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Results
Successful outcomes after sphincteroplasty range
between 23% and 100% (Table 1). Unfortunately, the
heterogeneity of patients in individual studies has
resulted in disagreement about which patient vari-
ables predict a successful outcome. Most authors
would agree that patients who have severe preopera-
tive incontinence, failed previous repairs, or who
demonstrate a persistent defect on follow-up
endoanal ultrasound are the least likely to have a suc-
cessful outcome following sphincteroplasty. There is
disagreement on other factors, such as age at time of
repair or parameters of anal physiologic testing.
Some authors have demonstrated correlation
between successful sphincteroplasty and certain
manometric parameters, such as squeeze pressure,
resting pressure, and anal canal length, but data are
conflicting, and many patients present clinically
without a measurable defect in sphincter pressure.
Regrettably, more recent data reveal the long-term
durability of overlapping sphincteroplasty to be disap-
pointing. Initial series reported successful outcomes in
between 70% and 80% of patients; however, as groups
followed their patients for more than 5 years, success
rates decreased to 50–60% [20, 21]. The study with the
longest follow-up to date demonstrated that although
36% of their cohort was incontinent to solid stools 3
years after sphincteroplasty, 58% had become inconti-
nent after 10 years [22]. It is unclear why such a dra-
matic deterioration in function occurs over time.
Aging, scarring, and worsening pudendal nerve func-
tion have all been postulated as a potential mechanism.
References
1. Lockhart-Mummery JP (1923) Diseases of the rectum
& colon and their surgical treatment. Macmillan,
Toronto
2. Blaisdell PC (1942) Repair of the incontinent sphincter
ani. Surg Gynec Obst 70:692–697
174
J.W. Ogilvie Jr., R.D. Madoff
Table 1. Results after sphincteroplasty. Studies were excluded if follow-up was not designated or less than 12 months, or a
more recent publication reported on the same cohort of patients
Group Year Number of Mean age Median Percent good, Percent
patients or range follow-up excellent obstetric
(months) results related
Browning [23] 1983 83 38 39 78 16
Fang [24] 1984 76 17-68 35 89 54
Christiansen [25] 1987 12 34 26 75 17
Pezim [26] 1987 40 40 67 62 58
Stern [27] 1987 11 47 7–40 73 55
Ctercteko [28] 1988 44 36 50 54 41
Abcarian [29] 1989 53 32 42 100 88
Yoshioka [30] 1989 27 34 48 26 33
Fleshman [31] 1991 55 34 12 72 87
Gibbs [32] 1993 33 47 43 73 58
Engel [33] 1994 55 42 15 76 100
Londono-Schimmer [34] 1994 94 43 59 50 64
Richard
a
[16] 1994 45/37 – 42/23 82/87 60/62
Sangalli [35] 1994 36 37 34 78 100
Simmang [11] 1994 14 66 12 71 79
Felt-Bersma [36] 1996 18 47 14 72 55
Nikiteas [14] 1996 42 – 38 67 76
Sitzler [37] 1996 31 42 12–36 74 71
Gilliland [9] 1998 77 47 24 55 69
Young [15] 1998 54 42 18 86 88
Karoui [38] 2000 74 56 40 51 83
Malouf [20] 2000 46 43 77 59 100
Osterberg [39] 2000 20 47 12 50 100
Morren
b
[40] 2001 55 39 40 56 84
Halverson [19] 2002 49 39 63 49 63
Pinta [41] 2003 39 53 22 59 100
Bravo Gutierrez [22] 2004 130 37 124 23 91
Barisic [42] 2006 65 36 80 48 72
a
The study was divided into two groups: with and without diverting colostomy
b
Thirteen percent were done via an end-to-end repair
Chapter 16 Sphincteroplasty
3. Blaisdell PC (1950) Plastic repair of the incontinent
sphincter ani. Am J Surg 79:174–183
4. Parks AG,McPartlin JF (1971) Late repair of injuries of
the anal sphincter. Proc R Soc Med 64:1187–1189
5. Slade MS, Goldberg SM, Schottler JL et al (1977)
Sphincteroplasty for acquired anal incontinence. Dis
Colon Rectum 20:33–35
6. Fernando R, Sultan AH, Kettle C et al (2006) Methods
of repair for obstetric anal sphincter injury. Cochrane
Database Syst Rev 3:CD002866
7. Sultan AH, Kamm MA, Hudson CN et al (1994) Third
degree obstetric anal sphincter tears: risk factors and
outcome of primary repair. BMJ 308:887–891
8. Cook TA,Mortensen NJ (1998) Management of faecal
incontinence following obstetric injury. Br J Surg
85:293–299
9. Gilliland R, Altomare DF, Moreira H Jr et al (1998)
Pudendal neuropathy is predictive of failure following
anterior overlapping sphincteroplasty. Dis Colon Rec-
tum 41:1516–1522
10. Oliveira L, Pfeifer J, Wexner SD (1996) Physiological
and clinical outcome of anterior sphincteroplasty. Br J
Surg 83:502–505
11. Simmang C, Birnbaum EH, Kodner IJ et al (1994) Anal
sphincter reconstruction in the elderly: does advanc-
ing age affect outcome? Dis Colon Rectum
37:1065–1069
12. Sangwan YP, Coller JA, Barrett RC et al (1996) Unilat-
eral pudendal neuropathy. Impact on outcome of anal
sphincter repair. Dis Colon Rectum 39:686–689
13. Chen AS, Luchtefeld MA, Senagore AJ et al (1998)
Pudendal nerve latency. Does it predict outcome of
anal sphincter repair? Dis Colon Rectum
41:1005–1009
14. Nikiteas N, Korsgen S, Kumar D et al (1996) Audit of
sphincter repair. Factors associated with poor out-
come. Dis Colon Rectum 39:1164–1170
15. Young CJ, Mathur MN, Eyers AA et al (1998) Success-
ful overlapping anal sphincter repair: relationship to
patient age, neuropathy, and colostomy formation.
Dis Colon Rectum 41:344–349
16. Richard C, Bernard D, Morgan S et al (1994) [Results
of anal sphincteroplasty for post-traumatic inconti-
nence: with or without colostomy]. Ann Chir
48:703–707
17. Fazio VW, Church JM, Delaney CP (eds) (2005) Cur-
rent therapy in colon and rectal surgery, 2nd edn. Else-
vier Mosby, Philadelphia, pp 108–109
18. Nicholls RJ, Dozois RR (eds) (1997) Surgery of the
colon & rectum. Churchill Livingstone, New York, p 75
19. Nessim A, Wexner SD, Agachan F et al (1999) Is bowel
confinement necessary after anorectal reconstructive
surgery? A prospective, randomized, surgeon-blinded
trial. Dis Colon Rectum 42:16–23
20. Malouf AJ, Norton CS, Engel AF et al (2000) Long-
term results of overlapping anterior anal-sphincter
repair for obstetric trauma. Lancet 355:260–265
21. Halverson AL, Hull TL (2002) Long-term outcome of
overlapping anal sphincter repair. Dis Colon Rectum
45:345–348
22. Bravo Gutierrez A, Madoff RD, Lowry AC et al (2004)
Long-term results of anterior sphincteroplasty. Dis
Colon Rectum 47:727–31; discussion 731–732
23. Browning GG, Motson RW (1983) Results of Parks
operation for faecal incontinence after anal sphincter
injury. Br Med J (Clin Res Ed) 286:1873–1875
24. Fang DT, Nivatvongs S, Vermeulen FD et al (1984)
Overlapping sphincteroplasty for acquired anal incon-
tinence. Dis Colon Rectum 27:720–722
25. Christiansen J,Pedersen IK (1987) Traumatic anal
incontinence. Results of surgical repair. Dis Colon
Rectum 30:189–191
26. Pezim ME, Spencer RJ, Stanhope CR et al (1987)
Sphincter repair for fecal incontinence after obstetri-
cal or iatrogenic injury. Dis Colon Rectum
30:521–525
27. Stern H, Gallinger S, Rabau M et al (1987) Surgical
treatment of anal incontinence. Can J Surg
30:348–350
28. Ctercteko GC, Fazio VW, Jagelman DG et al (1988)
Anal sphincter repair: a report of 60 cases and review
of the literature. Aust N Z J Surg 58:703–710
29. Abcarian H, Orsay CP, Pearl RK et al (1989) Traumat-
ic cloaca. Dis Colon Rectum 32:783–787
30. Yoshioka K,Keighley MR (1989) Sphincter repair for
fecal incontinence. Dis Colon Rectum 32:39–42
31. Fleshman JW, Peters WR, Shemesh EI et al (1991) Anal
sphincter reconstruction: anterior overlapping muscle
repair. Dis Colon Rectum 34:739–743
32. Gibbs DH,Hooks VH, 3rd (1993) Overlapping sphinc-
teroplasty for acquired anal incontinence. South Med J
86:1376–1380
33. Engel AF, Kamm MA, Sultan AH et al (1994
) Anterior
anal sphincter repair in patients with obstetric trauma.
Br J Surg 81:1231–1234
34. Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ
et al (1994) Overlapping anal sphincter repair for fae-
cal incontinence due to sphincter trauma: five year fol-
low-up functional results. Int J Colorectal Dis
9:110–113
35. Sangalli MR,Marti MC (1994) Results of sphincter
repair in postobstetric fecal incontinence. J Am Coll
Surg 179:583–586
36. Felt-Bersma RJ, Cuesta MA,Koorevaar M (1996) Anal
sphincter repair improves anorectal function and
endosonographic image. A prospective clinical study.
Dis Colon Rectum 39:878–885
37. Sitzler PJ,Thomson JP (1996) Overlap repair of dam-
aged anal sphincter. A single surgeon’s series. Dis
Colon Rectum 39:1356–1360
38. Karoui S, Leroi AM, Koning E et al (2000) Results of
sphincteroplasty in 86 patients with anal incontinence.
Dis Colon Rectum 43:813–820
39. Osterberg A, Edebol Eeg-Olofsson K,Graf W (2000)
Results of surgical treatment for faecal incontinence.
Br J Surg 87:1546–1552
40. Morren GL, Hallbook O, Nystrom PO et al (2001)
Audit of anal-sphincter repair. Colorectal Dis
3:17–22
41. Pinta T, Kylanpaa-Back ML, Salmi T et al (2003)
Delayed sphincter repair for obstetric ruptures: analy-
sis of failure. Colorectal Dis 5:73–78
42. Barisic GI, Krivokapic ZV, Markovic VA et al (2006)
Outcome of overlapping anal sphincter repair after 3
months and after a mean of 80 months. Int J Colorec-
tal Dis 21:
52–56
175
Sphincteroplasty is the most immediate and intuitive
approach to treating fecal incontinence following
obstetric, iatrogenic, or accidental trauma to the anal
sphincters and should still be considered the first
step in an ideal algorithm to treat these patients.
James Ogilvie and Robert Madoff must be commend-
ed for the excellent and comprehensive chapter on
sphincteroplasty presented in this book, which is the
result of his broad experience in the field and his nat-
ural ability to describe complex things in a simple
and direct way.
I would like to briefly comment on some of the
controversial points discussed by Ogilvie and Mad-
off. First is the variability of the success rate and its
natural decline over time. We know that continence
is not only the result of a well-functioning anal
sphincter but is a very complex combination of a
normal autonomic and somatic innervation of the
anorectal region (normal sensation, compliance, and
rectal motility), normal anorectum, solid luminal
content, and, of course, normally functioning anal
sphincters. Therefore, the reason for unreliable
results after sphincteroplasty is the possible coexis-
tence of other undetected functional anorectal
abnormalities. But what worries the surgeon about
the future of these patients is the common feeling
that the success rate is destined to decline with time
[1, 2]. Why this happens is still uncertain. Deteriora-
tion of muscle innervation and natural ageing of the
tissues are the factors most commonly blamed, but
the real cause is still unknown.
One of the few tests available for evaluating neural
integrity of that anatomical region is pudendal nerve
terminal motor latency (PNTML) developed at St.
Mark’s Hospital in the UK. However, the reliability of
this test has recently been questioned and, despite a
huge number of studies utilizing PNTML for assess-
ing patients with fecal incontinence, there is a ten-
dency to consider the test obsolete. Although
impaired pudendal nerve function is commonly
believed to be a negative prognostic factor for
sphincteroplasty [3, 4], several other experiences
have reported good outcomes independently of it
[5, 6]. As a consequence, a reliable neurological test
for evaluating innervation for the anal sphincters is
not available, and a sphincteroplasty is usually car-
ried out even in the presence of prolonged PNTML.
On the other hand, a sphincter electromyography
(EMG) could provide useful information, but there
are no studies clearly assessing the predictive value of
sphincter EMG or documenting any progressive mus-
cle deterioration over time after sphincteroplasty.
Another controversial point is what to do after
early or late failure of sphincteroplasty. This question
is still really open, particularly since the introduction
of the sacral nerve modulation technique, which for
the first time enables the surgeon to address not only
the sphincter muscles but also the other components
of the physiology of continence, such as rectal sensi-
tivity and motility. A recent paper [7] described a
successful outcome of sacral nerve modulation
(SNM) in patients with fecal incontinence after
sphincter lesions, and a randomized controlled trial
on this topic is running among centers of the Italian
Group for Sacral Nerve Modulation (GINS). These
data indicate that in selected cases of patients with
sphincter lesions, continence can be improved by
correcting the pelvic nerve function only. Further-
more, another study documented that a failed
sphincteroplasty can be redone with a reasonable
probability of success [8, 9].
Only in cases of resphincteroplasty or SNM failure
should major surgery such as dynamic graciloplasty
or artificial bowel sphincters be considered, but such
procedures should be confined to severe end-stage
fecal incontinence and be carried out by well-trained
colorectal surgical teams in order to minimize the
failure rate.
References
1. Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ
et al (1994) Overlapping anal sphincter repair for fae-
cal incontinence due to sphincter trauma: five year fol-
low-up functional results. Int J Colorectal Dis
9:110–113
Invited Commentary
Donato F. Altomare
Chapter 16 Sphincteroplasty · Invited Commentary
2. Barisic GI, Krivokapic ZV, Markovic VA, Popovic MA
(2006) Outcome of overlapping anal sphincter repair
after 3 months and after a mean of 80 months. Int J
Colorectal Dis 21:52–56
3. Gilliland R, Altomare DF, Moreira H Jr et al (1998)
Pudendal neuropathy is predictive of failure following
anterior overlapping sphincteroplasty. Dis Colon Rec-
tum 41:1516–1522
4. Sangwan YP, CollerJA, Barrett RC et al (1996) Unilat-
eral pudendal neuropathy. Impact on outcome of anal
sphincter repair. Dis Colon Rectum 39:686–689
5. Chen AS, Luchtefeld MA, Senagore AJ et al (1998)
Pudendal nerve latency. Does it predict outcome of
anal sphincter repair? Dis Colon Rectum 41:1005–1009
6. Buie WD, Lowry AC, Rothenberger DA, Madoff RD
(2001) Clinical rather than laboratory assessment pre-
dicts continence after anterior sphincteroplasty. Dis
Colon Rectum 44:1255–1260
7. Conaghan P, Farouk R (2005) Sacral nerve stimulation
can be successful in patients with ultrasound evidence
of external anal sphincter disruption. Dis Colon Rec-
tum 48:1610–1614
8. Giordano P, Renzi A, Efron J et al (2002) Previous
sphincter repair does not affect the outcome of repeat
repair. Dis Colon Rectum 45:635–640
9. Vaizey CJ, Norton C, Thornton MJ et al (2004) Long-
term results of repeat anterior anal sphincter repair.
Dis Colon Rectum 47:858–863
177
Historical Background
Postanal repair was developed by Sir Allan Parks in
the 1970s [1] and popularised in the early 1980s for
patients with neuromyopathic faecal incontinence.
The original objective of this operation was to restore
the anorectal angle, which was thought to be an
important factor in continence. In 1975, Parks sug-
gested the flap–valve theory that stressed the impor-
tance of the acute anorectal angle. According to this
theory, a rise in intra–abdominal pressure caused the
upper end of the anal canal to be occluded by anteri-
or rectal mucosa, preventing rectal contents from
entering the anal canal. Neuromyopathic faecal
incontinence was associated with perineal descent
and an obtuse anorectal angle, which rendered the
flap-valve-like mechanism ineffective. Further inves-
tigations, however, failed to show changes of the
anorectal angle, and currently, it is thought that an
improvement of muscular contractility is responsible
for any improvement in continence [2].
Postanal repair involves coaptation of the levator
ani, puborectalis and external anal sphincter posteri-
or to the anal canal and the anorectal junction by
approximating these muscles with nonabsorbable
sutures. The anatomical result of this procedure is
lengthening of the anal canal and possible reduction
of the anorectal angle.
Anatomic Consideration
The anal canal is 3–5 cm long, passing from the dis-
tal rectum to the anal verge. The puborectalis muscle
passes posterior to the anorectal junction, forming a
sling that draws the anorectal junction forwards
(Fig. 1). The length of the anal canal and the sling
action of the puborectalis are thought to be impor-
tant parts of the continence mechanism. Patients
with neuromyopathic incontinence have a shorter
anal canal and a straightening of the anorectal angle.
The anorectal angle is the angle between the longitu-
dinal axis of the rectum and the anal canal. It can be
assessed either by defecating proctography or mag-
netic resonance imaging (MRI). Normal values range
from 90° to 110° at rest, increasing to about 135° dur-
ing defecation. In patients with idiopathic inconti-
nence, the angle at rest is straightened to greater than
110°.
Indications
Postanal repair is currently performed on patients
with idiopathic faecal incontinence with no evidence
of sphincter defect on endoanal ultrasound. It should
only be offered when conservative treatment with
dietary manipulation, drug therapy and physiothera-
py has been implemented without success. The
patients expected to benefit most from postanal
repair are women with a history of multiple vaginal
deliveries [2–4].
Postanal Pelvic Floor Repair
Saleh M. Abbas, Ian P. Bissett
17
Fig. 1. Sagittal view of the pelvis on magnetic resonance
imaging (MRI). Note the dotted line indicating the inter-
sphincteric plane dissected in postanal repair. AC anal
canal, LA levator ani, EAS external anal sphincter, PR pub-
orectalis, IAS internal anal sphincter, PB pubic bone. (Pic-
ture by Professor Stuart Heap, University of Auckland,
Department of Anatomy and Radiology)
Preoperative Assessment
Operative intervention is undertaken in patients in
whom appropriate assessment has been performed.
This includes a careful history, clinical examination,
endoanal ultrasound and anal manometry. Further
tests that may be useful are a defecating proctogram,
pudendal nerve terminal motor latency (PNTML)
and needle electromyelogram (EMG). If these inves-
tigations identify a defect in the external sphincter,
then the patient should undergo a sphincter repair
rather than a postanal repair. Rectal prolapse should
be excluded by careful history and examination and
if necessary, a defecating proctogram.
Defecating proctography is a dynamic fluoroscop-
ic examination performed by instilling thick barium
contrast into the rectum and capturing lateral images
during defecation. It is useful in assessing both
anatomy and function of the anal canal and pelvic
floor during defecation. PNTML is the measurement
of the time from stimulation of the pudendal nerve at
the ischial spine to the response of the external anal
sphincter. Normal PNTML is <2.2 ms, and is often
prolonged in patients with neuropathic faecal incon-
tinence. Electromyography recruitment records the
change from basal electrical activity of motor units of
the external anal sphincter and levator muscles dur-
ing muscle activity. This may a useful adjunct in the
investigation of neuropathic incontinence.
Operative Technique
The patient is admitted on the day of surgery and
prior to the operation is given an enema to empty the
rectum. With induction of the anaesthetic, prophy-
lactic antibiotics are given in the form of 1 g Cefoxitin
and 500 mg metronidazole intravenously. The pa-
tient is placed in a prone jack-knife position, with the
buttocks spread apart using adhesive tape. A curvi-
linear incision is made 6 cm posterior to the anus
(Fig. 2), and dissection is directed to the intersphinc-
teric plane, which is relatively bloodless. Fibres of the
external sphincter are red in colour and contract with
diathermy stimulation, while those of the internal
sphincter are white and do not contract to diathermy
current. Dissection is then deepened in the inter-
sphincteric plane to the upper part of the external
sphincter and puborectalis muscle, finally exposing
the levator ani fascia and the mesorectal fat. This dis-
section is extended anteriorly to include half of the
circumference of the anal canal. A deep 90° angled
retractor is used to push the rectum anteriorly in
order to see the highest and the most lateral part of
levator ani (Fig. 3).
The levator ani is then approximated using 2/0
nonabsorbable sutures (Prolene or Ethibond). Using
a small curved needle to include a large bundle of
muscle fibres, three sutures are inserted at this
uppermost level. The sutures are then tied loosely to
180
S.M. Abbas, I.P. Bissett
Fig. 2. Incision is curvilinear posterior to the anal canal.
Reprinted with permission from Elsevier [5]
Fig. 3. Dissection in the intersphincteric plane to reveal puborec-
talis and levator ani. Reprinted with permission from Elsevier [5]
Chapter 17 Postanal Pelvic Floor Repair
create a lattice across the pelvis (Fig. 4). The pubo-
coccygeus muscle is approached next and additional
2/0 nonabsorbable sutures are placed in a similar
fashion by approximation of the lower fibres (Fig. 5).
Sutures in the puborectalis are the most important
in the repair, as this muscle is the strongest of the
pelvic floor. The sutures are placed as anteriorly as
possible, lifting the anorectal junction forwards. The
sutures are then tied loosely approximating the two
arms of the puborectalis. Usually, three sutures are
utilised to approximate the muscles of the external
sphincter. The approximation should not be tight
(Fig. 6). The skin is then closed using absorbable
sutures.
Postoperative Care
A urinary catheter is generally used to avoid reten-
tion and removed the following morning. Pain relief
is given according to the patient’s needs. Bowel sof-
teners are used in the immediate postoperative peri-
od to avoid faecal impaction and achieve semiliquid
stools; patients are instructed to avoid straining, as
this may disrupt the repair. The patient is usually dis-
charged home 24–48 h after the operation and
remains on laxatives for several weeks. Long-term
use of laxatives may be required.
Discussion
Parks first described postanal repair in 1975 [1], and
reported very good continence results in 80% of
patients. The procedure is usually performed on
patients with neuropathic faecal incontinence who
have an intact anal sphincter with poor sphincter
contractility. Typically, the patients are older women
with multiple vaginal deliveries and a weak pelvic
floor.
Since its description by Parks, postanal repair has
been applied in various parts of the world and re-
181
Fig. 4. Sutures in the upper levator ani are loosely tied to
create a lattice behind the rectum. Reprinted with permis-
sion from Elsevier [5]
Fig. 5. Approximation of pubococcygeus by nonabsorbable
sutures. Reprinted with permission from Elsevier [5]
Fig. 6. Approximation of external sphincter and puborectal-
is. Reprinted with permission from Elsevier [5]
ported to accomplish modest success [9, 11]. Studies
have shown improvement of 35 and 88% in faecal
incontinence following postanal repair [2, 6–12]
(Table 1), with only small numbers of patients
achieving full continence. Factors that have been sug-
gested to affect the outcome of postanal repair
include preoperative physiological parameters such
as resting anal tone, maximum squeeze pressure,
PNTML, concentric needle electromyography, unde-
tected external sphincter defects and pelvic floor
descent and anorectal angle, as seen preoperatively
on defecating proctography. None of these factors,
however, has predicted long-term outcome, with the
possible exception of maximal squeeze pressure
before surgery [9–11, 13–15]. The exact mechanism
of the effect of postanal repair is not fully under-
stood, although changes in the length of the anal
canal, rectal angle, change in resting anal pressure,
maximum squeeze pressure and pelvic floor descent
or anorectal angle following postanal repair have
been proposed as possible mechanisms. These have
not been proved on long-term follow-up to correlate
with the outcome [2]. A randomised controlled trial
by Deen et al. [14] in women with neuropathic faecal
incontinence compared total pelvic floor repair with
anterior levatorplasty and sphincter plication alone
and postanal repair alone. Review at 6 and 24 months
indicated that results were significantly better for
total pelvic floor repair than either of the other pro-
cedures.
The majority of patients with faecal incontinence
are found to have weak but intact external anal
sphincters. This is attributed to a variety of reasons,
such as diabetes and pudendal neuropathy [16]. Risk
factors for idiopathic incontinence are female gen-
der, advancing age, ill health and physical disability
[17]. A recent systematic review showed a prevalence
of faecal incontinence between 11% and 15% [17-19],
but the proportion of those who have neuropathic
incontinence is not known. A number of other treat-
ment options are available for this type of faecal
incontinence. These include conservative measures
aimed at achieving symptomatic control (such as
dietary manipulation, pharmacotherapy including
constipating agents, and phosphate enemas) and
pelvic floor retraining, also called biofeedback [20].
Newer modalities, such as sacral nerve neuromodu-
lation, have shown promise.
Conclusion
The patients most likely to benefit from postanal
repair are women with a history of multiple vaginal
deliveries and a weak but intact external anal sphinc-
ter on endoanal ultrasound. Although the initial
results of this procedure were promising, more
recent results have been variable. The current place
of postanal repair in the management of faecal incon-
tinence patients is unclear, as there are few data com-
paring it with other available procedures. It is of ben-
efit to patients with mild to moderate idiopathic fae-
cal incontinence and can be offered in conjunction
with other treatment modalities.
References
1. Parks AG (1975) Anorectal incontinence. P Roy Soc
Med 68:681–690
2. Athanasiadis S, Sanchez M, Kuprian A (1995) Long-
term follow-up of Parks posterior repair. An elec-
tromyographic, manometric and radiologic study of
31 patients. Langenbeck Arch Chir 380:22–30
3. Vaizey CJ, Kamm MA, Nicholls RJ (1998) Recent
advances in the surgical treatment of faecal inconti-
nence. Br J Surg 85:596–603
4. Browning GG, Parks AG (1983) Postanal repair for
neuropathic faecal incontinence: correlation of clini-
cal result and anal canal pressures. Br J Surg
70:101–104
5. Fielding LP, Goldberg SM (1993) Rob & Smith’s oper-
ative surgery. Surgery of the colon, rectum and anus,
5th edn. Butterworth-Heinemann, London
182
S.M. Abbas, I.P. Bissett
Table 1. Long-term results of continence for postanal repair in various studies
Study Improvement (%) Fully continent (%)
Womack et al. 1988 [6] 88 38
Yoshioka et al. 1989 [7] 81 34
Engel et al. 1994 [8] 50 21
Jameson et al. 1994 [9] 53 28
Athanasiadis et al. 1995 [2] 52 6
Reiger et al. 1997 [10] 58 31
Matsuoka et al. 2000 [11] 35 Not reported
Abbas et al. 2005 [12] 68 8.5
Chapter 17 Postanal Pelvic Floor Repair
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183
Introduction
Fecal incontinence is a terrible burden for patients.
In severe forms of incontinence, patients feel exclud-
ed from any social interaction. They prefer to stay at
home close to the toilet and try to avoid shopping,
attending parties, or visiting friends. If they do go
into public places, they know the location of every
public toilet. Even in their own homes, most of them
have rules with partner and children that the
moment the patient feels any urge, the toilet must be
free immediately. People who are not familiar with
this phenomenon can hardly understand how terri-
ble this can be for patients. Fecal continence is so
normal and taken for granted that those who have
never experienced it cannot imagine how life would
be if the moment arrived when he or she became
incontinent. The world shrinks to a size no bigger
than the patient’s home. These patients have the
choice of either accepting such a life or accepting a
colostomy.
Fecal continence is the ability to retain feces and
expel it in the appropriate place and at the appropri-
ate time. Continence is the result of delicate cooper-
ation of several factors: feces consistency, rectum
and sigmoid peristalsis, rectum capacity and compli-
ance, pelvic floor function, anorectal sensitivity, and
anal sphincter function. When one of these factors
becomes deficient, the quality of the other factors
determines whether or not the patient becomes
incontinent. For instance, when a patient has diar-
rhea, he or she stays continent as long as the sphinc-
ters are sufficient, but when sphincter and pelvic
floor function diminishes, the patient is unable to
hold liquid stool. For a long time, the anal sphincters
were considered to be the only factor determining
continence. Although this is no longer the case,
integrity of the anal sphincters is still recognized as
an important factor in fecal incontinence. Several
operating techniques have been developed to restore
dysfunctional sphincters.
Overlapping anal repair is by far the most fre-
quently used technique to restore anal sphincters [1].
Indications are restoration of the sphincters after
rupture due to obstetric causes, impalement trauma
of the perineum, or complications of perineal opera-
tions. The advantage in these situations is that the
ends of the sphincter are present around the anus,
and the operation can be performed through one
incision. The sphincters are rebuilt for sphincter
function and react to the patient’s own sensory input.
Results are initially very good but tend to deteriorate
over time [1–3]. When patients stay incontinent after
anatomical restoration of the sphincter and the
incontinence is not due to other factors, there are
other options. A Thiersch wire or a Silastic band [4]
can be brought around the anus, but these often
cause problems due to erosion, so these methods are
considered obsolete.
Two muscles have been used to augment the orig-
inal sphincters: the gluteus muscle [5] and the gra-
cilis muscle [6, 7]. The gluteus muscle has the advan-
tage of being a static muscle and can contract for a
longer time. However, its anatomical form and posi-
tion make it less attractive for sphincter function:
two gluteus muscles are needed to encircle the anus;
transposition hampers the original function of the
muscle, and patients are no longer able to walk stairs.
The gracilis muscle is the most ideal muscle to
encircle the anus. Its form and the position of the
main artery and nerve make it possible to free almost
the entire length of the muscle in the medial aspect of
the upper thigh. The proximal attachment of the
muscle to the pubic bone, as well as the nerve and
artery, remain intact. The distal part can be brought
around the anus subcutaneously. This transposition
causes no functional problems to the leg, and the
patient is able to walk, jump, and to play sport [8].
The intrinsic characteristics of the gracilis, however,
are not suitable for sphincter function. The gracilis
muscle is mainly composed of type II fibers, reflect-
ing its original function as an auxiliary muscle for
adduction, flexion, and exorotation in the hip and
the knee. These movements are always performed
with short-term contractions of the gracilis. The gra-
cilis consists mainly of these type II fibers, which are
Dynamic Graciloplasty
Cornelius G.M.I. Baeten, Jarno Melenhorst
18
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