Surgical Treatment of Anal Incontinence

169 Pages·1991·19.27 MB·English

by  Charles V. Mann MCh

SURGICAL TREATMENT OF ANAL INCONTINENCE
Charles V. Mann· Richard E. Glass
SURGICAL TREATMENT
OF ANAL INCONTINENCE
ILLUSTRATIONS BY B. HYAMS AND R. LANE
With 164 Figures
SPRINGER-VERLAG
London Berlin Heidelberg New York
Paris Tokyo Hong Kong
Charles V. Mann, MCh, FRCS
Consultant Surgeon, The London Hospital, Whitechapel, London El lBB, UK and
Consulting Surgeon, St. Mark's Hospital for Diseases of the Rectum and Colon,
London ECl V 2PS, UK
Richard E. Glass, MS, FRCS
Consultant Surgeon, Princess Margaret Hospital, Swindon SNl 4JU, UK
The illustration on the front cover is Figure 3.7. (page 28)
ISBN-13: 978-1-4471-3350-6 e-ISBN-13: 978-1-4471-3348-3
001: 10.1007/978-1-4471-3348-3
British Library Cataloguing in Publication Data
Mann, Charles V. (Charles Victor)
Surgical treatment of anal incontinence.
1. Man. Anus & rectum. Surgery
I. Title II. Glass, Richard E.
617.555
ISBN-13: 978-1-4471-3350-6
Library of Congress Cataloging-in-Publication Data
Mann, Charles V.
Surgical treatment of anal incontinence / Charles V. Mann and Richard E. Glass.
p. cm.
ISBN-13: 978-1-4471-3350-6
1. Fecal incontinence - Surgery. 2. Rectum-Surgery. 3. Perineum Surgery. I. Glass, Richard 1948-
II. Title
[DNLM: Fecal Incontinence-surgery. WI 650 M281s I
RD544.M361990
617.5'55-dc20
DNLMlDLC
for Library of Congress 90-10037
CIP
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted
under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or
transmitted, in any form or by any means, with the prior permission in writing or the publishers, or in the case
of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing
Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.
© Springer-Verlag London Limited 1991
Softcover reprint of the hardcover 1s t edition 1991
The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a
specific statement, that such names are exempt from the relevant laws and regulations and therefore free for
general use.
Product liability: The publisher can give no guarantee for information about drug dosage and application
thereof contained in this book. In every individual case the respective user must check its accuracy by
consulting other pharmaceutical literature.
Typeset by Goodfellow and Egan, Cambridge
2128/3830-543210 Printed on acid-free paper
To those unfortunate patients with anal incontinence
and to their surgeons
PREFACE
It is only in the last 25 years that the treatment of anal incontinence has become an
important surgical discipline. This is not only because our understanding of the
disorder has been greatly augmented by new investigative methods. It is also because
the hydrocarbon industry has provided us with suitable materials with which to carry
out the complex repairs that are now possible.
Like most new areas of therapy, initial enthusiasm has been modified by
experience. Some techniques have been amended or abandoned. Others have been
shown to have very specific indications and to pe unsuitable for general use. But the
total of cases treated by surgical means continues to grow, and as the field widens it is
apparent that large numbers of people are still suffering from anal incontinence
silently and unheard, and have been abandoned to their misery by society at large.
For some of these unfortunates, the consequences are appalling: they become
outcasts even within their own families; in some communities they are unable to
practise their religion. They are truly regarded as "dirty", and are shunned.
Because a large body of surgical experience has accrued, nowadays many of these
cases can be cured, and most of them substantially alleviated. But a mis-applied or
badly performed operation can be a disaster for both the patient and the surgeon.
For these reasons, we have decided that the time is ripe for a book specifically
directed at the techniques of procedures developed for the treatment of anal
incontinence. This book is unashamedly concerned with surgical craftsmanship. We
hope that by careful selection and application of these techniques, surgeons who
need to perform these operations will obtain the best results possible.
Because matching the patient's needs to the best available procedure must be
based on sound judgement, we give guidance from our own experience as to "what"
should be offered to "whom", and include advice on pre- and post-operative care
which can make the difference between success and failure.
Above all, we hope that readers enjoy the book and are stimulated to participate
actively in the development of this new and growing field of surgery. There is still
much to be done, and so many patients need your help.
London Charles V. Mann
January 1991 Richard E. Glass
CONTENTS
1 Essential Anatomy of Anal Continence ......................................... 1
General Introduction.. . . ... . . .... . . .. ... . . ... . . . ..... . .... . . . . .. . . ..... . . . . . ..... . . . . ..... . . 1
Structural Anatomy ......................................................................... 2
Development ............................................................................... 2
Anal Muscles ............................................................................... 2
Blood Supply ............................................................................... 4
Venous Drainage .......................................................................... 6
Nerve Supply ............................................................................... 6
Surgical Anatomy ............................................................................ 6
The Rectum ................................................................................ 6
The Anus .................................................................................... 8
2 Physiology of Anal Continence ................................................... 11
General Introduction ....... ................................................. ......... ....... 11
Patho-physiology of Continence ....................................................... 12
Proximal Alimentary Canal...... .... . ..... . ....... .... ..... .............. . ........ . .... 12
Colon ........................................................................................ 12
Ano-rectum ................................................................................ 14
Applied Physiology .......................................................................... 15
3 Abdominal Techniques ............................................................. 19
General Introduction ...... ...... ....... ...... ....... .... ...... ..... ..... ......... ........ ... 19
Abdominal Rectopexy with Prosthetic Implant (Syn. Wells Technique) ....... 20
Introduction ................................................................................ 20
Indications and Selection of Patients ................................................. 21
Preparation ................................................................................. 21
Operative Technique ..................................................................... 22
Post-operative Management ............................................................ 27
Abdominal Rectopexy with Prosthetic Sling (Syn. Ripstein Technique) ........ 30
Introduction ................................................................................ 30
Indications and Selection of Patients ................................................. 30
Preparation ................................................................................. 30
X CONTENTS
Operative Technique .......................................................... ........... 31
Post-operative Management............................................................ 35
Abdominal Rectopexy plus Colon Resection (Syn. Goldberg Technique)
Introduction ................................................................................ 35
Indications and Selection of Patients ................................................. 35
Preparation ................................................................................. 35
Operative Technique ..................................................................... 36
Post-operative Management .......................... .................................. 38
Results ....................................................................................... 38
4 Anterior Perineal Techniques .................................................... 39
General Introduction........................................................................ 39
Anterior Plication of Puborectalis and Anal Sphincter (Syn. Anterior
Buttress Technique) .............................. ................................. .... 41
Indications and Selection of Patients ................................................. 41
Operative Technique ..................................................................... 41
Post-operative Management............................................................ 45
Anterior Sling Procedure (Syn. Notaras Technique) ................................ 45
Indications and Selection of Patients ................................................. 45
Preparation ................................................................................. 46
Operative Technique..................................................................... 46
Post -operative Management ............................................................ 49
Results ....................................................................................... 50
5 Posterior Perineal Techniques................ . .. . . . . . . ... . . . ... . . . . . . . . .... . . . .. . 51
General Introduction................................ .... ............ ........................ 51
Post-anal Intersphincteric Repair (Syn. Parks Technique) ......................... 52
Introduction ................................................................................ 52
Indications and Selection of Patients ................................................. 52
Preparation ................................................................................. 54
Operative Technique ..................................................................... 54
Post-operative Management ............................................................ 61
Results ....................................................................................... 62
Post-rectal Buttress Repair (Syn. Wyatt Technique) ................................ 62
Introduction ................................................................................ 62
Indications and Selection of Patients ................................................. 62
Preparation ................................................................................. 62
Operative Technique ..................................................................... 63
Post-operative Management ............................................................ 68
Results ....................................................................................... 68
6 Circum-anal Techniques. . .. .............. ... ............. . . . . . . ............ . . . .... 69
General Introduction............................... ..... .................................... 69
Circum-anal Wire (or Nylon) Encirclement (Syn. Thiersch Procedure) ........ 69
Indications and Selection of Patients ................................................. 70
CONTENTS xi
Preparation ..... ... ... ... ............ ........ .... ...... ....... ....... ........ ...... ......... 70
Operative Technique..................................................................... 70
Post-operative Management............................................................ 72
Circum-anal Cicatrical Fixation (Syn. SaraffofTechnique) ........................ 73
Introduction ................................................................................ 73
Indications and Selection of Patients ................................................. 73
Operative Technique ..................................................................... 74
Post-operative Management ............................................................ 76
Results ....................................................................................... 76
Gracilis Muscle Sling Technique (Syn. Pickrell-von Rapport Technique) ...... 77
Introduction ................................................................................ 77
Indications and Selection of Patients ................................................. 77
Preparation ................................................................................. 79
Operative Technique..................................................................... 79
Post-operative Management ............................................................ 82
Results ....................................................................................... 82
7 Per-anal Techniques ................................................................ 85
General Introduction ........................................................................ 85
Anterior (Rectal) Mucosectomy .......................................................... 86
Introduction ................................................................................ 86
Indications and Selection of Patients ................................................. 87
Preparation ................................................................................. 87
Operative Technique ..................................................................... 87
Post-operative Management ............................................................ 89
Rectal Wall Plication (Syn. Delorme Technique) .................................... 89
Introduction ................................................................................ 89
Indications and Selection of Patients ................................................. 89
Preparation ................................................................................. 90
Operative Technique ..................................................................... 90
Post-operative Management ............................................................ 94
Rectosigmoidectomy (Syn. Altemeier Technique) ................................... 94
Introduction ................................................................................ 94
Indications and Selection of Patients ................................................. 95
Preparation ................................................................................. 95
Operative Technique..................................................................... 96
Post-operative Management ............................................................ 99
Results....................................................................................... 101
8 Technique of Anal Sphincter Repair (Syn. Overlap Technique) .......... 103
Introduction ................................................................................ 103
Indications and Selection of Patients ................................................. 104
Preparation ................................................................................. 104
Operative Technique..................................................................... 104
Post-operative Management ............................................................ 106
xii CONTENTS
9 Techniques for Congenital Anal Deformity Encountered in Later Life.. 107
General Introduction........................................................................ 107
Identification and Assessment of Abnormality ..................................... 109
General Principles Underlying the Operations..................................... 110
Selection and Preparation of Patients for Surgery ................................. 112
Covered Anus Deformity with Associated Perineal Fistula ("False Anus") ... 113
Anterior Ectopic Deformity ............................................................... 116
No Definite Anal or Puborectalis Muscle............................................... 121
Ectopic Opening Adjacent to an Anal Orifice ("Shot-gun Deformity") ........ 121
Cloacal-type Deformity........... ..................... ........... ... ......... ....... .... 123
Post-operative Management ............................................................ 123
Summary ....................................................................................... 125
10 Techniques for Repair of Traumatic Injury of the Anal Sphincters.. . . . . 127
General Introduction ........................................................................ 127
Indications and Selection of Patients ................................................. 127
Preparation for Surgery .................................................................. 128
Acute Primary Repair of Traumatised Anal Sphincter and Pelvic Floor ........ 128
Introduction ................................................................................ 128
Operative Technique ..................................................................... 128
Post-operative Management ............................................................ 132
Trans-vaginal Injury to the Anus and Rectum ........................................ 132
Introduction ................................................................................ 132
Repair of Acute Trans-vaginal Injury..... ..... .......... ............................... 133
Operative Technique ..................................................................... 133
Post-operative Management ............................................................ 135
Delayed Repair of Chronic Unhealed Recto-vaginal Septal Defect ... ........ ... 135
Preparation ................................................................................. 135
Operative Technique ..................................................................... 135
Post-operative Management ............................................................ 138
11 Techniques for Repair of Recto-vaginal Fistula .............................. 139
Low Recto-vaginal Fistula .................................................................. 139
General Introduction ........................................................................ 139
Indications and Selection of Patients ................................................. 140
Preparation ................................................................................. 141
Excision and Repair of Low Juxta-sphincteric Fistula ............................... 141
Introduction .... .... .... .... ... .... ...... ..... ...... ..... .... ... .... ........................ 141
Operative Technique ..................................................................... 141
Post-operative Management ............................................................ 142
Per-vaginal Direct Repair of Low Supra-sphincteric Fistula. ...... ......... .... ... 142
Introduction ................................................................................ 142
Operative Technique..................................................................... 144
Post-operative Management ........................................................ .... 144
CONTENTS xiii
Per-anal Closure of Low Supra-sphincteric Fistula by Advancement Flap ..... 146
Introduction ......... ..... ........ .... ......... ..... .... ..... ..... .... ...... ....... ......... 146
Operative Technique ..................................................................... 146
Post-operative Management ............................................................ 146
High Recto-vaginal Fistula ....... ... ..... ......... .... ..... ..... .... ....... ...... ...... .... 148
General Introduction. .... ......... ........ ..... .... .... .... ...... .... ....... ...... ....... ... 148
Indications and Selection of Patients ... ............. .... ...... ....... ..... ....... .... 149
Preparation ......... .... ..... .... .... .... .................. ......... ........ ..... ....... .... 149
Direct Closure using Interposed Omental Graft ...................................... 149
Introduction .................................................................. ... . ...... . .... 149
Operative Technique ..................................................................... 150
Post-operative Management ............................................................ 151
Extended Resection with Colo-anal Anastomosis.................................... 151
Introduction ................................................................................ 151
Operative Technique ..................................................................... 153
Post-operative Management ............................................................ 157
Subject Index ............................................................................... 159