Abstract
The etiology of anal sphincter incompetence can be multifactorial. Traumatic delivery can cause tearing of the internal and external anal sphincter musculature, particularly in the anterior segment. Repair immediately after delivery usually is highly effective, but some patients will develop significant stool incontinence. Pudendal nerve damage after traumatic delivery or other injury can cause sphincter neuropathy and poor sphincteric function. Posterior or lateral episiotomy can be another factor in anal sphincter damage. Surgery, inflammation, traumatic injury, or radiation can directly damage the anal sphincter, and neurogenic disease (e.g., paraplegia with sacral arc lesion) is often associated with anal incompetence.
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6.1 Electronic Supplementary Material
Video 6.1
Anal sphincter reconstruction. The patient is prepped and placed in lithotomy position after irrigation of the rectum with an antibiotic solution. An inverted U incision is made in the perineum, reaching the posterior fourchette superiorly and the ischial tuberosity laterally. A flap of skin is dissected free to reach the external anal sphincter fibers. The ischial fossa is entered in each side just lateral to the levator and external anal fibers. Sequentially, #0 figure-of-eight delayed absorbable sutures are applied at the 3–12 and 9 o’clock positions. The sutures include the external sphincter fibers, anterior rectal wall, and contralateral external sphincter fibers. The sutures are applied while a finger is inserted in the rectum. Pulling from the sutures with each pass, we should feel the tightening of the anal sphincter. Three to four sutures are applied. The area is irrigated with antibiotic solution and the vaginal flap is advanced to cover the area of the reconstruction (MP4 110278 kb) (MP4 216258 kb)
Video 6.2
Bladder neck closure. The patient had a wide-open necrotic urethra due to indwelling catheter and neurogenic bladder. An inverted U flap of the anterior vaginal wall is prepared to expose the periurethral fascia. The retropubic space is entered to free all adhesions. A circular incision is made around the urethra. Anteriorly, the dissection is carried out directly toward the periosteum of the pubic bone. The retropubic space is entered between the inferior rami of the symphysis and the urethra by detaching the pubourethral fascia. The lateral attachments of the urethra to the lateral pelvic wall are transected using a coagulation knife. The urethra is excised and the bladder neck closed with multiple layers of delayed absorbable sutures. Sutures are applied to the anterior bladder wall and the bladder neck and tied to displace the bladder neck toward the retropubic space and far from the vaginal incision. If required, a Martius flap is performed. The vaginal flap is advanced distally to cover the reconstruction area (MP4 187852 kb) (MP4 184599 kb)
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Raz, S. (2015). Reconstructive Surgery. In: Atlas of Vaginal Reconstructive Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2941-2_6
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DOI: https://doi.org/10.1007/978-1-4939-2941-2_6
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