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The complete release of the levator ani sling in fecal incontinence
The Complete Release of the Levator Ani Sling in Fecal Incontinence By PETER K. KOTTMEIER AND ROMAN DZIADIW
HE IMPORTANT ROLE of the puborectalis muscle in the control of anal continence has been stressed for many years, 1 but little use has been made of the other levator muscles in patients whose anal sphincter or puborectalis muscle was destroyed or is nonfunctioning. Previous use of the levator muscles consisted of procedures which utilized only part of the levator sling to repair either the sphincter or the puborectalis muscle. 2 Instead of using the levator for the repair of either sphincter or puborectalis muscle, we have attempted to use the levator sling as an independent muscular sling in view of its accessible anatomical location. As previously reported 8 the partial release of the levator ani in children with persistent fecal incontinence following abdominoperineal repairs for imperforate anus has led to considerable improvement. Further experience with the complete release of the levator ani sling, first attempted in the previously reported group, has convinced us that the complete release not only facilitates the operative procedure but leads to considerably improved results. Three patients have had a complete release of the levator ani sling resulting in complete continence. These patients, including the previously reported case, had developed fecal incontinence following trauma or surgical procedures: a 10 year old boy following perineal bums, an 11 year old boy post drainage of a presacral abscess after a Swenson procedure for Hirschsprung's disease and a 76 year old woman following fistulectomies. Additional complete levator ani release was performed in two males with imperforate ani and rectourethral fistulae. A long follow-up in the latter cases is needed to evaluate both indication and result of the complete release as part of the primary abdominoperineal repair. The normal relation of the rectum to the levator ani muscles is shown in Figure 1. The puboreetalis muscle circles the rectum laterally and posteriorly and blends with the sphincter. Since the puborectalis muscle is neither attached to the medium raphe nor to the coccyx, it is relatively mobile and can compress the rectum posteriorly and laterally. The other components of the levator sling, however, the pubocoecygeus and ileoeoccygeus muscles, are attached posteriorly and, therefore, contribute only little to the compression of the rectum. To achieve the fullest effect of the levator sling, the posterior ahd posterolateral attachments of the pubococeygeus and ileococeygeus muscles are released to allow a free anterior pull, as shown in Figure 2. In our original procedure, 3 we
T
From the Pediatric Surgical Service, Department of Surgery and Department of Radiology, State University Kings County Medical Center, Brooklyn, New York. PETERK. KOTTM~IER, M.D.: Assistant Professor of Surgery, State University of New York, Downstate Medical Center; Chief Pediatric Surgical Service, Kings County Hospital Center, Brooklyn, N. Y. ROMANDZIADIW,M.D.: Assistant Professor of Radiology, State University of New York, Downstate Medical Center; Attending Roentgenologist, Kings County Hospital Center, Brooklyn, N. Y,
111 JOURNAL OF PEDIATRICSURGERY,VOL. 2, No, 2 (APRIL), 1967
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Fig. 1.--Normal relation of rectum to levator ani muscles. The schematic diagram shows the normal position of the rectum anterior to the puborectalis muscle. The pubococeygeus and ileococcygeus muscles are attached to the medium raphe and coccyx.
Fig. 2.---Postoperative complete release of the levator sling. The coccyx has been excised and the posterior and posterolateral attachments of pubococcygeus and ileococcygeus muscles are severed, allowing an increased anterior pull of the entire levator sling.
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approached the levator through a posterior midline incision extending from 1 em. behind the anus to the coccyx. The levator was then identified, and the posterior e/a of the ileococcygeus muscles were released from their posterior attachment, split longitudinally up to the insertion and released. The posterior thirds of the ileocoeeygeus muscles were then approximated in the midline to prevent prolapse of the rectum through the existing muscle defect. This caution appears to be unnecessary and we now excise the coccyx and release the entire puhococcygeus and ileococcygeus muscle sling without an attempt to close the defect. If the entire ileoeoeeygeus muscle is released, the upper portion is tightened posterior to the rectum with interrupted chromic sutures. While one finger is placed within the rectum the upper part of the ileocoecygeus muscle is approximated snugly until the entire sling is felt to push the rectum anteriorly without occluding it. This complete release not only achieves a more acute anterior angulation of the rectum, as seen in the partial release, but also enlarges the muscular levator sling encircling the rectum. The release of the levator sling either increases the effect of the puborectalis muscle or, in the absence of the latter, replaces it. The normal levator mechanism, as seen during einefluoroseopy in a 10 year old boy, is shown in Figure 3. The dentate line is marked, and the normal position of the puborectalis muscle is seen in the position of rest, defecation and contraction. The distance between the dentate line and the puborectalis muscle is small, and only a minor change of rectal position occurs during rest and defecation. During contraction an anterior angulation of the rectum is seen, and the distance between dentate line and puborectalis muscle is approximately doubled. Due to the posterior attachment of the pubococcygeus and ileoeoecygeus museles, this contraction is almost entirely due to the contraction of the puborectalis muscle alone. Shown in Figure 4 are the preand postoperative findings in an 8 year old boy, 3 years post partial revision of the levator sling performed as a secondary repair of an imperforate anus. In the preoperative picture the posterior position of the rectum can be seen. Postoperatively, a mild anterior angulation of t~:e rectum is seen during defecation without constriction. During contraction, the partially revised levator sling acts like a horizontal shutter mechanism, which effectively occludes the rectum by marked anterior compression which, however, is still limited to a relatively smaller area as compared with the length of the occluded rectal segment obtained with the complete release of the levator sling. A more extensive change in the position of the rectum is seen in Figure 5, in a 10 year old boy whose perineum, including sphincter and puboreetalis muscle, was destroyed by a third degree burn. In the preoperative picture the posterior position of the rectum can be seen, with the rectum in close proximity to the sacrum and coccyx. Postoperatively during rest, an anterior reetal angulation is seen which not only exceeds the anterior angulation normally found, but also the angulation following the partial release in Figure 4. The postoperative function of the released levator is shown in the same patient during rest, defecation and contraction. The anterior angulation during rest position is partially main-
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Fig. 3.--Normal levator mechanism in a 10 year old male during rest, defecation and contraction (left to right).
Fig. 4.--(A) Preoperative rectal position in an 8 year old male, (B) defecating and (C) contracting 3 years following partial release of the levator sling. tained during defecation, but relaxation does occur and no evidence of stricture is seen. During contraction, a horizontal shutter effect of the released levator is seen with complete occlusion of the rectum. This "shutter mechanism" in this patient (M. S. ), is more apparent than in the patient shown in Figure 4, since the ileococcygeus and pubococcygeus muscles were completely released with the excision of the coccyx. In Figure 6A and 6B, the resting position of the rectum is compared in a normal control patient and a patient with complete release of the levator mechanism. The rectal occlusion produced by the puborectalis muscle in the normal patient is limited to a small area as compared with the rectal occlusion in the patient with the revised levator sling. The broad muscle sling, formed by the complete release of the levator muscle, is in a better position mechanically to occlude the rectum even during the rest period. In Figure 6C and 6D, a comparison of the contraction of a normal levator sling and the contraction of a completely released levator sling is shown. The contraction of the normal levator sling limits the anterior angulation to a small area close to the dentate line. During contraction of the revised levator sling the area of rectal compression is considerably enlarged and the effect of the contraction, therefore, increased. The follow-up of these patients has ranged up to 4 years, and no stricture formation has become apparent. The levator sling, which physiologically resembles the sphincter muscle in its tonus, relaxes during defecation, maintains an increased anterior pull during rest phase, and permits complete voluntary occlusion. Postoperative einefluoroscopy, as well as pressure studies, have
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Fig. 5.--(A) Preoperative and (B) postoperative rectal position in a 10 year old male during rest, following complete release of the levator sling; (C) completely released levator sling during rest, (D) defecation, and (E) contraction. shown that the increased pressure zone corresponds with the length of the released levator sling. The complete release of the levator ani sling is, therefore, anatomically and functionally superior to the previously used partial release. Although most of the patients with anal incontinence in the pediatric age group had had repairs of imperforate or ectopic ani, loss of fecal control secondary to trauma or surgery is also seen in children. Since the retraction of the divided sphincter, which may occur after fistulectomies, often makes the surgical repair of the sphincter difficult, 4 if not impossible, the release of the levator can be used as either adjunct to the sphincter repair or replacement of the sphincter action in patients whose sphincter is completely destroyed. The relative ease with which the procedure can be performed and the apparent absence of complications have led us to extend the indication of this procedure by including patients with primary abdominoperineal repair for high imperforate anus. In these patients, however, the levator muscles are only released and no attempt to tighten or suture the sling is made. The release of the levator sling has the additional advantage of opening the supra levator space, simplifying the identification of the puborectalis muscle as well as possible rectourethral fistula. The follow-up of these patients is too short to evaluate the late postoperative results. In patients with secondary release of the levator sling, however, the muscular function has persisted and neither obstruction nor development of megacolon has been seen. It should also be pointed out that if the revision of the levator sling is performed for the repair of imperforate anus, the sling is located above the area
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Fig. 6.mComparison of (A) normal levator and (B) completely released levator sling during rest, and (C) of normal levator ani, and (D) completely released levator sling during contraction. of skin and mueosal sensory reception and complete continence cannot be assured, for the patient is not aware of the passage of liquid stool or flatus until the sensory area has been reached. To achieve complete control, skin flaps may have to be brought into the anal canal above the lowest point of the levator sling, a concept which has been advocated by Hiatt and Santulli. ~ This was attempted in one of our patients who had had partial release of the levator sling as a secondary repair for imperforate anus. The elevation of the skin flaps into the anal canal considerably improved his anal continence. NOTE: A 6 year old girl with b o t h urinary and fecal incontinence following repair of imperforate anus came to Dr. Anthony Shaw at Harlem Hospital. Jointly with one of us a complete release of the levator sling was performed with resultant continence of urine and stool sufficient to permit attendance at school. SUMMARY
The complete release of the levator ani sling in patients with anal incontinence, due either to loss of sphincter or puborectalis muscle, is not only technically easier to perform but has shown improved results as compared with the partial release of the levator ani sling previously reported. 3 The effective-
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117
ness of the revised levator sling is b a s e d o n the p a r t i c u l a r p h y s i o l o g i c a l p r o p e r t i e s of t h e levator muscle, r e s e m b l i n g the s p h i n c t e r m u s c l e , a n d t h e a n a t o m i c a l p o s i t i o n w h i c h p e r m i t s a m a r k e d a n t e r i o r a n g u l a t i o n a n d comp r e s s i o n of the r e e t u m . SUMMARIO IN I N T E R L I N G U A Incontinentia fecal post reparo operative de ano imperforate ha remanite un problema persistente in un numero significative de patientes. Quando le functionamento exterosphincteral e/o puborectal es perdite in consequentia de trauma operatori, le altere componentes del levator anal pote esser usate pro meliorar o restaurar continentia anal. REFERENCES 1. Stephens, F. D.: Congenital Malformations of the Rectum, Anus and Genitourinary Tract. Edinburgh & London, E & S Livingstone Ltd., 1963. 2. Loygue, G., and Dubois, F.: Surgical treatment of anal incontinence. Amer. J. Proct. 15:361-374, 1964. 3. Kottmeier, P. K.: A physiological approach to the problem of anal incontinence through use of the levator ani
as a sling. Surgery 60:1262-1266, 1966. 4. Block, I. R.: Repair of the incontinent sphincter ani following operative injury. Surg. Gynec. Obst. 109:111-116, 1959. 5. Hiatt, R. B., and Santulli, T. U.: Important factors influencing the treatment of imperforate anus. Dis. Colon Rect. 5:110-115, 1962.
HE IMPORTANT ROLE of the puborectalis muscle in the control of anal continence has been stressed for many years, 1 but little use has been made of the other levator muscles in patients whose anal sphincter or puborectalis muscle was destroyed or is nonfunctioning. Previous use of the levator muscles consisted of procedures which utilized only part of the levator sling to repair either the sphincter or the puborectalis muscle. 2 Instead of using the levator for the repair of either sphincter or puborectalis muscle, we have attempted to use the levator sling as an independent muscular sling in view of its accessible anatomical location. As previously reported 8 the partial release of the levator ani in children with persistent fecal incontinence following abdominoperineal repairs for imperforate anus has led to considerable improvement. Further experience with the complete release of the levator ani sling, first attempted in the previously reported group, has convinced us that the complete release not only facilitates the operative procedure but leads to considerably improved results. Three patients have had a complete release of the levator ani sling resulting in complete continence. These patients, including the previously reported case, had developed fecal incontinence following trauma or surgical procedures: a 10 year old boy following perineal bums, an 11 year old boy post drainage of a presacral abscess after a Swenson procedure for Hirschsprung's disease and a 76 year old woman following fistulectomies. Additional complete levator ani release was performed in two males with imperforate ani and rectourethral fistulae. A long follow-up in the latter cases is needed to evaluate both indication and result of the complete release as part of the primary abdominoperineal repair. The normal relation of the rectum to the levator ani muscles is shown in Figure 1. The puboreetalis muscle circles the rectum laterally and posteriorly and blends with the sphincter. Since the puborectalis muscle is neither attached to the medium raphe nor to the coccyx, it is relatively mobile and can compress the rectum posteriorly and laterally. The other components of the levator sling, however, the pubocoecygeus and ileoeoccygeus muscles, are attached posteriorly and, therefore, contribute only little to the compression of the rectum. To achieve the fullest effect of the levator sling, the posterior ahd posterolateral attachments of the pubococeygeus and ileococeygeus muscles are released to allow a free anterior pull, as shown in Figure 2. In our original procedure, 3 we
T
From the Pediatric Surgical Service, Department of Surgery and Department of Radiology, State University Kings County Medical Center, Brooklyn, New York. PETERK. KOTTM~IER, M.D.: Assistant Professor of Surgery, State University of New York, Downstate Medical Center; Chief Pediatric Surgical Service, Kings County Hospital Center, Brooklyn, N. Y. ROMANDZIADIW,M.D.: Assistant Professor of Radiology, State University of New York, Downstate Medical Center; Attending Roentgenologist, Kings County Hospital Center, Brooklyn, N. Y,
111 JOURNAL OF PEDIATRICSURGERY,VOL. 2, No, 2 (APRIL), 1967
112
K O T T M E I E R AND DZIADIW
Fig. 1.--Normal relation of rectum to levator ani muscles. The schematic diagram shows the normal position of the rectum anterior to the puborectalis muscle. The pubococeygeus and ileococcygeus muscles are attached to the medium raphe and coccyx.
Fig. 2.---Postoperative complete release of the levator sling. The coccyx has been excised and the posterior and posterolateral attachments of pubococcygeus and ileococcygeus muscles are severed, allowing an increased anterior pull of the entire levator sling.
RELEASE OF LEVATOR ANI SLING
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approached the levator through a posterior midline incision extending from 1 em. behind the anus to the coccyx. The levator was then identified, and the posterior e/a of the ileococcygeus muscles were released from their posterior attachment, split longitudinally up to the insertion and released. The posterior thirds of the ileocoeeygeus muscles were then approximated in the midline to prevent prolapse of the rectum through the existing muscle defect. This caution appears to be unnecessary and we now excise the coccyx and release the entire puhococcygeus and ileococcygeus muscle sling without an attempt to close the defect. If the entire ileoeoeeygeus muscle is released, the upper portion is tightened posterior to the rectum with interrupted chromic sutures. While one finger is placed within the rectum the upper part of the ileocoecygeus muscle is approximated snugly until the entire sling is felt to push the rectum anteriorly without occluding it. This complete release not only achieves a more acute anterior angulation of the rectum, as seen in the partial release, but also enlarges the muscular levator sling encircling the rectum. The release of the levator sling either increases the effect of the puborectalis muscle or, in the absence of the latter, replaces it. The normal levator mechanism, as seen during einefluoroseopy in a 10 year old boy, is shown in Figure 3. The dentate line is marked, and the normal position of the puborectalis muscle is seen in the position of rest, defecation and contraction. The distance between the dentate line and the puborectalis muscle is small, and only a minor change of rectal position occurs during rest and defecation. During contraction an anterior angulation of the rectum is seen, and the distance between dentate line and puborectalis muscle is approximately doubled. Due to the posterior attachment of the pubococcygeus and ileoeoecygeus museles, this contraction is almost entirely due to the contraction of the puborectalis muscle alone. Shown in Figure 4 are the preand postoperative findings in an 8 year old boy, 3 years post partial revision of the levator sling performed as a secondary repair of an imperforate anus. In the preoperative picture the posterior position of the rectum can be seen. Postoperatively, a mild anterior angulation of t~:e rectum is seen during defecation without constriction. During contraction, the partially revised levator sling acts like a horizontal shutter mechanism, which effectively occludes the rectum by marked anterior compression which, however, is still limited to a relatively smaller area as compared with the length of the occluded rectal segment obtained with the complete release of the levator sling. A more extensive change in the position of the rectum is seen in Figure 5, in a 10 year old boy whose perineum, including sphincter and puboreetalis muscle, was destroyed by a third degree burn. In the preoperative picture the posterior position of the rectum can be seen, with the rectum in close proximity to the sacrum and coccyx. Postoperatively during rest, an anterior reetal angulation is seen which not only exceeds the anterior angulation normally found, but also the angulation following the partial release in Figure 4. The postoperative function of the released levator is shown in the same patient during rest, defecation and contraction. The anterior angulation during rest position is partially main-
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Fig. 3.--Normal levator mechanism in a 10 year old male during rest, defecation and contraction (left to right).
Fig. 4.--(A) Preoperative rectal position in an 8 year old male, (B) defecating and (C) contracting 3 years following partial release of the levator sling. tained during defecation, but relaxation does occur and no evidence of stricture is seen. During contraction, a horizontal shutter effect of the released levator is seen with complete occlusion of the rectum. This "shutter mechanism" in this patient (M. S. ), is more apparent than in the patient shown in Figure 4, since the ileococcygeus and pubococcygeus muscles were completely released with the excision of the coccyx. In Figure 6A and 6B, the resting position of the rectum is compared in a normal control patient and a patient with complete release of the levator mechanism. The rectal occlusion produced by the puborectalis muscle in the normal patient is limited to a small area as compared with the rectal occlusion in the patient with the revised levator sling. The broad muscle sling, formed by the complete release of the levator muscle, is in a better position mechanically to occlude the rectum even during the rest period. In Figure 6C and 6D, a comparison of the contraction of a normal levator sling and the contraction of a completely released levator sling is shown. The contraction of the normal levator sling limits the anterior angulation to a small area close to the dentate line. During contraction of the revised levator sling the area of rectal compression is considerably enlarged and the effect of the contraction, therefore, increased. The follow-up of these patients has ranged up to 4 years, and no stricture formation has become apparent. The levator sling, which physiologically resembles the sphincter muscle in its tonus, relaxes during defecation, maintains an increased anterior pull during rest phase, and permits complete voluntary occlusion. Postoperative einefluoroscopy, as well as pressure studies, have
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Fig. 5.--(A) Preoperative and (B) postoperative rectal position in a 10 year old male during rest, following complete release of the levator sling; (C) completely released levator sling during rest, (D) defecation, and (E) contraction. shown that the increased pressure zone corresponds with the length of the released levator sling. The complete release of the levator ani sling is, therefore, anatomically and functionally superior to the previously used partial release. Although most of the patients with anal incontinence in the pediatric age group had had repairs of imperforate or ectopic ani, loss of fecal control secondary to trauma or surgery is also seen in children. Since the retraction of the divided sphincter, which may occur after fistulectomies, often makes the surgical repair of the sphincter difficult, 4 if not impossible, the release of the levator can be used as either adjunct to the sphincter repair or replacement of the sphincter action in patients whose sphincter is completely destroyed. The relative ease with which the procedure can be performed and the apparent absence of complications have led us to extend the indication of this procedure by including patients with primary abdominoperineal repair for high imperforate anus. In these patients, however, the levator muscles are only released and no attempt to tighten or suture the sling is made. The release of the levator sling has the additional advantage of opening the supra levator space, simplifying the identification of the puborectalis muscle as well as possible rectourethral fistula. The follow-up of these patients is too short to evaluate the late postoperative results. In patients with secondary release of the levator sling, however, the muscular function has persisted and neither obstruction nor development of megacolon has been seen. It should also be pointed out that if the revision of the levator sling is performed for the repair of imperforate anus, the sling is located above the area
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KOTT_XI~IE~ AND EZIADIW
Fig. 6.mComparison of (A) normal levator and (B) completely released levator sling during rest, and (C) of normal levator ani, and (D) completely released levator sling during contraction. of skin and mueosal sensory reception and complete continence cannot be assured, for the patient is not aware of the passage of liquid stool or flatus until the sensory area has been reached. To achieve complete control, skin flaps may have to be brought into the anal canal above the lowest point of the levator sling, a concept which has been advocated by Hiatt and Santulli. ~ This was attempted in one of our patients who had had partial release of the levator sling as a secondary repair for imperforate anus. The elevation of the skin flaps into the anal canal considerably improved his anal continence. NOTE: A 6 year old girl with b o t h urinary and fecal incontinence following repair of imperforate anus came to Dr. Anthony Shaw at Harlem Hospital. Jointly with one of us a complete release of the levator sling was performed with resultant continence of urine and stool sufficient to permit attendance at school. SUMMARY
The complete release of the levator ani sling in patients with anal incontinence, due either to loss of sphincter or puborectalis muscle, is not only technically easier to perform but has shown improved results as compared with the partial release of the levator ani sling previously reported. 3 The effective-
1RELEASE OF LEVATOR ANI SLING
117
ness of the revised levator sling is b a s e d o n the p a r t i c u l a r p h y s i o l o g i c a l p r o p e r t i e s of t h e levator muscle, r e s e m b l i n g the s p h i n c t e r m u s c l e , a n d t h e a n a t o m i c a l p o s i t i o n w h i c h p e r m i t s a m a r k e d a n t e r i o r a n g u l a t i o n a n d comp r e s s i o n of the r e e t u m . SUMMARIO IN I N T E R L I N G U A Incontinentia fecal post reparo operative de ano imperforate ha remanite un problema persistente in un numero significative de patientes. Quando le functionamento exterosphincteral e/o puborectal es perdite in consequentia de trauma operatori, le altere componentes del levator anal pote esser usate pro meliorar o restaurar continentia anal. REFERENCES 1. Stephens, F. D.: Congenital Malformations of the Rectum, Anus and Genitourinary Tract. Edinburgh & London, E & S Livingstone Ltd., 1963. 2. Loygue, G., and Dubois, F.: Surgical treatment of anal incontinence. Amer. J. Proct. 15:361-374, 1964. 3. Kottmeier, P. K.: A physiological approach to the problem of anal incontinence through use of the levator ani
as a sling. Surgery 60:1262-1266, 1966. 4. Block, I. R.: Repair of the incontinent sphincter ani following operative injury. Surg. Gynec. Obst. 109:111-116, 1959. 5. Hiatt, R. B., and Santulli, T. U.: Important factors influencing the treatment of imperforate anus. Dis. Colon Rect. 5:110-115, 1962.