Gracilis Muscle Transplant

Unlock Your Hip Flexors

Unlock Your Hip Flexors

Get Instant Access

Pickrell et al. [21] described the original procedures; further reports and modifications have since been

Fig. 31.8 A Electromanometric investigation of a child after palmaris longus transplantation: preoperatively (top trace), 3 months after operation (middle trace), and 1 year after the operation (bottom trace). B Continence after palmaris longus transposition. Injection of 30 ml of air (L30) into the rectosigmoid (RS). Contractions of the muscle complex reinforced by the palmaris longus muscle interrupting the evacuation of flatus. Note the spontaneous relaxation of the internal anal sphincter. AR Anorectum, ARP anorectal resting pressure profile (also ARRPP), R rectum, prop. preoperatively, postpone. postoperatively

Fig. 31.8 A Electromanometric investigation of a child after palmaris longus transplantation: preoperatively (top trace), 3 months after operation (middle trace), and 1 year after the operation (bottom trace). B Continence after palmaris longus transposition. Injection of 30 ml of air (L30) into the rectosigmoid (RS). Contractions of the muscle complex reinforced by the palmaris longus muscle interrupting the evacuation of flatus. Note the spontaneous relaxation of the internal anal sphincter. AR Anorectum, ARP anorectal resting pressure profile (also ARRPP), R rectum, prop. preoperatively, postpone. postoperatively made [22-26], including those by Brandesky and Holschneider [27] in 24 patients, showing definite improvements in 21; Berger et al. [28], who obtained poor results in 8 patients; and Brandesky et al. [29], who achieved improvement in 8 of 11 patients, but had poor results in myelomeningocele children. In the original method [21], the gracilis muscle was used as a neurovascular pedicle transplant. The muscle was detached distally and freed from the surrounding tissue up to its proximal one-third, where the neural innervation from the femoral nerve joins the muscle medially. From this point the muscle was transposed to the perineum, where it surrounded the anorectum subcutaneously, then dorsally, and again anteriorly. The tendon of the gracilis muscle was then fixed to the contralateral ischial tuberosity (Fig. 31.9).

Holschneider states that to obtain a good functional result, some requirements must be met. First, the gracilis muscle should be long enough so that the muscle belly and not the tendon surrounds the anal canal. Second, the gracilis muscle should have one good neurovascular supply in the most proximal one-

third of the thigh, because more distal vessels and nerves must be divided during the operation to allow the transposition of the muscle. Third, the muscle should be fixed with minimal tension to the contralateral ischial tuberosity. Dilatation should be unnecessary if the tension is correct. Fourth, although infection is a high risk in gracilis muscle transplantation, Holschneider never uses a colostomy and states that the infection rate is very low because of 24-h postoperative antibiotic prophylaxis and very careful postoperative care.

Holschneider and Lahoda [30] were able to show that commencing a few weeks to 9 months postopera-tively, the patient learns to contract the gracilis muscle sling without a simultaneous contraction of the other adductor muscles of the thigh. On the other hand, the patient learns to contract his adductor muscles without simultaneous contraction of the gracilis muscle sling, A good result is shown in Fig. 31.10. However, variations in the innervation of the gracilis muscle, with a low neurovascular support joining the muscle at its distal end in about 15-20% of patients, may lead

Grazilis Syndrom

Fig. 31.9 A-D Schematic drawing of gracilis muscle transplantation according to Pickrell [21]. A Incisions on the thigh. B Electrostimulation of the innervating branches of the femoral nerve. C Pull-through of the gracilis muscle to the perineum

Fig. 31.9 A-D Schematic drawing of gracilis muscle transplantation according to Pickrell [21]. A Incisions on the thigh. B Electrostimulation of the innervating branches of the femoral nerve. C Pull-through of the gracilis muscle to the perineum to poor results. To avoid these problems Hartl's modification [31] of Pickrell's method used the gracilis muscles of both sides simultaneously. A disadvantage of this technique is that if an infection affects both muscles, there is no possibility for a second gracilis transposition.

In another modification, Holle et al. [19] first de-nervated and then transposed the gracilis muscle sling as a vascularized pedicle transplant (Fig. 31.11). After the muscle is transposed to the perineum, it is divided into two equal parts and attached closely to the pelvic floor. Both parts of the muscle belly are sutured to the ischiococcygeal ligament so that the ano-rectum is now lying in between the gracilis muscle belly. According to Holle et al., reinnervation of the denervated muscle will take place from the puden-dal nerve within about 9 months [19]. Therefore, the gracilis muscle can be contracted simultaneously with the pelvic floor muscles and is able to exert a passive continence reaction, which was never possible following the original operation procedure [21].

The success of the operation of Holle et al. [19] depends on two points: (1) There should be no scarring

Gracilis Sling Operation

and around the anorectum. D Transposition of the muscle finished. The gracilis muscle is fixed at the contralateral ischial tuberosity

and around the anorectum. D Transposition of the muscle finished. The gracilis muscle is fixed at the contralateral ischial tuberosity of the pelvic floor from previous operations, because this disturbs the ingrowing nerve fibers, and (2) the vascular supply should be uniform in both parts of the gracilis muscle; unfortunately, this is not always the case.

Holschneider et al. [20] have extended these studies in goats by performing a microsurgical anastomosis between the pudendal nerve and the gracilis branch of the femoral nerve. Although the nerve pathways were reestablished, the division of the muscle into two parts (as in the Holle technique) sometimes leads to muscle death. Holschneider et al. are therefore not in favor of the Holle method.

A further modification of Pickrell's method was made by Dittertova and Grim [32], who combined Pickrell's gracilis muscle transplantation with Hartl's modification. They use the proximal two-thirds of both gracilis muscles, but prepare the neurovascular supply of both muscles so that the muscles and their neurovascular flaps can be transposed at the pelvic floor. Both parts of the gracilis muscle are sutured at the os pubis of each side and fixed to each other behind the anorectum, forming a muscle sling. The is-

Pubis Malformation
Fig. 31.10 Gracilis muscle transplant (from Holschneider [55], with permission of publisher). A Under resting conditions. B When contracting

sue with this modification is avoidance of damage to the innervation of the transplanted muscle segments (Fig. 31.12).

In assessing their own results, Holschneider et al. stated that gracilis transplantation creates a myogenic stenosis that is able to establish a high-pressure barrier and to relax, but is not able to contract reflexly [20]. Electromanometrically they observed a postoperative rise in the anorectal pressure barrier. The patient was able to stop propulsive waves by voluntary contractions of this muscle and to avoid defecation. The anorectal squeezing pressure profile also increased (Figs. 31.13 and 31.14).

Gracilis Muscle Transplant
Fig. 31.11 Schematic representation of gracilis transplantation of Holle [19], reproduced from Holschneider [55] with permission of the publisher

31.5.1.1 Follow-Up

Eight out of 56 of Holschneider's patients with Pick-rell's gracilis transplantations acquired a postoperative infection. Eight others developed anal stenosis that could be gently dilated. Five children developed an ileus because of adhesions as a late complication of the primary pull-through procedure. In one pa tient mucosal ectopy persisted, and three other children developed a keloid scarring of the distal thigh [25]. Twenty-eight out of 40 patients in whom the operation was performed at least 2 years previously developed good continence. The children ceased soiling and had regular stools or suffered a little staining under conditions of stress and diarrhea. Three children had a small degree of persistent soiling, but did

Fig. 31.12 Technical details of gracilis transplantation. A Branches of the femoral nerve to the gracilis muscle in situ. B Additional vessel in the distal part of the muscle. Note damage to the nerve supply and an additional distal vessel will lead to atrophy and fibrosis of the muscle

L 30 ml 1000 jlV I

AR AT

DEFACATION

Fig. 31.13 Electromyography and electromanometry after gracilis muscle transplantation. Injection of 30 ml of air (L) into the rectosigmoid (RS), leading to a propulsisve wave in the rectum (R) and anorectum (AR). Defecation starts but is immediately interrupted by a vigorous contraction of the gracilis muscle. GR Electromyography of the gracilis muscle

AR AT

DEFACATION

Fig. 31.13 Electromyography and electromanometry after gracilis muscle transplantation. Injection of 30 ml of air (L) into the rectosigmoid (RS), leading to a propulsisve wave in the rectum (R) and anorectum (AR). Defecation starts but is immediately interrupted by a vigorous contraction of the gracilis muscle. GR Electromyography of the gracilis muscle not wear napkins. Nine patients remained completely incontinent. Manometrically, the anorectal pressure profile increased to values over 20 mmHg in 31 patients, and remained poor (under 15 mmHg) in 9 patients. The squeezing pressure profile increased to values higher than 20 mmHg in 38 children and remained poor (under 19 mmHg) in 2. The adaptation reaction was normal in 23 patients, remained shortened in 14, and was lacking in 3.

The increased pressure profile led to a maturation of the pulled-through colon, which acquired rectal qualities. During some years, however, the contractile force of the gracilis muscle diminished, probably because of atrophy of the muscle. Nevertheless these patients did not become incontinent, because in the meantime the pelvic floor muscles grew strong enough to balance the diminished anorectal resting pressure barrier. Holschneider's results are similar to those reported in the literature.

Recently, Kotobi et al. published their results with the Pickrell intervention in 23 children for anal incontinence secondary to ARM [33]. After a mean follow up of 6 years the functional result was estimated to be good in 25%, intermediate in 45% and poor in 30%.

Gracilis Muscle Transplant

Fig. 31.14 Squeeze pressure of 33 patients, 5 years after gracilis muscle transplantation surgery. In seven patients the maximal squeeze pressure dropped down again in this follow-up period after a primary increase in all transplanted children. From Holschneider [55] with permission of the publishers

Fig. 31.14 Squeeze pressure of 33 patients, 5 years after gracilis muscle transplantation surgery. In seven patients the maximal squeeze pressure dropped down again in this follow-up period after a primary increase in all transplanted children. From Holschneider [55] with permission of the publishers

Clinical improvement could therefore be obtained in 70% of the cases. This corresponds to our earlier experience.

Was this article helpful?

0 0
Staying Relaxed

Staying Relaxed

Start unlocking your hidden power with self hypnosis by relaxing and staying relaxed. This is just the audio you have been looking for to do just this.

Get My Free MP3 Audio


Responses

  • Lance
    Why gracilus is used in transplantation of any damaged muscle?
    2 years ago

Post a comment