Flap Smooth Muscle Transplantation

Because of the poor aforementioned results, Holschneider and Hecker [57] introduced the flap smooth muscle transplant for the treatment of high ARM. The procedure can be performed as a primary operation following the abdominosacroperineal pull-through procedure in high anomalies, or as a secondary procedure in failed cases.

As a primary operation, Holschneider first performs an abdominoperineal or abdominosacrope-rineal pull-through procedure. After having pulled down the colon through the puborectalis sling and the muscle complex, the mucosa is resected from the colon. The seromuscular cuff is turned back 180 prestretched to 120-140% of the original length, and then attached to the serosa of the pulled-down colon with Vicryl sutures. The reversed muscle segment is brought back just above the pelvic floor (Figs. 31.17 and 31.18).

Postoperative studies in goats and in children have shown normal internal sphincter relaxations with an amplitude and duration directly proportional to the distending rectal volume, a normal anorectal pressure profile, and normal defecation behavior, with opening and closing of the anal canal during defecation (Figs. 31.19 and 31.20).

Normal Anal Canal

Fig. 31.17 A-D Reverse smooth muscle plasty according to Holschneider (reproduced from Holschneider and Hecker [58] with permission of the publisher). A High anorectal malformation. B After abdominoperineal pull-through of the colon to the perineum. C The seromuscular cuff is turned up 180 degrees orally and sutured to the serosa of the pulled-through colon. D The bowel is pulled back cranially within the puborec-talis sling.

Fig. 31.17 A-D Reverse smooth muscle plasty according to Holschneider (reproduced from Holschneider and Hecker [58] with permission of the publisher). A High anorectal malformation. B After abdominoperineal pull-through of the colon to the perineum. C The seromuscular cuff is turned up 180 degrees orally and sutured to the serosa of the pulled-through colon. D The bowel is pulled back cranially within the puborec-talis sling.

It is not necessary to prestretch the muscle cuff more than one-third over the resting condition, as proposed by Hofmann-von Kap-herr and Koltai [58], as this leads to stenosis.

Flap smooth muscle transplantation has been added to the Peña and de Vries PSARP as a secondary procedure. When the muscle complex is too hypo plastic to become a satisfactory sphincter, one can incise the seromuscular cuff of the pulled-down rectum or colon, detach the mucosa from the circular muscle layer, prestretch the seromuscular cuff to about 120140%, and suture both seromuscular layers to each other. The most important point in this kind of procedure is the amount of prestretching of the muscle

Smooth Muscle Layer And Mucosa
Fig. 31.18 Flapped smooth muscle transplantation in situ (from Holschneider and Hecker [58] with permission of the publisher). A Extirpation of the mucosa and turning back the smooth muscle layer.

B Prestretching of the smooth muscle segment by about one-third over resting conditions and suturing to the serosa of the pulled-down colon

Mucosa Flap AnalDefecography
Fig. 31.20 A-D Defecography after reverse smooth muscle plasty. Narrowing and opening of the strengthened internal anal sphincter has been effected by the plasty

graft. Hofmann-von Kap-herr et al. [59] modified the Holschneider technique by creating a smooth- muscle fold-over double-plasty (SMSD-plasty), but pre-stretched the muscle cuff more severely, in some parts not only duplicating, but triplicating the muscle layers. In recent studies in the goat, Holschneider could show that such a high amount of prestretching results in stenosis and fibrosis of the muscle graft.

In Holschneider's series with his own technique, ten patients were operated upon. Eight of them showed normal internal sphincter relaxation and an anorectal resting pressure of over 20 mmHg, six children became completely continent or suffered from soiling only under stress conditions and diarrhea, one remained incontinent, and in the other child an anal stenosis required bouginage.

A secondary smooth muscle flap plasty was also performed in 12 children; 7 became completely continent, 2 remained incontinent because of stenosis and required bouginage, and 3 improved but continued to suffer from soiling under stress conditions and diar rhea. However, after the introduction of PSARP, this procedure has only been used by us in children with rectal prolapse combined with spinal lesions. In these patients with a flat bottom and neurogenic defecation disorders, a sacroperineal redo procedure combined with smooth muscle plasty and fixation of the rectum to the sacral or ischial fascia could be supported. In cases with simple ectopy of parts of the rectal mucosa, a perineal skin flap plasty is recommended. One should carefully distinguish between mucosal and rectal prolapse. In patients with mucosal prolapse the mucosa is not fixed by the longitudinal muscle fibers of the rectum at the perineal skin. Therefore, gliding in the submucosal layer is possible. In contrast, rectal prolapse involves all muscle layers. It occurs because the pulled-down rectum is not fixed to the lateral pelvic fascia after the lateral wings (ailerons latereaux) have been cut during preparation. In these cases a laparoscopic fixation of the rectum to the presacral fascia is the method of choice. However, this is not always possible and resection of the prolapsing bowel may be necessary. This should be performed with great care to the sphincter fibers.

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