Free Autogenous Muscle Transplant for Strengthening of the Levator Ani Palmaris Longus Transplant

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Hakelius [13] and Hakelius et al. [14-16] originally described the procedure in which a graft of muscle (usually the palmaris longus, less commonly the sartorius, or extensor digitorum brevis) is first de-nervated 2 weeks before transplantation and is then

Weeks Pubic Bone

transplanted as a U-shaped sling around the rectum, in close contact with the puborectalis, and anchored to the pubic bone (Figs. 31.6 and 31.7). Denervation allows muscle survival as it initiates a lower level of energy consumption. The graft becomes reinnervated from the puborectalis over a period of 9 months. Central atrophy of the muscle occurs, but the surviving one-third facilitates continence.

Grotte et al. [16] reported the follow-up of 21 patients. Continence was virtually normal in ten patients, nine were "socially satisfactory", and in two the results were poor. The procedure has undoubted merit. Successful reports were also given by Mollard et al. [17] and by Holschneider and Hecker [18] (Fig. 31.8).

The problem with this operation is similar to that of transposition of denervated gracilis muscle described by Holle et al. [19]. Scarring of the pelvic floor prevents reinnervation, and fibrosis of the regenerating muscle graft remains a critical factor for the ingrowing nerve fibers. A further problem is the degree to which the graft is prestretched. On the one hand, it is necessary to prestretch the muscle sufficiently to obtain a better angulation of the anorectal angle and to achieve a compression of the rectum from both

Fig. 31.4 A-C Levator ani release and plication(from Stephens and Smith [2], Fig. 21-3-21-5). A The posterior coccygeal attachment of the levator sling is illustrated schematically. B The levator sling has been severed from its posterior attachment, and the rectum pushed anteriorly. C The levator tightened behind the rectum to its sheath on the acute angulation of the rectum

Incision AniLevator Plication

Fig. 31.5 Steps of levatorplasty (reproduced from Puri and Nixon [12] with permission of the publishers). A Incision. B Beginning of flap reflection. C Exposition of the levator ani in the midline. D Coccyx separated from the sacrum, and levator freed from adjacent attachments. E Plication of the mobilized levator. Max Maximus, Ext external

Fig. 31.5 Steps of levatorplasty (reproduced from Puri and Nixon [12] with permission of the publishers). A Incision. B Beginning of flap reflection. C Exposition of the levator ani in the midline. D Coccyx separated from the sacrum, and levator freed from adjacent attachments. E Plication of the mobilized levator. Max Maximus, Ext external

Incision Ani

Fig. 31.6 Schematic representation of palmaris longus transplantation [13,14]. Reproduced from Holschneider and Hecker [18] with permission of the publisher)

Gracilis Muscle Transplant

Fig. 31.7 A-D Palmaris longus transplantation. A Preparation palmaris longus muscle divided and resutured to the muscle of the palmaris longus muscle, which was denervated 14 days belly, creating a sling. Sling ready for transposition. D Palmaris previously. B Dorsal incision in the natal cleft. C Tendon of the longus sling in situ close to the muscle complex

Fig. 31.7 A-D Palmaris longus transplantation. A Preparation palmaris longus muscle divided and resutured to the muscle of the palmaris longus muscle, which was denervated 14 days belly, creating a sling. Sling ready for transposition. D Palmaris previously. B Dorsal incision in the natal cleft. C Tendon of the longus sling in situ close to the muscle complex sides. On the other hand, striated muscles can only be prestretched about 15% over resting conditions for the fibers to survive.

Studies in the rat [20] have shown that necrosis increases in proportion to the degree of prestretching. In human studies, six out of nine patients treated with Hakelius-Grotte free muscle transplantation became continent for solid bowel contents, and three for liquid content, but none were continent for flatus. These results are less favorable than those reported by Hake-lius et al. [13-15] and Grotte et al. [16]. Postoperative electromanometric studies have shown that the ano-

rectal pressure difference is improved by transplantation and that there is some reflex response coincidental with puborectalis sling contractions.

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