowrectovaginalfistula:short-and
long-termresults.ColorectalDis.2011;13(6):e112–5. SantoroGA,AbbasMA.Complexanorectalfistulas.In:SteeleSR,HullTL,ReadTE,Saclarides
TJ,SenagoreAJ,WhitlowCB,eds.TheASCRSTextbookofColonandRectalSurgery.New
York,NY:SpringerScienceBusinessMediaLLC,2016:275–88. TsangCB,MadoffRD,WongWD,etal.Analsphincterintegrityandfunctioninfluencesoutcome
inrectovaginalfistularepair.DisColonRectum1998;41(9):1141–6.
PARTIV
OPERATIONSFORFECAL INCONTINENCE
Chapter15
OverlappingRepair
LaurenR.Wilson,TracyL.Hull,andBrooke
Gurland

INDICATIONS/CONTRAINDICATIONS

Inotherwisehealthyyoungwomen,directsphinctertraumaor neuropathicinjuriessustainedduringvaginaldeliveriesaretheprincipal causativefactorsinthedevelopmentoffecalincontinence.Prospective studiesusinganalultrasoundhaveshownthatanalsphincterinjuriescan occuraftervaginaldeliverieswithoutanyvisiblesignsofperinealtrauma in9–38%ofpatients.Arecent,large,population-basedstudyrevealedan incidenceoffecalincontinenceinalmost20%ofhealthyadultwomen.A delayedpresentationoffecalincontinencecanoccurastheeffectsof agingincludingcomorbiditiesthatleadtorectalurgencyandhormonal changessummatewiththoseofpriorpelvicmuscularandneurologic injuriestoproduceovertsymptomsofurinaryincontinence,pelvicorgan prolapse,andfecalincontinence.
Giventhedelayedpresentationinmanywomenandthevaried contributingfactorstofecalincontinence,thereisawiderangeof treatmentoptions,whichareimplementedstartingwithnoninvasive measuresbeforeproceedingtoinvasiveprocedures.Treatmentoptions fortheincontinentpatientsincludenonoperativeinterventionssuchas medicationstoimprovestoolconsistencyandbiofeedback,procedures includinginjectionofbulkingagentsandcontrolleddeliveryof radiofrequencyenergy(Secca;MederiTherapeutics,Norwalk,CT),and operativeinterventionsincludinganalsphincteroplasty,sacralnerve stimulation(SNS),postanalrepair,graciloplasty,transobuturator posterioranalsling(TOPAS;AmericanMedicalSystems,Minnetonka, MN),andFenix(JohnsonandJohnson,Somerville,NJ)ormagnetic sphincteraugmentation.Presently,theartificialbowelsphincterisnot beingmanufacturedforuseintheUnitedStates,andthestimulatorused
fordynamicgraciloplastyisalsonolongeravailable.
Althoughtherearemanymodalitiesavailabletosurgeonsandpatients withfecalincontinence,sphincteroplastyhastraditionallybeenthemost commonlyperformedprocedureforfecalincontinenceresultingfroma sphincterdefect.Overlappinganalsphincterrepairisanoperationthat maybeofferedtotheincontinentpatientwithananatomicallydisrupted externalanalsphincter(EAS)muscle,particularlyiftheywishtoavoidan implantabledeviceorliveinacommunityinwhichpostoperative maintenanceisnotavailable.Itcanbeperformedregardlessofthe etiologyoftheinjurytothesphinctercomplex,butismostcommonly performedfollowinganobstetricinjury.
Transanalultrasound,manometry,andpudendalnervelatenciesare diagnosticstudiesusedintheevaluationofpatientswithfecal incontinence.Thesetestscanhelptodelineateotheretiologiesoffecal incontinence,andmayprovideobjectivemeasuresofanalneuromuscular functionthatwouldnotbeotherwisedetectedonclinicalexamination. Analsphincterinjuriesaredetectedbyabreakinthemuscularring visualizedon2Dor3Danalultrasonography.Defectsmaybereportedas EAS,internalanalsphincter(IAS),orcombinedinjuries.
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Therehavebeennumerousstudiesevaluatingtheeffectofpudendal neuropathybyPudendalNerveTerminalMotorLatency(PNTML)in incontinenceandsuccessofanterioroverlappingsphincterrepair.As summarizedbyGoetzandLowry,thereareafewpapersthatsuggestthat prolongedPNTMLpredictpoorpostoperativefunctioninpatients undergoinganterioroverlappinganalsphincteroplasty,whereasothers havefailedtodemonstratethisassociation.Therefore,whereassome centersusePNTMLaspartoftheevaluationforfecalincontinence,other centersdonot.
PREOPERATIVEPLANNING
Adetailedbowelhistoryisperformedtoassessstoolconsistencyand frequencyofbowelmovements(BMs).Loose,wateryBMsmaybe difficulttocontroleveninthesettingofnormalsphincterfunction,and evaluationofdiarrheashouldbeinitiatedbeforeconsideringsphincter repair.Bulkingagentsandconstipatingmedicationsarerecommendedas thefirst-linetherapytominimizeBMs,thusdecreasingincontinent episodes.Marklandetal.comparedpsylliumwithloperamideforthe treatmentoffecalincontinence.Bothmedicationswereeffectivefor improvingfecalincontinenceandqualityoflife(QoL),butloperamide hadmoresideeffects,specificallyconstipation.
Chronicmedicalconditionssuchasneurologicdiseases,obesity, chronicobstructivepulmonarydisease,diabetes,andotherconditions thatmaypredisposethepatienttodiarrheasuchasacholecystectomy stateorbariatricsurgeryshouldbeidentifiedandoptimizedpriortoa surgicalintervention.Patientsshouldbeaskedaboutsymptomsofother pelvicorganproblemsincludingurinaryincontinenceandpelvicorgan prolapse.
Thefollowinginformationshouldbecollectedregardingfecal accidents:urgentversuspassiveincontinence,typeofincontinence(gas, liquid,solid,ormucus),frequency,quantityoffecalincontinence(FI), andhowFIaffectsQoL.WerecommenddiscussingspecificQoL indicatorsrelatedtoFIincludingchangingdietaryhabits,changingdaily behavior,andemotionalconcernssuchasanxietyandembarrassment withpatients.Avalidatedincontinencescoringsystemshouldalwaysbe usedtocompareseverityofFIpre-andpost-interventionwithregardto thetypeofincontinenceandfrequency,aswellasQoLmeasures.There areseveralvalidatedscoringsystemswiththemajorityofpractitioners usingeithertheClevelandClinic(Wexner)ortheStMark’s(Vaizey) scorestoassesstheseverityofFIandtosomedegreeQoL.Thesescores canbecombinedwithotherscalesmorespecifictoQoLsuchastheFecal IncontinenceQualityofLife(FIQoL)scoreforamoredetailed assessmentofFIandQoL.TheFIQoLsubscoresincludelifestyle,coping andbehavior,depressionandself-perception,andembarrassment. Consistencyinusingscoringsystemsallowsforbothobjective assessmentsofpatientimprovementonanindividualleveland comparabilityacrossstudypopulationsforoverlappingsphincteroplasty andothermodalitiestotreatFI.Itisimportanttounderstandwhich aspectsofFIaremostbothersometoeachpatientbecauselow-severity scoresmayalsobeassociatedwithpoorQoL.Settingpatientexpectations astohowsurgicalrepairmightimprovetheirfunctioniscriticaltolong-
termsuccess.
Physicalexaminationoftheperineumshouldassessforvisible contractionofthesphinctermuscleandnoevidenceofrectalprolapse. Theabsenceofsphinctercontractionsduringperinealexaminationscan beapoorprognosticindicator.Completeevaluationshouldincludea vaginalexaminationtoevaluateforpelvicorganprolapse,as comanagementwithagynecologicsurgeonmaybenecessary.Anorectal manometry,endorectalultrasound,andinsomecasespudendalnerve studiesmaybeperformedtohelpguideinterventions.
Adiscussionaboutrealisticpostoperativeoutcomesisveryimportant. Itisrareforapreviouslyincontinentpatienttoexperienceperfect continencefollowingsphincteroplastyoranyothercontinenceprocedure. Somedegreeofgasandstoolincontinenceshouldbeexpected. Importantly,manywomenconsidertheiroperationasuccessalthough reportinghighratesofFI.Womenwithmorepredictablebowelhabits, butwithFIofsolidstooltendtoimprovepostoperativelycomparedwith womenwithgasincontinencethatisfrequentlynotcorrectedwith sphincterrepair.Asreferencedpreviously,theuseofscoringsystemscan helpframeexpectationswithpatientsastowhichaspectsoftheirbowel incontinencemayimproveaftersurgery.Forexample,apatientwithgas incontinenceonly,whichisthemostdifficulttoresolvesurgically,would havelow-severityscores,butmayreportasevereimpactontheQoLand belesslikelytoimprovetheQoLwithintervention.
Overlappingsphincterrepairisgenerallyperformedwithouta divertingstomaunlessthereisacomplexinjurywithacloacaldefect,or complexrectovaginalfistula.Hasegawaetal.demonstratedequivalent sphincter-relatedoutcomesbetweengroupsrandomizedto sphincteroplastywithorwithoutdivertingstoma.However,patientsin thestomagroupsufferedstoma-relatedcomplications.
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Immediatepreoperativepreparationsatourinstitutionincludea mechanicalbowelpreparation24hoursbeforesurgery,andasingledose ofintravenousantibioticsadministered30minutespriortoskinincision.

SURGERY

OperativeTechnique
Anumberofdifferenttechniqueshavebeendescribedfor sphincteroplasty,andthechoiceoftechniqueisoperator-dependent.Two techniquesaredescribedforoverlappingrepairofthesphincter.Anen blocoverlappingsphincteroplastyavoidsseparatingtheinternaland externalsphincters.TheothertechniqueinvolvesseparationoftheIAS andEASfollowedbyananteriorlevatorplasty,IASimbrication,and overlappingrepairoftheEAS(seesphincteroplastyvideo).
OperativePositioning
Foreitherapproach,thepatientispositionedinthepronejackknife positiononaKraskeRoll.
Theprocedureisperformedundergeneralorspinalanesthesia. Althoughwepreferpronejackknifeposition,thelithotomypositionmay
00:00/00:00
OverlappingAnalSphincteroplasty
beusedifthepatientisundergoingaconcomitanturinaryanterior compartmentprolapseprocedure.
Largetapesareusedtoseparatethebuttocksfortheexposureofthe anusifperformedintheproneposition.TheLoneStarretractorcanalso
beused. Theperianalarea,vagina,andperineumarepreparedsterilely.
Abladdercatheterisplaced. Asolutionofbacitracinirrigantispreparedandusedthroughoutthe
proceduretoirrigatetheoperativefield. Electrocauteryisusedthroughouttheproceduretomaintainhemostasis.
Ananterior120-degreecurvilinearincisionismadethroughtheskinof theperineumwitha15-bladescalpel(Fig.15-1).
FIGURE15-1Curvilinearincisionmadealongthe
perinealbody.
TheskinedgesaregraspedwithAllisclampsforexposure,andflapsare developedtowardtheanalvergeandthevaginausingsharpdissection.
Careistakennotto“buttonhole”theskin. Lateraldissection,wherethemuscleanatomyisintact,canhelpto
identifytheproperplaneofdissection.TheEASisthemedialborderof theischiorectalfossa,andidentificationoftheischiorectalfatisauseful
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