Anorectal Continence Following Sphincter Reconstruction Util izing the Giuteus Maximus Muscle: A Case Report

By Zafer Skef, Jayant Radhakrishnan, and Hernan M. Reyes Chicago, Illinois

�9 Rectal incontinence following pull-through pro- cedure for high imperforate anus remains a difficult problem. Based on recent knowledge of the segmen- tal neurovascular supply of the gluteus maximus muscle, the inferior half of the muscle on both sides was used for anorectal sphincter reconstruction on a 10-year-old boy who was totally incontinent follow- ing a pull-through procedure for a high imperforate anus. The technique of constructing this sphincter is simple and utilizes principles of muscle tendon trans- fer without jeopardizing the function of gait. Further- more, the gluteus maximus muscle, being an acces- sory muscle of anal continence, is an ideal structure for this reconstruction. Colostomy can be prevented with the use of good preoperative bowel preparation and a constipating program for 1 week postopera- tively. The results are directly related to the success of the operative procedure, and the maturity and degree of motivation of the child to undergo bowel- control training.

INDEX WORDS: Anal incontinence; anorectal sphincter reconstruction; imperforate anus.

I~ ECAL INCONTINENCE is a major psy- chosocial problem. Prior to 195l, the glu-

teus maximus muscle was commonly used to reconstruct the anorectal sphincter because of its proximity to the anus and its function as an accessory muscle of anal continence. The results were not uniformly successful and thereafter Pickrell ~ advocated the use of the gracilis muscle for this purpose. Recent knowledge indicating the possibility of dissecting the inferior half of both gluteus maximus muscles together with preserving its neurovascular supply without pro- ducing serious sequela to the functions of the thigh and hip, provides us with a strong, anatom- ically ideal, and effective muscle for reconstruc- tion of the anorectal sphincter following failed pull-through procedures for imperforate anus or after trauma?

ANATOMICAL CONSIDERATIONS

The gluteus maximus muscle is a strong thigh extensor and a lateral rotator of the hip. It originates from the upper part of the ilium, back of the sacrum, coccx, and the sacrotuberous ligament and inserts into the femur and iliotibial tract) The blood supply comes from the hypo-

gastric artery through its branches; the superior and inferior gluteal artenes supply the superior and inferior half of the muscle respectively. The insertion of this muscle is further vascularized through several perforating branches of the medial and lateral femoral circumflex arteries) Its motor innervation is through the inferior gluteal nerve. The sacrifice of the entire muscle in an ambulatory patient will cause difficulty in climbing stairs; however, the use of the anatomi- cally dissected lower half will preserve its func- tion. With careful dissection, the lower half of the gluteus maximus muscle together with its neurovascular supply can be developed for anal sphincter reconstruction. 2

MATERIALS AND METHODS

Based on a recent experience reported for sphincter recon- struction following trauma, a 10-year-old male patient at our institution underwent an anorectal sphincter reconstruction because of total fecal incontinence. This patient had a colostomy for a high imperforate anus at birth and a pull- through procedure at 2 years of age. Rectal examination revealed no voluntary or involuntary function of the puborec- talis sphincter and despite dietary control and daily enemas, the patient was constantly soiling his clothes. He had normal urinary continence. Preoperatively, the patient was placed on a bowel prep with antibiotics and elemental diet. Following induction of anesthesia, the patient was placed in a jack-knife position and four separate incisions were made (Fig. 1A); the upper incisions extended from the midsacrum to the ischial tuberosity. The lower incisions were made circumanal, lateral to the mucocutaneous junction. The inferior half of the gluteus maximus muscle was then dissected from its origin at the coccyx and approximately 4 to 5 cm of muscle together with its periosteal origin was dissected laterally (Fig. 1B). The inferior gluteal neurovascular bundle was identified and preserved. Adequate length for inferior and anterior rotation of the muscle flap was provided by dividing the restricting

From the Division of Pediatric Surgery, University of Illinois at the Medical Center, Chicago and Cook County Children's Hospital, Chicago.

Presented before the 14th Annual Meeting of the Ameri- can Pediatric Surgical Association, Hilton Head Island, South Carolina, May 4-7, 1983.

Address reprint requests to Zafer Skef, MD, Division of Pediatric Surgery, University of Illinois, PO Box 6998, Chicago, IL 60680.

�9 1983 by Grune & Stratton, Inc. 0022/3468/83/1806-0025501.00/0

Journal of Pediatric Surgery, Vol. 18, No. 6 (December), 1983 779

780 SKEF. RADHAKRISHWAN, AND REYES

A

"i Inferl

LINE, ~ OF INCISIONS B

~ r " ~ ~ C o c c y g e a I Origin

DEVELOPMENT OF MUSCLE FLAPS

Fig. 1, (A) Lines of incisions. IB) Development of the muscle flaps.

bands. A similar flap was now developed in the opposite side. Both flaps were divided into two halves starting from its resected end thereby producing two identical halves of 4 to 5 cm long (Fig. 2A). Each half of the flap on one side was passed subcutaneously around the rectum, one anteriorly and the other posteriorly. Both ends of the flap were then sutured together with 2-0 vicryl sutures creating a sling. The divided flap on the opposite side was passed in a similar fashion and both ends sutured together as well (Fig. 2B). During the suturing of the created sling, the index finger was placed inside the rectum to make sure that the sphincter created was snug around the rectum. Suction drains were then placed and the wound was closed.

Postoperatively, the patient was placed in a supine or prone position and was not allowed to sit for 10 days or climb stairs for three weeks. Bowel movements were minimized by keep- ing the patient on nothing by mouth for 1 week together with tincture of paregoric or diphenoxylate hydrochloride with atropine (Lomotil) during this period of time. Nutrition was

provided for by intravenous hyperalimentation. More simple tightening exercises were started 2 weeks following surgery.

Ten months postoperatively, the child was able to feel fullness in the rectum as well as the urge to have a bowel movement. He was able to control his bowels and remained clean between bowel movements. Occasional soiling episodes occurred however, when the stools were liquid or when he was asleep. On rectal examination, a strong voluntary contraction of the now-created anorectal sphincter was demonstrated.

DISCUSSION

C o n t i n e n c e is r e p o r t e d to be poor in a p p r o x i -

m a t e l y a f o u r t h of t h e c h i l d r e n w i t h s u p r a l e v a t o r

i m p e r f o r a t e a n u s fo l lowing p u l l - t h r o u g h p roce -

dures . 6 M u c h h i g h e r f igures have been r e p o r t e d

w h e n n o r m a l c o n t i n e n c e was c o n s i d e r e d as con-

trols . 7 T h e g rac i l i s mu c l e , w h e n used to r e co n -

/

A. B SLING CREATION

Fig. 2. (A) Rotation of the muscle flaps, (B) Sling creation.

ANORECTAL SPHINCTER RECONSTRUCTION 781

s t ruct the anorec ta l sphincter , has been effective in increasing the anorec ta l pressure profile in about two-thi rds of the patients . Unfor tuna te ly , the longterm follow-up fai led to show uni formly good results because the cont rac t i le force of the graci l is muscle was noted to d iminish with t ime. 7 I t is suggested tha t this is p robab ly re la ted to devascular iza t ion of the distal one-four th of the muscle therby producing a muscle tha t acts as an elast ic stenosis r a the r than as a sphincter . 2 The gluteus max imus muscle normal ly functions as an accessory muscle of ana l continence. Ches t - wood 8 (1902) and Bis t rom 9 (1944) ut i l ized por- tions of this muscle for ana l sphincter reconstruc- tion. A modificat ion recent ly publ ished by Hen tz using the inferior ha l f of the gluteus max imus

muscle with its in tac t neurovascular supply appears to adhere to the principles of muscle tendon t ransfer , i.e., the pull is d i rec t and the proper rest ing length and tension re la t ionships a re easi ly achieved. The opposing effect of the two muscles produces a powerful sl ing cont rac- t ion providing for an effective sphincter mecha- nism.

Effective cont inence appears to be secondary to a good ini t ia l t ra in ing p rog ram of muscle control to ma in ta in the contrac t i le force of the gluteus max imus muscle. Tra in ing of the pa t ien t is l ikewise a ma jo r considera t ion in achieving good bowel control and tha t the m a t u r i t y of the child has a signif icant influence in ob ta in ing excel lent results. 6

REFERENCES

1. Pickrell KL, Broadbent TR, Masters FW, et al: Con- struction of a rectal sphincter and restoration of anal conti- nence by transplanting the gracilis muscle. Ann Surg 135:853-862, 1952

2. Hentz VR: Construction of a rectal sphincter using the origin of the gluteus maximus muscle. Plast Reconstruc Surg 70:1, 82-85, 1982

3. Brash JC: Cunningham's Manual of Practical Anato- my, Vol. 1. New York, N.Y., Oxford University Press, 1957, pp 232-233

4. Mathes S, Nahai F: Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis, MO., C. V. Mosby Co., 1982, pp 66-67

5. Scheflan M, Nahai F, Bostwick J: Gluteus maximus

island musculocutaneous flap for closure of sacral and ischial ulcers. Plast Reconstruc Surg 68:533-538, 1981

6. Kiesewetter WB: Rectum and anus malformations, in MM Ravitch, et al (eds.): Pediatric Surgery Vol. 2, 3rd Ed. Chicago, Year Book Publishers, 1979, pp 1071-1072

7. Hecker WC, Holschneider WCH: Longterm follow-up in congenital anomalies. Pediatric Surgical Symposium, Pittsburgh, PA, 1979, pp 54-55

8. Chestwood CH: Plastic operation for restoration of the sphincter ani with report of a case. Med Rec 61:529-534, 1902

9. Bistrom O: Plastischer Ersatz des M. sphincter ani. Acta Chir Scand 90:431~,48, 1944