Kottmeier  and coworkers [9,10] described an operation to gain increased effectiveness of the leva-tor ani in secondary repair. An attempt was made to improve fecal continence through the utilization of salvageable remnants of the levator sling through: (1) enhancement of the motor function by increasing the anterior shutter action of the levator muscle, and (2) increasing the area of sensory perception of the leva-tor by enlarging the levator sling through a posterior release and plication (Fig. 31.4).
With the patient in either a lateral position with knees flexed or a jackknife position, the perineum is opened through a posterior midline incision or through an inverted chevron incision. The coccygeal attachment of the levator muscle is transected, and the dissection is carried into the presacral space. The rectum or the pulled-through intestine is freed from its presacral attachment and pushed anteriorly. This maneuver will reveal the levator sling with its upper components, the ileococcygeal and pubococcygeal muscles. The ileococcygeal muscle is split sharply in a horizontal plane parallel to its fibers. The entire leva-tor sling, consisting of ileococcygeal, pubococcygeal, and if present, puborectalis muscle, is then liberated from its posterior attachment. A finger is placed into the rectum, and the levator sling is then snugly tightened around the rectum with interrupted nonabsorb-able sutures to achieve an acute anterior angulation. The presacral space is irrigated with saline and Beta-dine and closed with multiple interrupted absorbable sutures. The skin is closed with sutures. Drainage of the presacral space is not necessary.
Follow-up examination of 18 patients with a leva-torplasty for incontinence following repair of ARM showed that complete restoration of continence occurred in 8 children, 6 improved, and gross incontinence persisted in 4 children . Kottmeier later reported [see 4] 35 children in whom this procedure was performed, with similar results.
It is remarkable that the nerve supply to the levator is not divided in this procedure; nevertheless, the ac companying radiographs show forward and backward movement of the muscle, with a considerable shutter effect on the rectal lumen. Gross  also described a similar procedure.
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