VM05 - Anterior Sphincteroplasty for Fecal Incontinence

Purpose/Background: The patient is a 14-year-old girl.
Main Complaint: Fecal incontinence for 14 years.
History of present illness: The patient underwent anoplasty at birth due to anal atresia and developed fecal incontinence after surgery. The symptoms did not improve with aging.
Rectal examination: The anus was cave-like and the perineal body was thin.
Digital examination: The anal sphincter was relaxed, sphincter contraction was weak.
Wexner fecal incontinence score: 20 points.
MRI examination showed the presence of external anal sphincter on both sides and posterior side of the anus, but absence on the anterior side.
Other laboratory tests: no abnormality.

Methods/Interventions: Sphincteroplasty is the operation most frequently performed in patients suffering from moderate-to-severe anal incontinence who do not respond to conservative treatment. Overlapping anal sphincter repair is an operation that may be offered to the incontinent patient with an anatomically disrupted external anal sphincter muscle. It can be performed regardless of the etiology of the injury to the sphincter complex. So, sphincteroplasty was performed for this patient.
Preparation: Complete bowel mechanic preparation is essential.
Anesthesia: general anesthesia
Position: prone position
Technique:
1. A perineal curvilinear incision was made.
2. Rectovaginal septum was injected with a 1:100,000 solution of saline with epinephrine.
3. Rectovaginal septum was dissected along anatomical plane between rectum and vagine until to reach levator ani muscle.
4. The external sphincter ends were isolated on both sides, no more than 180°,or not beyond the midline of the anus to avoid damage to innervation.
5. Internal sphincteroplasty was performed by imbricating the internal sphincter.
6. External sphincteroplasty was performed by overlapping the external sphincter with vertical mattress suture.
7. The perineoplasty was performed in a "Y" shape, and the central incision remain open for drainage.
8. A drainage tube was placed in the rectovaginal septum.

Results/Outcomes: The operation was completed. The postoperative management was as follows:
1. Patient can drink water 3 hours after surgery.
2. The day after surgery, patient’s dietary change regulated to liquid diet and enteral nutrition for 3 days.
3. Prophylactic antibiotics were used for 2 days.
4. Keeping the stools soft, the area clean, and pain tolerable.
The patient discharged a week after surgery and recovered well. Pelvic floor rehabilitation was performed, such as biofeedback, starting 3 months after surgery to improve efficacy.

Conclusion/Discussion: Anterior Sphincteroplasty play a positive role in the management of fecal Incontinence, as it carries a good outcome when pelvic floor rehabilitation is also combined, provided that strict indications are followed.