Bilateral Gracilis Transplant

BILATERAL GRACILIS TRANSPLANT

Ak Gvalani*, Ub Bhat**, Js Pandya***
*Professor (Gen. Surgery); **Lecturer (Plastic Surgery); ***Assoc Professor (Gen. Surgery) BYL Nair Ch. Hospital and TN Medical College, Dr. AL Nair Road, Mumbai 400 008.

Reconstruction of the anal sphincter was performed using the Gracilis muscles in a patient who had become totally incontinent following fistulectomy. Bilateral gracilis muscles flaps were raised keeping their proximal ends and the pedicles intact. Each one was made to encircle the anal canal in such a way that it was sutured to the inferior ramus of the pubic bone of the same side. This resulted in the formation of a double sling around the anal canal. This technique worked so well that the patient achieved complete continence with respect to solids, liquids and gases.

INTRODUCTION

Anal incontinence is a great misfortune on an individual. Unfortunately for this problem there has not been an effective answer.

The solution can be either a primary repair of the damaged sphincter, or a construction of a new sphincter. For the neo sphincter various structures have been used like fascia, glutei, transverse perinea and the gracilis muscles. Most recently an inflatable silastic cuff has been implanted around the anal canal.[1]

Pickrell described the transplantation of the gracilis muscle and since then it has been the most favourable, however the results are not consistently good because of the very nature of this muscle i.e. it is a fast twitching easily fatigable muscle. To overcome this drawback there are two options. One is to electrically stimulate the muscle fibers (Williams). This is tedious and expensive. Second is to modify the manner in which this muscle is used, this has been reported by Nixon [2] as Hartl’s [3] modification. This is an ingenious method of transplanting bilateral gracilis where each muscle forms an ‘U’ shaped loop around the anal canal mimicking puborectalis like sling. Together they form a very effective sphincter. This technique is simple. We have carried out this procedure in our case report with dramatically good results.

CASE REPORT

The patient, a 30 year old male, had undergone the surgery of fistulectomy 3 years ago following which he developed total anal incontinence. Patient remained incontinent for 3 years during which time he visited many doctors and was finally referred to us at the Nair Hospital. On examination, the patient had a gaping anus with deficient anal sphincter near about 5’O clock position with anal mucosa visible in that area.

Since the injury was 3 years old and the edges of the torn sphincter had retracted it was decided to construct a new sphincter. We tool up the patient for the surgery of Graciloplasty wherein both the gracilis muscles were transplanted around the anus to form a sling and thus a new anal sphincter. Each gracilis muscle was mobilized from the attachment on the Tibia up to the neurovascular hilum (9-11 cms below the pubic tubercle) and sutured to the inferior ramus ofthe pubic of the same side after passing it through a subcutaneous tunnel the anal canal as shown in the figure.

Postoperatively, the patient was kept constipated for 2 days, started on liquid diet on day 3 and subsequently on full diet. Patient passed flatus on post-operative day 2 and passed stools on day 4. Over a period of one month the patient gradually achieved complete control over his newly formed anal sphincter and became continent in relation to solids, liquids and gases.

Fig 1. (a) Incision on the thigh, (b) Gracilis muscle mobilized, (c) Gracilis sutured to the inferior ramus of the pubis of the same side, (d) Final reconstruction

DISCUSSION

Anal incontinence may be due to (1) central nervous disease or nerve injury, (2) anorectal diseases (3) trauma to anal sphincter and (4) injuries to the sphincter following operations on the anal canal. The greatest number of cases falls in the last category. In one series of 133 cases of anal incontinence 51% followed fistulectomy.[4]

Where the deficit is not large reapproximation of refreshened edges of the sphincter damaged or extensively destroyed, not a single procedure has been uniformly successful. Basically the techniques that have been described involve the encirclement of the damaged anal canal with either strips of muscle or fascia.[5]

Pickrell in 1951 described the use of the gracilis muscle. It was mobilized from the pullies and finally sutured to the ischium.[6]

However, the gracilis is a muscle of a mixed type containing mainly type II fast twitch, easily fatigable fibers. It is therefore unsuitable for maintaining continuous contraction necessary for the sphincter function by chronic low frequency electrical stimulation over a prolonged period this muscle has been converted into a type I slow twitch, fatigue resistant muscle.[7] This method is tedious and expensive. Another method to overcome the drawbacks related to the gracilis muscle has been suggested by Hartle who used both the gracilis muscles to form a puborectalis - like sling around the anal canal.

This anal neosphincter serves as an ideal substitute as it takes over the full function of puborectalis sling, the anorectal ring and the external anal sphincter. The neosphincter is dynamic, with intact blood and intact nerve supply. It also restores the anorectal angle, which is important for maintaining anal continence.

In this case report we share our experience with this technique which is simple and very effective, but for some reason it is not so popular. We feel that this technique should be popularised and it can become the procedure of choice for this condition

REFERENCES

1.Christiansen J, Lorentzen M. Implantation of artificial sphincter for anal incontinence. Lancet1987; 2 : 244-5.

2.Nixon HH. Operation for incontinence following anorectal anomalies : Levatorplasty and gracilis transplantation. Rob and Smith’s Operative Surgery colon, rectum and anus. 5th ed. Chapman and Hill; 1993 ; 460-61.

3.Hartl H. Modifizerte Gracilisplastik pediatrie und Podologie. 1972 ; Suppl. 2 : 99-107.

4.Blaisdell PC. Repair of incontinent sphincter. Ann Surg Gynaec & Obstt 1940; 70 : 692.

5.State D, Katz A. The use of superficial transverse perineal muscles in the treatment of post surgical anal incontinence. ann surg 1955; 142 : 262-4.

6.Pickrell KL, Broadbent TR, Masters FW, Metzger JT. Construction of a rectal sphincter and restoration of anal continence by transplanting the gracilis muscle. Ann Surg 1952; 152 : 853-62.

7.Williams NS, Hallan RI, Koeze TH, Pilot MA, Watlens ES. Construction of a neoanal sphincter by transposition of the gracilis and prolonged neuromuscular stimulation for the treatment of faecal incontinence. Ann R Coll Surg Engl 1990; 72 : 108-113.

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