- Email: [email protected]
Plastic repair of the incontinent sphincter ani
PLASTIC REPAIR OF THE INCONTINENT PAUL
C.
SPHINCTER ANI”
BLAISDELL, M.D.
Pasadena, Calijornia
I
N previous articIes we have discussed at length both the background and specific details of the surgica1 repair of the incontinent sphincter ani. Attention was directed to some aspects of the anatomic and physiologic vulnerability of the sphincter ani muscle in relation to surgical and obstetric injury of reasonab1.v necessary degree and, on the other hand, of unJu.stified degree.**2*3 Statistical analysis was made of a series of cases tracing the exact origins of injury, appraising the factors of responsibility and incompetence and reporting in the aggregate the rather discouraging resuIts of orthodox repair.4 Finally, several improvements in the surgical technic of repair were described. 4,5 WhiIe this articIe is a complete statement in itself, it is also a pIarmed part of a more inclusive exposition. INDEPENDENT
ROLE
OF
ANAL
DEFORMITY
Heretofore, anal incontinence has been considered both from the standpoint of function and repair exclusiveIy in terms of muscIe incompetence. At times this is true or at least near enough the truth for practical purposes. nlore commonly the variance is of serious import to the patient; for in addition to the variabIe of muscIe ineffIcacy, there is aIso the independent factor of ana deformity which can be responsibIe of itself for cIinica1 incontinence independent of demonstrable sphincter impairment. Or when conjoined with muscIe impairment the degree of incontinence is out of all proportion to the actual physioIogic incompetence of the muscIe. Symptoms of incontinence are attributable to two distinct etioIogic mechanisms or variable combinations thereof. (Digressing for a moment it is well to reiterate here what we have emphasised on previous occasions that it may take very Iittle deviation from normal to produce untoward symptoms out of seeming proportion to objective evidence of injury. As a matter of fact, there are many victims of minor though embarrassing degrees of incontinence-evidenced only by inability to
controI gas or by soiling-whose diagnosis is never entered on a chart. It is not uncommon with fissurectomies, for example, with too deep incision of the sphincter. The surgeon fails to inquire about the matter and the patient does not complain because he assumes the weakness to be an unavoidable residue.) Perhaps the more obvious of the two etiologic mechanisms of incontinence is by way of uniform dilatation of the whole circumference of the anal musculature. It may be the fauIt of the surgeon through excessive stretching of the sphincter at operation, an evil which the competent proctoIogist bears constantI!in mind. It may likewise foIlow the removal of large hemorrhoids which by constant prolapse over the years have gradualIy stretched the muscle. In the Iatter instances the muscIe fails to contract to its original size and thus to accommodate for the spaces vacated by the hemorrhoids. On the other hand, severance of the anal sphincter of certain degree for a given quadrant or IOCUS,~may aIso increase the circumference to the point of residual malfunction but due entireIy to IocaI retraction and separation of ends. If the gap between these separated ends were filled in with tissue, any kind of tissue, it would make IittIe difference as to whether diIatation or incision produced the increased circumference. Such is not the case, however, for with severance there is always Ieft this definite residual hiatus which of itself and independent of increased circumference allows uncontroIIed escape of bowel contents. Typically this hiatus is a channel or sort of vaIIe> which after bisecting fibers of the sphincter graduaIly joins the anal cana at an acute this channel is conangIe. On inspection spicuously and constantly patulous even though the remaining circumference of the anal canal itself remains visibly closed. On closer inspection persistent fecal soiling of the scar-Iined pocket is significant evidence of the independent and often predominant roie of the deformity in the uncontroIled leakage. Further
* From the Department of ProctoIogy, CoIIege of IMedicalEvangelists, Los Angeles, Calif. I74
American
Journal
of Surgery
BIaisdeII-Incontinent
Sphincter
Ani
175
Flc. I. CIassic operation for repair of incontinent sphincter ani muscIe. The inadequacies and indifferent results are mentioned in the test and mere previousIp described in detail.”
substantiating evidence that the hiatus is an additional factor to the result of simpIe diIatation can be found in the proIapse of the mucous membranesolely down the channeI of deformity At and nowhere else around the circumference. lirst this is demonstrable only at the upper end and through an anoscope. Later a glistening spot of prolapsing mucous membrane is visibIe approaching the outer end of the anus down the channel. In the light of this anaIysis the ideal surgical approach for reestablishment of continence should have the objective not only of restoring the original circumference of the sphincter but also of obliterating the pocket defect, and not either as a possible incidental effect but as a pIanned objective of equal or greater importance. This distinction from a practical and surgica1 standpoint makes considerable difference; for whiIe it is true that repair of the sphincter muscle envisions concomittant obIiteration of the defect, it is soleIy by use of muscIe tissue. Our concept, on the other hand, seeks use of any tissue available for obIiteration of the cavity as a pIanned
.lanuar_y,
1950
FIG. 2. Intravaginal reefing operation near completion; this has proven satisfactory in a limited fieId.4
BIaisdeII-Incontinent
Sphincter
Ani
FIG. 3. Two-stage transpIantation of muscle-bearing flaps designed for large defects; lines of incision for first stage arc shown. A tongue-shaped flap of musclebearing tissue on each side with the tip at -4 is transplanted and fixed at A.
objective and in addition to muscIe repair. This also permits overcorrection, an important adjunct to a favorabIe end resuIt. In the past orthodox repair has assumed and must assume compIete regression to the origina status by we11 nigh perfect union of the carefuIIy dissected bare muscle ends (Fig. I) if both mechanisms of incontinence as sources of symptoms are to be counteracted. On this premise if successfuIIy carried out, any anaIysis such as ours wouId obviously be onIy academic. UnfortunateIy, it is not as simpIe as it sounds and it has proven far more diffIcuIt to repair the muscIe than to injure it, whiIe overcorrection sufficient to insure uItimate compIete obIiteration of the deformity has been out of the question. The indifferent resuIts compiIed from the records of a Iarge number of proctoIogists4 cannot but bear out the innate obstacles to this operation as a reIiabIe and dependabIe procedure even in the hands of expert surgeons. It has proven to be contingent on a fortuitous combination of invariabIy favorable circumstances and termination, with IittIe leeway for shortcoming in any. Dissecting out the frayed ends of muscIe embedded in scar tissue is apt to prove tedious and exacting and the excessive trauma is not compatible with precise plastic surgery, the more so in view of the high potentiaIities of infection so near to the anus. Sutures must engage substantia1 bites of fuII-beIIied muscle tissue which means dissection well past the area of frayed out ends even to admit end-to-end apposition to say nothing of overlapping for overcorrection. Thus the surgeon can be insidiousIy if not
FIG. 4. Two-stage transpIantation (continued); wire sutures arc shown being placed. We would now insist on mattress sutures tied over small buttons for any anal pIastic surgery.
rather necessarily Iured into excessive sacrifice of tissue, which, with better planning, couId otherwise be used for fiIling in and correcting the deformity. As a result the surgeon is apt to welcome the cIose of his task onIy to find a suture line under excessive tension and suddenIy to face the realization which he had perhaps not broached to the patient that the Iatter might not onIy be unimproved by surgery but might even be worse. EarIy in our quest for improvement we Iayed down two a priori and absoIute requisites and discarded without further consideration a11that failed to so qualify. First, the operation must be simpIe; secondIy, if it should fail in instances, it must not aIIow of making the patient any worse. Simplicity was regarded not only as a generalIy desirabIe virtue in itseIf but essential here for various reasons. Not the least important reason was that comparatively few surgeons have anything like extensive experience with such cases and dissections. We could not under any circumstances reconciIe tedious dissection in the potentiaIIy infected region of the anus with our concept of the best in plastic surgery and certainIy we did not feel equaI to facing a patient made worse by the ordea1. A first suggestion was that of an intravaginal approach by way of a surgicalIy cIeaner field through norma unscarred tissue and to a normal segment of muscIe. (Fig. 2.) In addition the apposition of the broader surfaces of a tuck American
Journal
of Surgery
Blaisdell-Incontinent
Sphincter
Ani
I77
FIG. 5. Second stage of operation shown in Figures 3 and 4; in our original description this was suggested as a complete operation in itself for minor defects. Here, too, we would now substitute wire mattress sutures tied over buttons. Note that only haIf of extraneous tissue available bulges into the defect. With our inversion operation described in the text and illustrated in Figures 6,7 and 8 this amount of tissue is doubled for desirable overcorrection.
as compared to apposition of dissected ends contravenes by the sheer take up any necessity for separate and special attention to thedeformity. The latter tends to be obliterated by the forces and mechanism involved. Unfortunately, however, this operation is not universa1 in apphcation; it is obviously useIess in the mare and comparatively so in cases of anterior injury whiIe thejexperience required is perhaps disproportionate to the incidence of use. MUSCLE-REARING
FLAP
Further thought toward a more comprehensive pattern led to the use of the musclebearing flap,” and the perspective afforded by time and tria1 has Ient conviction that this wiII prove a basic concept in the management of anaI incontinence. Theretofore it had apparentIy always been assumed necessary to dissect out and denude the muscle ends for suturing. While it is possible to surmise a number of reasons for this assumption such as its c1ear necessity in most locations of the body, they were unconvincing as applied here and experience in another direction has vindicated our skepticism. The muscIe-bearing ffap was first described by us in connection with one of the more severe and unusual exampIes of muscIe injury necessitating a two-stage sliding graft (Figs. 3, 4 and 5) but it is more broadly conceived as a basic element which can be adopted to different plans and varying situations. As described it incorporated a segment of sphincter muscle which itself was not dissected out but which effectiveIy lent its function to a properIy shaped flap.
January,
I 950
FIG. 6. Inversion operation. A, first incision is shown and freeing of skin over scar. Preservation of this Hap prevents a fistutous wound; it is important for the same reason not even to button-hoIe it. This first incision should be placed so as to have relationship shown with secondary incisions. B, the whole thickness of external sphincter is grasped in AIlis forceps at both A and B in turn and peripheral circular incisions made to join original incision. Dissection of these is carried as deeply as possible without hazarding the slightest perforation which here, atso, would prove disastrous.
The second stage of this muscIe-bearing Bap operation consisted of a semi-Iunar incision concentric with the anus across the remaining gap, the ends of the incision then being apposed by stee1 suture. It was determined at that time that this pattern tended to obIiterate the hiatus by the inversion of extraneous non-muscle tissue as can be seen in’: Figure 3 which accompanied our articIe. Indeed, it wouId stiI1 be recommended (with the substitu-
178
Ulaisdell-incontinent
tion of mattress sutures tied over buttons) except that we have since evolved an even better method of obliterating the pocket whiIe still retaining the principle of the musclebearing flap. The present design then is an adaptation of the principles just mentioned to the more common problems of repair. Additionally, it not only obviates and simplifies much in the preparation of the heterogeneous flap but provides the maximum in obliterating the scar-lined hiatus of anything we have been able to devise. The muscIe-bearing flap is sufficiently freed only by deep, sharp dissection concentrically and peripherally along the outer border to permit of independent role. Care is taken against penetration of the scar flap or of the mucosa or against other dissection which might cause a fistuIous wound necessitating, for cure later, reseverance of the muscle and undoing of all accomphshed by the attempted repair. One who does not understand these implications shouId take heed. There is one othe; pertinent concept which, ahhough no doubt understood and/or empIoyed by design or not, has escaped discussion. It is best described by the term “setting of the wound ” and is perhaps most familiarly exemp1ified in the case of an open piIonida1 wound.6 Everyone is famiIiar with the resiIiency of the latter at the time of operation and the ease with which the whoIe wound margins can be moved and slid, whereas later during the course of healing the wound becomes as though frozen and any changes of reIationship are possible only by actual cutting. It is feasibIe and, indeed, often necessary to make definite use of this setting of the wound in plastic surgery of the anus. In a region where primary healing is the exception, firm and undisturbed setting of the wound over a sufficient period can compensate in remarkabIe measure. For this reason we make provision by means of wire suture tied over small buttons for protracted and effective retention. To the same end and as Iater described unusua1 provision is made for bowel eliminations. We now wish to describe the wider use and application of muscIe-bearing ffaps in aIIeviation of the common type of reIativeIy minor anal injury with incontinence. Presented herewith is an operation of marked simplicity and which in other respects, also, fulfills the criteria herein imposed. It has the following advantages over the usual repair: it is very much simpler, easier and quicker. The deformity is not onIy
Arli
Sphincter-
readiIy HIed in but overcorrection is also achieved by the most advantageous use of the maximum avaiIabIe tissue. This overcorrection is important as it alone offsets the inevitabIc yielding of tissue during the extended healing period and is accomplished here chiefly by the use of tissue other than muscle. Th’is useful tissue is sacrificed as extraneous by the dissection of the classica operation while onI> half of this avaiIabIe tissue is thus utilized in our previous plan represented in Figure 5. In the old operation tension on the suture line is an a1most tota1Iy uncontroIIabIe factor, in direct ratio to a pre-ordained bridging of space. With our operation there is no such predetermined and necessarv minimum and even division into stage operations is possibIe. Most important, tension is a controllable variable even after suture. Furthermore, the apposition of tissue is over much broader surfaces than afforded by mere touching of musc1e ends. For al1 these reasons our operation offers better prospect of effective wound healing. FinaIIy, if the worst befeI1 postoperatively, it is hard to postulate how a patient could be any worse off for the attempt which is not the case with dissection of the muscle ends. TECHNIC
OF
THE
INVERSION
OPERATION
An incision is made through the skin dcIineating the outer edge of the pocket defect and the surface tissue covering the latter is carefu1Iy dissected free. (Fig. 6.) Of inestimable vaIue for this is a Jones tonsil knife specially honed and stropped to bring the curved end as we11 as the sides to razor sharpness. Preservation of this tissue intact is important for even minute buttonholing may transform the operative dissection into a fistulous wound. The fuI1 body of the sphincter is seized within the bite of an Allis forceps, the teeth paraIIeIing the fibers and placed exactly at the periphery (Fig. 6~) a IittIe above the first incision. A second incision is made close to the Allis forceps aIong the periphery of the sphincter, freeing a Asp containing one end of the muscIe and joining the original incision. The cut shouId go as deepIy as possible without penetration of the intra-anal surface of the flap which wou1d be disastrous. A third incision in
similar manner frees a muscle-bearing flap on the other side of the defect. The two flaps are then united by a mattress suture with the peripheraIly freshcncd surfaces in apposition. (Fig. 7.) The two ends of the muscle and other intervening tissue are in-
American Journal qf Suraerv
Blaisdell-Incontinent
7
Sphincter
Ani
170
8
FIG. ,. Placing of first steel wire stitch over buttons and diagram of result achieved. \Ve have found this stitch to be more readily tightened to position and more effective if anchored at x as shown by dotted line; otherwise it tends to slip over the side in the direction of the arrow. If this stitch is correctly p&cd, the buttons should disappear into the anus. FIG. 8. Second steel suture pIaced, too tightly as shown here. Often one or more additional will be found advantageous. No attempt is made to approximate skin edges; indeed, this is averted purposely to prevent an abscess. A little packing is placed in the wound to expedite its setting. It is our present advice that the wound be carefullv examined in five davs with the Datient under anesthesia in lithotomy position. Ineffective or constricting sut;res arc then adjusted or replaced.
vaginated toward the center of the anus to till the defect. Progressive trial sutures of absorbable and more easily handled material may or mav not precede the final steel suture to determine the proper baIance of the three variable factors involved, viz., amount of invaginated tissue, final restored muscle continence and wound tension. The latter can be lessened even after final suture, if found to be desirable, by extending the peripheral incisions further but the effect of this on tina continence must also be kept in mind. It is important to prevent cutting of the tissue by the stee1 suture over a prolonged period and for this purpose both ends of a11 mattress sutures are secured over baby buttons availabIe at the dime store. We are positive that this detail of technic is a necessity and wish to emphasize that no confidence whatever is placed in anything but wire mattress sutures over buttons for any anal plastic surgery. Large substantial bites are likewise essentia1. A diamond-shaped defect will then be found to have formed IateraI to the sutured flaps. One or more wire retention sutures, also with buttons, are placed here to reIieve tension on the muscle suture. (Fig. 8.) The wound is not completeIy closed and, indeed, the skin edges should purposely be prevented from union before healing of the deeper tissue has taken pIace. We have followed these wounds carefully from day to day postoperatively frequently January,
I 950
under pentothal. At present we routinely examine the wound thoroughIy at the end of five days preferably in the operating room and under an anesthetic in order to remove sutures under too much tension and replace ineffectual ones. Thus at the Ieast maximum protection is afforded the wound during the critica period of first bowe1 responses. This bother may seem out of proportion to the magnitude of the surgery but so is the outcome to the patient. There is tendency for both patient and surgeon to approach this operation too Iightly simply because it falls into a minor category. It requires a good dea1 of experience to assess the proper tension correctly and even buttons will easiIy and do commonly slough clear through from pressure necrosis. Over and over again one tends to err on the side of excessive tension, a fault that is in some measure counteracted by the use of buttons, resuture of the wound and tenacious postoperati\,e inspection and care. Surgical technic itself no matter how meticulous may prove futile unless maximum protection is afforded the sutured sphincter. In addition to constant surveillance and certitude of suture effectiveness this is insured principaIly by preoperative and postoperative measures to defer bowel movements after surgery, to maintain soft consistency for some time and above a11 to prevent impaction and sudden explosive evacuations. Special care must he taken to avoid the Iatter on first bowel move-
180
BIaisdelI-Incontinent
ments foIIowing the Iong initial deferment. The judicious use of Iiquid and non-residue diet, enemas and/or cathartics for severa days constitutes the mainstay of preoperative preparation. Requisite postoperative care partakes more of the nature of personaIized nursing on the part of the surgeon than is commonIy associated. The intelligent use of retention enemas and in-and-out flushing of cIeansing enemas are indispensabIe. The onIy suggestion outside of we11 known basic principIes is a device empIoyed by us for the simultaneous use of continuous drip and suction in the rectum to prevent accumulation therein of stoo1. We made use of two very small urethra1 catheters fastened together and Ieft in pIace simuItaneously, one for drip and one for suction. It was found advantageous to insert them to different IeveIs inside the rectum and then to alternate their functions over periods of severa hours. It is worth whiIe experience to foIIow through these more meticuIous preoperative and postoperative regimens with several ordinary recta1 cases as rehearsaIs for achieving objectives when critica1. SUMMARY It is reafirmed that repair of the incontinent sphincter ani does not necessitate dissection and isoIation and suture of the bare muscIe ends. Instead, the use of muscIe-bearing ffaps is advocated. The principIe was described by us severa years ago in connection with one of the more unusua1 types of muscle injury. This paper reports an adaptation of this principle to the more common probIems of repair with an even simpIer operation. The technic of the operation is incIuded and its advantages ennumerated. REFERENCES I. BLAISDELL, PAUL C. Operative 2. 3.
4. 5. 6.
injury to the anal sphincter. J. A. M. A., 112: 614, ‘9x9. BLAISDELL, PAUL C. Traumatic injuries of the rectum. J. A. M. A., 128: 559, 1945. BLAISDELL,PAUL C. Pathogenesis of anal fissure and . . lmphcations as to treatment., Surg., Gynec. eY Obst., 65: 672, 1937. BLAISDELL, PAUL C. Repair of the incontinent sphincter ani. Surg., Gynec. ti Obst., 70: 692, rg4z. BLAISDELL, PAUL C. Repair of the incontinent sphincter ani. Surg., Gynec. @ Obst., 75: 634, 1942. BLAISDELL, PAUL C. The healing open piIonida1 wound. J. A. ht. A., 133: 916, 1947. DISCUSSION
HAROLD DODD (London, EngIand): My purpose is to recaI1 the usefuIness and simplicity of
Sphincter
Ani
Thiersch’s operation for ana incontinence and to describe an aseptic method of performing it. My notice was seriousIy drawn to the procedure by my former chief, Mr. GabrieI, in 1947 when hc introduced a discussion on the subject at the RoyaI Society of Medicine in London. Thiersch must have practiced and taught the operation as earIy as 1889 but I beIieve he never pubIished it. Goldman reports on six patients treated by it in 1892, whiIr Lenorant’ coIIected thirty-four cases and reported them to the Society of Surgery of Paris in 1906. In a r5o-page supplement of the Acta Chirurgica Scandinavicaz pubIished last year Thiersch’s operation was not mentioned, so it was either unknown or not considered worthy of description. Thiersch’s operation consists of the insertion of a circle of silver wire around the anus. It is performed for Ioss of tone of the sphincter ani with recta1 incontinence and for a patuIous anus with or without some proIapse of the Iower rectum. The patients who are chiefly eIderIy, cachetic and fidgety women, suffer from an incontinent discharge of peIIets of feces and mucus which necessitates their aIways wearing a diaper. The ana cIeft disappears and the anus is IeveI with the buttocks. Later a trumpet-Iike presentation of anaI mucus membrane appears which may be foIIowed by some proIapse of the Iower rectum. Tbierscb’s Original Operation. This was described by Lenorant of Paris in 1906: “A curved needIe, armed with a strong silver thread is introduced at the IeveI of the retro-ana raphe 1% cm. from the anus. With it, one describes a trajectory round the anus to some extent and one brings the needle out again. The needIe is re-introduced at the exact point of convergence and this manoeuvre is repeated unti1 the needIe comes out at its place of origina entry. The two ends of the wire are fastened.” Mr. GabrieI in his book” gives approximateIy the same directions for the operation using a Doyen’s curved needle to carry the wire. He has performed the operation sixteen times. It is my purpose to describe to you an aseptic method of introducing the wire. I think that as the area into which the siIver wire is put is aIways a potentiaIIy infected one, it must be introduced asepticaIIy; otherwise infection and pain may foIIow which wouId necessitate its remova1. The skin of the buttocks is washed daily with aIcoho1. SuIfathaIadine is given for four days beforehand to steriIize the aIimentary tract and peniciIIin and a suIfa drug tweIve hours prior to the operation. A genera1 or IocaI anesthetic is equaIIy satisfactory. The special instruments required consist of two Iarge-bore aspirating needIes such as couId be used to aspirate a chest (they must be 4 to 5 inches Iong) and a piece of No. 19 or 20 gauge siIver wire about IO inches in length.
American
Journal
of Surgery
BIaisdeII-Incontinent
Sphincter
Ani
181
RELATION INCISIONS
------
OF TO ANUS:
-___-_.
anterior incision -mm--- 6 _---_ a--
.
*II ‘/2
4, p 2 -
-.
. ‘\
LITHOTOMY
POSITION
--::;--=‘. . .
B---m
-\
FE. 1 The patient is placed in the lithotomy position with the buttocks raised on a piHow and protruding beyond the end of the operating tabIe. The skin of the buttocks and the vuIva are excluded by suitable draping. Two incisions W inch in length arc made in the middIe Iine, in front of and behind the anus beginning x inch away from the anal verge. (Fig. I.) The needles and wire shouId be inserted without touching the skin. One needle is passed through the posterior incision and is directed forward CircumferentiaIIy to the Ieft of the anus, J$ to pi inch away and $5 to 41 inch deep to the skin. Its point emerges through the center of the anterior incision. The other needIe is passed in a similar manner to the right of the anus. Owing to the laxness of the periana1 tissues the needIes raise two paraIIe1 foIds of skin which hide the anus between them. (Figs. 2 and 3.) The siIver wire, bent Iike a hairpin, is handIed by forceps. (Fig. 4.) Its ends are threaded into the Iumina of the needIes from before backwards unti1 they appear posteriorIy through the shanks of the needles. They are seized and withdrawn to their fuII extent. This approximates the needIe points so that the wire is scarceIy visibIe between them. Traction on both the wire and the needIes draws them deepIy into the anterior wound between the retracted skin edges. (Fig. 5.) The needIes are now removed, leaving the wire ends protruding through the posterior incision. These are firmIy twisted four times with forceps,
January,
1930
yg5 -,iif) h
THE NEEDLE POINT IS INSERTED INTO THE POSTERIOR WOUND WITHOUT TOUCHING THE SKIN. IT IS PASSED v;‘. DEEP TO THE SKIN AND k;. AWAY FROM THE EVERTED ANAL VERGE.
FIG.
2
Blaisdell--Incontinent
I82
having been puIled so as to embrace comfortably the proximal joint of an assistant’s index fingcl Lvhich has been inserted into the anal canal for this specific purpose. Unless the wire ends are firmly secured, they may sIip apart during the straining of defecation. The wire stump is inverted deeply
NEEDLES
Sphincter
Ani
carefully so that it gently encircles the proximal joint of the assistant’s index finger. Rationale of the Operation. Lenorant gave the folIowing exptanation of Thiersch’s operation: “According to Thiersch, the operation acts in two ways: the mechanica action of the wire in replacing
Ily-4 POSITION
WIRE LOOP DRAWN WITHOUT TOUCHING
INTO THE
INCISION SKIN
anterior incision closed
WIRE TW AND TUR
FIG. 4
into the fat to lie away from and not to irritate the skin. (Fig. 6.) In one patient I had to replace a broken stainIess steel wire. In another woman with an extreme degree of laxness and mucosa1 prolapse I inserted a second wire 34 inch externa1 to the first. Lenorant describes a patient who, after the wire was inserted too tightIy, suffered from fecal impaction of the rectum and digita emptying was required. This is a reminder not to make the ring too smaI1 and to estimate the size of the ring
Frc.
6
the reIaxed sphincter, and the presence of a foreign body in the perianal tissues encouraging ceIIuIar proliferation and bringing about a soIid adherence between the rectum and the neighboring parts. Thiersch hoped to be abIe to remove the wire when the resuIt had been obtained, but on this point the
American
Journal
oj Surgeq
Blaisdell-Incontinent facts ha.ve contradicted him. Whenever the wire, is t)roken or rrmovctl, prolapse again occurs.” Lrnorant’s opinion of forty-three years ago holds true today. Messrs. GabrieI and Abel and other British surgeons have recentIy spoken of its usefulness. It does relieve patients of their incontinence of feces. The Aftercare. Patients are instructed to keep their stooIs soft but formed and to obtain a daiIy evacuation. Watery stooIs may Ieak partIy while impacted feces may require digital removal; or if the wire has been drawn too tightly, enIargement of its ring wiI1 be necessary. A gIycerine suppository or enema may be necessary daiIy. Regarding the Thiersch operation of sixty years ago, I am reminded of a saying by Mr. Deansley, Iate surgeon of Wolverhampton: “What’s new isn’t necessariIy true, and what’s true, isn’t always new.” The Thiersch operation is a useful, simpIe, rapid procedure for the tiresome condition of ana incontinence in oIder patients. It makes them much more comfortablr physically, they fee1 secure and they are abIe to get about and take part again in life’s activities. Further, the procedure can aIso be used to suppIement a larger operation for complete proIapse of the rectum in which the anus remains gaping open. To recapitulate, Thiersch’s operation is valuable for some patients with incontinence of feces and prolapsus mucosus recti. The wire must be inserted asepticaIIy and must be of sufficient size to fit the proxima1 joint of the assistant’s finger. Immediate relief is bestowed.
Sphincter
Ani
I. LENVKAN~. Bull. IO, 1906.
Mew
183
Sot. tie C&r.
de Paris,
p:
2. Ano Recta1 Infections
and Anal Incontinence. Acta cbir. Scandinav., SuppIement 135, p. 96, 194.8. 3. GABRIEL, WILLIAM B. The Principles and Practice 01 Recta1 Surgery. 4th ed., p. 133-159. Springfield, III., 1948. CharIes C. Thomas, PubIisher.
PAUL C. BLAISDELL (Pasadena, CaIif.): We arc gratefu1 for the description of the siIver wire operation which Mr. Dodd has presented. It wouId have obvious use when the sphincter muscIe was absent, paraIyzed or injured beyond hope of repair. Or, in conjunction with operations which envision return of function, such as our own, the siIver wire might we11 be used with advantage to extend protection during the critica period of heaIing and recovery. These meetings were ushered in with a quotation from an American author, quoted by our English guests. Perhaps it is fitting, therefore, to close with a quotation from an English author. One of the Iines which has stayed with mc over the years is from Browning’s “Andrea De1 Sarto,” teIIing of the “fauItIess painter.” This remarkabIc feIIow dashed off superb paintings without effort whereas his confreres toiIed at great Iengths with vastly inferior results. It is rather apropos to most in out profession who have to strive so hard for so little. At times, when it is most discouraging, these words of Browning come to mind: “Ah, but a man’s reach shouId exceed his grasp, Or what’s a heaven for?”
C.
SPHINCTER ANI”
BLAISDELL, M.D.
Pasadena, Calijornia
I
N previous articIes we have discussed at length both the background and specific details of the surgica1 repair of the incontinent sphincter ani. Attention was directed to some aspects of the anatomic and physiologic vulnerability of the sphincter ani muscle in relation to surgical and obstetric injury of reasonab1.v necessary degree and, on the other hand, of unJu.stified degree.**2*3 Statistical analysis was made of a series of cases tracing the exact origins of injury, appraising the factors of responsibility and incompetence and reporting in the aggregate the rather discouraging resuIts of orthodox repair.4 Finally, several improvements in the surgical technic of repair were described. 4,5 WhiIe this articIe is a complete statement in itself, it is also a pIarmed part of a more inclusive exposition. INDEPENDENT
ROLE
OF
ANAL
DEFORMITY
Heretofore, anal incontinence has been considered both from the standpoint of function and repair exclusiveIy in terms of muscIe incompetence. At times this is true or at least near enough the truth for practical purposes. nlore commonly the variance is of serious import to the patient; for in addition to the variabIe of muscIe ineffIcacy, there is aIso the independent factor of ana deformity which can be responsibIe of itself for cIinica1 incontinence independent of demonstrable sphincter impairment. Or when conjoined with muscIe impairment the degree of incontinence is out of all proportion to the actual physioIogic incompetence of the muscIe. Symptoms of incontinence are attributable to two distinct etioIogic mechanisms or variable combinations thereof. (Digressing for a moment it is well to reiterate here what we have emphasised on previous occasions that it may take very Iittle deviation from normal to produce untoward symptoms out of seeming proportion to objective evidence of injury. As a matter of fact, there are many victims of minor though embarrassing degrees of incontinence-evidenced only by inability to
controI gas or by soiling-whose diagnosis is never entered on a chart. It is not uncommon with fissurectomies, for example, with too deep incision of the sphincter. The surgeon fails to inquire about the matter and the patient does not complain because he assumes the weakness to be an unavoidable residue.) Perhaps the more obvious of the two etiologic mechanisms of incontinence is by way of uniform dilatation of the whole circumference of the anal musculature. It may be the fauIt of the surgeon through excessive stretching of the sphincter at operation, an evil which the competent proctoIogist bears constantI!in mind. It may likewise foIlow the removal of large hemorrhoids which by constant prolapse over the years have gradualIy stretched the muscle. In the Iatter instances the muscIe fails to contract to its original size and thus to accommodate for the spaces vacated by the hemorrhoids. On the other hand, severance of the anal sphincter of certain degree for a given quadrant or IOCUS,~may aIso increase the circumference to the point of residual malfunction but due entireIy to IocaI retraction and separation of ends. If the gap between these separated ends were filled in with tissue, any kind of tissue, it would make IittIe difference as to whether diIatation or incision produced the increased circumference. Such is not the case, however, for with severance there is always Ieft this definite residual hiatus which of itself and independent of increased circumference allows uncontroIIed escape of bowel contents. Typically this hiatus is a channel or sort of vaIIe> which after bisecting fibers of the sphincter graduaIly joins the anal cana at an acute this channel is conangIe. On inspection spicuously and constantly patulous even though the remaining circumference of the anal canal itself remains visibly closed. On closer inspection persistent fecal soiling of the scar-Iined pocket is significant evidence of the independent and often predominant roie of the deformity in the uncontroIled leakage. Further
* From the Department of ProctoIogy, CoIIege of IMedicalEvangelists, Los Angeles, Calif. I74
American
Journal
of Surgery
BIaisdeII-Incontinent
Sphincter
Ani
175
Flc. I. CIassic operation for repair of incontinent sphincter ani muscIe. The inadequacies and indifferent results are mentioned in the test and mere previousIp described in detail.”
substantiating evidence that the hiatus is an additional factor to the result of simpIe diIatation can be found in the proIapse of the mucous membranesolely down the channeI of deformity At and nowhere else around the circumference. lirst this is demonstrable only at the upper end and through an anoscope. Later a glistening spot of prolapsing mucous membrane is visibIe approaching the outer end of the anus down the channel. In the light of this anaIysis the ideal surgical approach for reestablishment of continence should have the objective not only of restoring the original circumference of the sphincter but also of obliterating the pocket defect, and not either as a possible incidental effect but as a pIanned objective of equal or greater importance. This distinction from a practical and surgica1 standpoint makes considerable difference; for whiIe it is true that repair of the sphincter muscle envisions concomittant obIiteration of the defect, it is soleIy by use of muscIe tissue. Our concept, on the other hand, seeks use of any tissue available for obIiteration of the cavity as a pIanned
.lanuar_y,
1950
FIG. 2. Intravaginal reefing operation near completion; this has proven satisfactory in a limited fieId.4
BIaisdeII-Incontinent
Sphincter
Ani
FIG. 3. Two-stage transpIantation of muscle-bearing flaps designed for large defects; lines of incision for first stage arc shown. A tongue-shaped flap of musclebearing tissue on each side with the tip at -4 is transplanted and fixed at A.
objective and in addition to muscIe repair. This also permits overcorrection, an important adjunct to a favorabIe end resuIt. In the past orthodox repair has assumed and must assume compIete regression to the origina status by we11 nigh perfect union of the carefuIIy dissected bare muscle ends (Fig. I) if both mechanisms of incontinence as sources of symptoms are to be counteracted. On this premise if successfuIIy carried out, any anaIysis such as ours wouId obviously be onIy academic. UnfortunateIy, it is not as simpIe as it sounds and it has proven far more diffIcuIt to repair the muscIe than to injure it, whiIe overcorrection sufficient to insure uItimate compIete obIiteration of the deformity has been out of the question. The indifferent resuIts compiIed from the records of a Iarge number of proctoIogists4 cannot but bear out the innate obstacles to this operation as a reIiabIe and dependabIe procedure even in the hands of expert surgeons. It has proven to be contingent on a fortuitous combination of invariabIy favorable circumstances and termination, with IittIe leeway for shortcoming in any. Dissecting out the frayed ends of muscIe embedded in scar tissue is apt to prove tedious and exacting and the excessive trauma is not compatible with precise plastic surgery, the more so in view of the high potentiaIities of infection so near to the anus. Sutures must engage substantia1 bites of fuII-beIIied muscle tissue which means dissection well past the area of frayed out ends even to admit end-to-end apposition to say nothing of overlapping for overcorrection. Thus the surgeon can be insidiousIy if not
FIG. 4. Two-stage transpIantation (continued); wire sutures arc shown being placed. We would now insist on mattress sutures tied over small buttons for any anal pIastic surgery.
rather necessarily Iured into excessive sacrifice of tissue, which, with better planning, couId otherwise be used for fiIling in and correcting the deformity. As a result the surgeon is apt to welcome the cIose of his task onIy to find a suture line under excessive tension and suddenIy to face the realization which he had perhaps not broached to the patient that the Iatter might not onIy be unimproved by surgery but might even be worse. EarIy in our quest for improvement we Iayed down two a priori and absoIute requisites and discarded without further consideration a11that failed to so qualify. First, the operation must be simpIe; secondIy, if it should fail in instances, it must not aIIow of making the patient any worse. Simplicity was regarded not only as a generalIy desirabIe virtue in itseIf but essential here for various reasons. Not the least important reason was that comparatively few surgeons have anything like extensive experience with such cases and dissections. We could not under any circumstances reconciIe tedious dissection in the potentiaIIy infected region of the anus with our concept of the best in plastic surgery and certainIy we did not feel equaI to facing a patient made worse by the ordea1. A first suggestion was that of an intravaginal approach by way of a surgicalIy cIeaner field through norma unscarred tissue and to a normal segment of muscIe. (Fig. 2.) In addition the apposition of the broader surfaces of a tuck American
Journal
of Surgery
Blaisdell-Incontinent
Sphincter
Ani
I77
FIG. 5. Second stage of operation shown in Figures 3 and 4; in our original description this was suggested as a complete operation in itself for minor defects. Here, too, we would now substitute wire mattress sutures tied over buttons. Note that only haIf of extraneous tissue available bulges into the defect. With our inversion operation described in the text and illustrated in Figures 6,7 and 8 this amount of tissue is doubled for desirable overcorrection.
as compared to apposition of dissected ends contravenes by the sheer take up any necessity for separate and special attention to thedeformity. The latter tends to be obliterated by the forces and mechanism involved. Unfortunately, however, this operation is not universa1 in apphcation; it is obviously useIess in the mare and comparatively so in cases of anterior injury whiIe thejexperience required is perhaps disproportionate to the incidence of use. MUSCLE-REARING
FLAP
Further thought toward a more comprehensive pattern led to the use of the musclebearing flap,” and the perspective afforded by time and tria1 has Ient conviction that this wiII prove a basic concept in the management of anaI incontinence. Theretofore it had apparentIy always been assumed necessary to dissect out and denude the muscle ends for suturing. While it is possible to surmise a number of reasons for this assumption such as its c1ear necessity in most locations of the body, they were unconvincing as applied here and experience in another direction has vindicated our skepticism. The muscIe-bearing ffap was first described by us in connection with one of the more severe and unusual exampIes of muscIe injury necessitating a two-stage sliding graft (Figs. 3, 4 and 5) but it is more broadly conceived as a basic element which can be adopted to different plans and varying situations. As described it incorporated a segment of sphincter muscle which itself was not dissected out but which effectiveIy lent its function to a properIy shaped flap.
January,
I 950
FIG. 6. Inversion operation. A, first incision is shown and freeing of skin over scar. Preservation of this Hap prevents a fistutous wound; it is important for the same reason not even to button-hoIe it. This first incision should be placed so as to have relationship shown with secondary incisions. B, the whole thickness of external sphincter is grasped in AIlis forceps at both A and B in turn and peripheral circular incisions made to join original incision. Dissection of these is carried as deeply as possible without hazarding the slightest perforation which here, atso, would prove disastrous.
The second stage of this muscIe-bearing Bap operation consisted of a semi-Iunar incision concentric with the anus across the remaining gap, the ends of the incision then being apposed by stee1 suture. It was determined at that time that this pattern tended to obIiterate the hiatus by the inversion of extraneous non-muscle tissue as can be seen in’: Figure 3 which accompanied our articIe. Indeed, it wouId stiI1 be recommended (with the substitu-
178
Ulaisdell-incontinent
tion of mattress sutures tied over buttons) except that we have since evolved an even better method of obliterating the pocket whiIe still retaining the principle of the musclebearing flap. The present design then is an adaptation of the principles just mentioned to the more common problems of repair. Additionally, it not only obviates and simplifies much in the preparation of the heterogeneous flap but provides the maximum in obliterating the scar-lined hiatus of anything we have been able to devise. The muscIe-bearing flap is sufficiently freed only by deep, sharp dissection concentrically and peripherally along the outer border to permit of independent role. Care is taken against penetration of the scar flap or of the mucosa or against other dissection which might cause a fistuIous wound necessitating, for cure later, reseverance of the muscle and undoing of all accomphshed by the attempted repair. One who does not understand these implications shouId take heed. There is one othe; pertinent concept which, ahhough no doubt understood and/or empIoyed by design or not, has escaped discussion. It is best described by the term “setting of the wound ” and is perhaps most familiarly exemp1ified in the case of an open piIonida1 wound.6 Everyone is famiIiar with the resiIiency of the latter at the time of operation and the ease with which the whoIe wound margins can be moved and slid, whereas later during the course of healing the wound becomes as though frozen and any changes of reIationship are possible only by actual cutting. It is feasibIe and, indeed, often necessary to make definite use of this setting of the wound in plastic surgery of the anus. In a region where primary healing is the exception, firm and undisturbed setting of the wound over a sufficient period can compensate in remarkabIe measure. For this reason we make provision by means of wire suture tied over small buttons for protracted and effective retention. To the same end and as Iater described unusua1 provision is made for bowel eliminations. We now wish to describe the wider use and application of muscIe-bearing ffaps in aIIeviation of the common type of reIativeIy minor anal injury with incontinence. Presented herewith is an operation of marked simplicity and which in other respects, also, fulfills the criteria herein imposed. It has the following advantages over the usual repair: it is very much simpler, easier and quicker. The deformity is not onIy
Arli
Sphincter-
readiIy HIed in but overcorrection is also achieved by the most advantageous use of the maximum avaiIabIe tissue. This overcorrection is important as it alone offsets the inevitabIc yielding of tissue during the extended healing period and is accomplished here chiefly by the use of tissue other than muscle. Th’is useful tissue is sacrificed as extraneous by the dissection of the classica operation while onI> half of this avaiIabIe tissue is thus utilized in our previous plan represented in Figure 5. In the old operation tension on the suture line is an a1most tota1Iy uncontroIIabIe factor, in direct ratio to a pre-ordained bridging of space. With our operation there is no such predetermined and necessarv minimum and even division into stage operations is possibIe. Most important, tension is a controllable variable even after suture. Furthermore, the apposition of tissue is over much broader surfaces than afforded by mere touching of musc1e ends. For al1 these reasons our operation offers better prospect of effective wound healing. FinaIIy, if the worst befeI1 postoperatively, it is hard to postulate how a patient could be any worse off for the attempt which is not the case with dissection of the muscle ends. TECHNIC
OF
THE
INVERSION
OPERATION
An incision is made through the skin dcIineating the outer edge of the pocket defect and the surface tissue covering the latter is carefu1Iy dissected free. (Fig. 6.) Of inestimable vaIue for this is a Jones tonsil knife specially honed and stropped to bring the curved end as we11 as the sides to razor sharpness. Preservation of this tissue intact is important for even minute buttonholing may transform the operative dissection into a fistulous wound. The fuI1 body of the sphincter is seized within the bite of an Allis forceps, the teeth paraIIeIing the fibers and placed exactly at the periphery (Fig. 6~) a IittIe above the first incision. A second incision is made close to the Allis forceps aIong the periphery of the sphincter, freeing a Asp containing one end of the muscIe and joining the original incision. The cut shouId go as deepIy as possible without penetration of the intra-anal surface of the flap which wou1d be disastrous. A third incision in
similar manner frees a muscle-bearing flap on the other side of the defect. The two flaps are then united by a mattress suture with the peripheraIly freshcncd surfaces in apposition. (Fig. 7.) The two ends of the muscle and other intervening tissue are in-
American Journal qf Suraerv
Blaisdell-Incontinent
7
Sphincter
Ani
170
8
FIG. ,. Placing of first steel wire stitch over buttons and diagram of result achieved. \Ve have found this stitch to be more readily tightened to position and more effective if anchored at x as shown by dotted line; otherwise it tends to slip over the side in the direction of the arrow. If this stitch is correctly p&cd, the buttons should disappear into the anus. FIG. 8. Second steel suture pIaced, too tightly as shown here. Often one or more additional will be found advantageous. No attempt is made to approximate skin edges; indeed, this is averted purposely to prevent an abscess. A little packing is placed in the wound to expedite its setting. It is our present advice that the wound be carefullv examined in five davs with the Datient under anesthesia in lithotomy position. Ineffective or constricting sut;res arc then adjusted or replaced.
vaginated toward the center of the anus to till the defect. Progressive trial sutures of absorbable and more easily handled material may or mav not precede the final steel suture to determine the proper baIance of the three variable factors involved, viz., amount of invaginated tissue, final restored muscle continence and wound tension. The latter can be lessened even after final suture, if found to be desirable, by extending the peripheral incisions further but the effect of this on tina continence must also be kept in mind. It is important to prevent cutting of the tissue by the stee1 suture over a prolonged period and for this purpose both ends of a11 mattress sutures are secured over baby buttons availabIe at the dime store. We are positive that this detail of technic is a necessity and wish to emphasize that no confidence whatever is placed in anything but wire mattress sutures over buttons for any anal plastic surgery. Large substantial bites are likewise essentia1. A diamond-shaped defect will then be found to have formed IateraI to the sutured flaps. One or more wire retention sutures, also with buttons, are placed here to reIieve tension on the muscle suture. (Fig. 8.) The wound is not completeIy closed and, indeed, the skin edges should purposely be prevented from union before healing of the deeper tissue has taken pIace. We have followed these wounds carefully from day to day postoperatively frequently January,
I 950
under pentothal. At present we routinely examine the wound thoroughIy at the end of five days preferably in the operating room and under an anesthetic in order to remove sutures under too much tension and replace ineffectual ones. Thus at the Ieast maximum protection is afforded the wound during the critica period of first bowe1 responses. This bother may seem out of proportion to the magnitude of the surgery but so is the outcome to the patient. There is tendency for both patient and surgeon to approach this operation too Iightly simply because it falls into a minor category. It requires a good dea1 of experience to assess the proper tension correctly and even buttons will easiIy and do commonly slough clear through from pressure necrosis. Over and over again one tends to err on the side of excessive tension, a fault that is in some measure counteracted by the use of buttons, resuture of the wound and tenacious postoperati\,e inspection and care. Surgical technic itself no matter how meticulous may prove futile unless maximum protection is afforded the sutured sphincter. In addition to constant surveillance and certitude of suture effectiveness this is insured principaIly by preoperative and postoperative measures to defer bowel movements after surgery, to maintain soft consistency for some time and above a11 to prevent impaction and sudden explosive evacuations. Special care must he taken to avoid the Iatter on first bowel move-
180
BIaisdelI-Incontinent
ments foIIowing the Iong initial deferment. The judicious use of Iiquid and non-residue diet, enemas and/or cathartics for severa days constitutes the mainstay of preoperative preparation. Requisite postoperative care partakes more of the nature of personaIized nursing on the part of the surgeon than is commonIy associated. The intelligent use of retention enemas and in-and-out flushing of cIeansing enemas are indispensabIe. The onIy suggestion outside of we11 known basic principIes is a device empIoyed by us for the simultaneous use of continuous drip and suction in the rectum to prevent accumulation therein of stoo1. We made use of two very small urethra1 catheters fastened together and Ieft in pIace simuItaneously, one for drip and one for suction. It was found advantageous to insert them to different IeveIs inside the rectum and then to alternate their functions over periods of severa hours. It is worth whiIe experience to foIIow through these more meticuIous preoperative and postoperative regimens with several ordinary recta1 cases as rehearsaIs for achieving objectives when critica1. SUMMARY It is reafirmed that repair of the incontinent sphincter ani does not necessitate dissection and isoIation and suture of the bare muscIe ends. Instead, the use of muscIe-bearing ffaps is advocated. The principIe was described by us severa years ago in connection with one of the more unusua1 types of muscle injury. This paper reports an adaptation of this principle to the more common probIems of repair with an even simpIer operation. The technic of the operation is incIuded and its advantages ennumerated. REFERENCES I. BLAISDELL, PAUL C. Operative 2. 3.
4. 5. 6.
injury to the anal sphincter. J. A. M. A., 112: 614, ‘9x9. BLAISDELL, PAUL C. Traumatic injuries of the rectum. J. A. M. A., 128: 559, 1945. BLAISDELL,PAUL C. Pathogenesis of anal fissure and . . lmphcations as to treatment., Surg., Gynec. eY Obst., 65: 672, 1937. BLAISDELL, PAUL C. Repair of the incontinent sphincter ani. Surg., Gynec. ti Obst., 70: 692, rg4z. BLAISDELL, PAUL C. Repair of the incontinent sphincter ani. Surg., Gynec. @ Obst., 75: 634, 1942. BLAISDELL, PAUL C. The healing open piIonida1 wound. J. A. ht. A., 133: 916, 1947. DISCUSSION
HAROLD DODD (London, EngIand): My purpose is to recaI1 the usefuIness and simplicity of
Sphincter
Ani
Thiersch’s operation for ana incontinence and to describe an aseptic method of performing it. My notice was seriousIy drawn to the procedure by my former chief, Mr. GabrieI, in 1947 when hc introduced a discussion on the subject at the RoyaI Society of Medicine in London. Thiersch must have practiced and taught the operation as earIy as 1889 but I beIieve he never pubIished it. Goldman reports on six patients treated by it in 1892, whiIr Lenorant’ coIIected thirty-four cases and reported them to the Society of Surgery of Paris in 1906. In a r5o-page supplement of the Acta Chirurgica Scandinavicaz pubIished last year Thiersch’s operation was not mentioned, so it was either unknown or not considered worthy of description. Thiersch’s operation consists of the insertion of a circle of silver wire around the anus. It is performed for Ioss of tone of the sphincter ani with recta1 incontinence and for a patuIous anus with or without some proIapse of the Iower rectum. The patients who are chiefly eIderIy, cachetic and fidgety women, suffer from an incontinent discharge of peIIets of feces and mucus which necessitates their aIways wearing a diaper. The ana cIeft disappears and the anus is IeveI with the buttocks. Later a trumpet-Iike presentation of anaI mucus membrane appears which may be foIIowed by some proIapse of the Iower rectum. Tbierscb’s Original Operation. This was described by Lenorant of Paris in 1906: “A curved needIe, armed with a strong silver thread is introduced at the IeveI of the retro-ana raphe 1% cm. from the anus. With it, one describes a trajectory round the anus to some extent and one brings the needle out again. The needIe is re-introduced at the exact point of convergence and this manoeuvre is repeated unti1 the needIe comes out at its place of origina entry. The two ends of the wire are fastened.” Mr. GabrieI in his book” gives approximateIy the same directions for the operation using a Doyen’s curved needle to carry the wire. He has performed the operation sixteen times. It is my purpose to describe to you an aseptic method of introducing the wire. I think that as the area into which the siIver wire is put is aIways a potentiaIIy infected one, it must be introduced asepticaIIy; otherwise infection and pain may foIIow which wouId necessitate its remova1. The skin of the buttocks is washed daily with aIcoho1. SuIfathaIadine is given for four days beforehand to steriIize the aIimentary tract and peniciIIin and a suIfa drug tweIve hours prior to the operation. A genera1 or IocaI anesthetic is equaIIy satisfactory. The special instruments required consist of two Iarge-bore aspirating needIes such as couId be used to aspirate a chest (they must be 4 to 5 inches Iong) and a piece of No. 19 or 20 gauge siIver wire about IO inches in length.
American
Journal
of Surgery
BIaisdeII-Incontinent
Sphincter
Ani
181
RELATION INCISIONS
------
OF TO ANUS:
-___-_.
anterior incision -mm--- 6 _---_ a--
.
*II ‘/2
4, p 2 -
-.
. ‘\
LITHOTOMY
POSITION
--::;--=‘. . .
B---m
-\
FE. 1 The patient is placed in the lithotomy position with the buttocks raised on a piHow and protruding beyond the end of the operating tabIe. The skin of the buttocks and the vuIva are excluded by suitable draping. Two incisions W inch in length arc made in the middIe Iine, in front of and behind the anus beginning x inch away from the anal verge. (Fig. I.) The needles and wire shouId be inserted without touching the skin. One needle is passed through the posterior incision and is directed forward CircumferentiaIIy to the Ieft of the anus, J$ to pi inch away and $5 to 41 inch deep to the skin. Its point emerges through the center of the anterior incision. The other needIe is passed in a similar manner to the right of the anus. Owing to the laxness of the periana1 tissues the needIes raise two paraIIe1 foIds of skin which hide the anus between them. (Figs. 2 and 3.) The siIver wire, bent Iike a hairpin, is handIed by forceps. (Fig. 4.) Its ends are threaded into the Iumina of the needIes from before backwards unti1 they appear posteriorIy through the shanks of the needles. They are seized and withdrawn to their fuII extent. This approximates the needIe points so that the wire is scarceIy visibIe between them. Traction on both the wire and the needIes draws them deepIy into the anterior wound between the retracted skin edges. (Fig. 5.) The needIes are now removed, leaving the wire ends protruding through the posterior incision. These are firmIy twisted four times with forceps,
January,
1930
yg5 -,iif) h
THE NEEDLE POINT IS INSERTED INTO THE POSTERIOR WOUND WITHOUT TOUCHING THE SKIN. IT IS PASSED v;‘. DEEP TO THE SKIN AND k;. AWAY FROM THE EVERTED ANAL VERGE.
FIG.
2
Blaisdell--Incontinent
I82
having been puIled so as to embrace comfortably the proximal joint of an assistant’s index fingcl Lvhich has been inserted into the anal canal for this specific purpose. Unless the wire ends are firmly secured, they may sIip apart during the straining of defecation. The wire stump is inverted deeply
NEEDLES
Sphincter
Ani
carefully so that it gently encircles the proximal joint of the assistant’s index finger. Rationale of the Operation. Lenorant gave the folIowing exptanation of Thiersch’s operation: “According to Thiersch, the operation acts in two ways: the mechanica action of the wire in replacing
Ily-4 POSITION
WIRE LOOP DRAWN WITHOUT TOUCHING
INTO THE
INCISION SKIN
anterior incision closed
WIRE TW AND TUR
FIG. 4
into the fat to lie away from and not to irritate the skin. (Fig. 6.) In one patient I had to replace a broken stainIess steel wire. In another woman with an extreme degree of laxness and mucosa1 prolapse I inserted a second wire 34 inch externa1 to the first. Lenorant describes a patient who, after the wire was inserted too tightIy, suffered from fecal impaction of the rectum and digita emptying was required. This is a reminder not to make the ring too smaI1 and to estimate the size of the ring
Frc.
6
the reIaxed sphincter, and the presence of a foreign body in the perianal tissues encouraging ceIIuIar proliferation and bringing about a soIid adherence between the rectum and the neighboring parts. Thiersch hoped to be abIe to remove the wire when the resuIt had been obtained, but on this point the
American
Journal
oj Surgeq
Blaisdell-Incontinent facts ha.ve contradicted him. Whenever the wire, is t)roken or rrmovctl, prolapse again occurs.” Lrnorant’s opinion of forty-three years ago holds true today. Messrs. GabrieI and Abel and other British surgeons have recentIy spoken of its usefulness. It does relieve patients of their incontinence of feces. The Aftercare. Patients are instructed to keep their stooIs soft but formed and to obtain a daiIy evacuation. Watery stooIs may Ieak partIy while impacted feces may require digital removal; or if the wire has been drawn too tightly, enIargement of its ring wiI1 be necessary. A gIycerine suppository or enema may be necessary daiIy. Regarding the Thiersch operation of sixty years ago, I am reminded of a saying by Mr. Deansley, Iate surgeon of Wolverhampton: “What’s new isn’t necessariIy true, and what’s true, isn’t always new.” The Thiersch operation is a useful, simpIe, rapid procedure for the tiresome condition of ana incontinence in oIder patients. It makes them much more comfortablr physically, they fee1 secure and they are abIe to get about and take part again in life’s activities. Further, the procedure can aIso be used to suppIement a larger operation for complete proIapse of the rectum in which the anus remains gaping open. To recapitulate, Thiersch’s operation is valuable for some patients with incontinence of feces and prolapsus mucosus recti. The wire must be inserted asepticaIIy and must be of sufficient size to fit the proxima1 joint of the assistant’s finger. Immediate relief is bestowed.
Sphincter
Ani
I. LENVKAN~. Bull. IO, 1906.
Mew
183
Sot. tie C&r.
de Paris,
p:
2. Ano Recta1 Infections
and Anal Incontinence. Acta cbir. Scandinav., SuppIement 135, p. 96, 194.8. 3. GABRIEL, WILLIAM B. The Principles and Practice 01 Recta1 Surgery. 4th ed., p. 133-159. Springfield, III., 1948. CharIes C. Thomas, PubIisher.
PAUL C. BLAISDELL (Pasadena, CaIif.): We arc gratefu1 for the description of the siIver wire operation which Mr. Dodd has presented. It wouId have obvious use when the sphincter muscIe was absent, paraIyzed or injured beyond hope of repair. Or, in conjunction with operations which envision return of function, such as our own, the siIver wire might we11 be used with advantage to extend protection during the critica period of heaIing and recovery. These meetings were ushered in with a quotation from an American author, quoted by our English guests. Perhaps it is fitting, therefore, to close with a quotation from an English author. One of the Iines which has stayed with mc over the years is from Browning’s “Andrea De1 Sarto,” teIIing of the “fauItIess painter.” This remarkabIc feIIow dashed off superb paintings without effort whereas his confreres toiIed at great Iengths with vastly inferior results. It is rather apropos to most in out profession who have to strive so hard for so little. At times, when it is most discouraging, these words of Browning come to mind: “Ah, but a man’s reach shouId exceed his grasp, Or what’s a heaven for?”