The complete release of the levator ani sling in fecal in continence

Abstract

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