In all patients who need a sacroperineal or sacroab-dominoperineal reexploration and levator repair, magnetic resonance imaging (MRI) and a cinedefe-cography should be performed before the secondary repair. Prior to intended repair, defecography indicates whether there is complete or partial loss of ano-rectal angulation and movement so that the incontinence is indeed due to muscle inaction rather than to some simply correctable factor such as constipation.
MRI is able to show the presence of muscular damage or hypoplasia and the wrong position of the pulled-down rectum.
For reconstruction, we usually use the technique of Stephens and Smith , which is basically a sacro-perineal exposure of the entire muscle complex, as shown in Figs. 31.1 and 31.2. The purpose of the operation is to place the rectum so that it lies adjacent to the urethra or vagina, with the levator muscles drawn together behind it. The most anterior muscle bundles are approximated in the midline as far anteriorly as possible, preferably indenting the rectum to the point of occlusion.
The age of these patients is usually 3 years or older, and for this reason it is deemed unnecessary to perform a preliminary colostomy. The pelvis and the levator muscles are larger in these patients than in the newborn and are larger compared with the size of the collapsed rectum, which is tucked up anteriorly against the urethra or vagina. Needless to say, the bowel should be empty. The patient is anesthetized, a bladder catheter is passed into the urethra, and the patient is turned into the jackknife position. A gauze with Betadine is inserted into the anal canal. A natal cleft incision is made from sacrum to anus, which is encircled by a circumferential racket extension. The incision is deepened in the midline through the fat using a muscle stimulator to identify muscle as it comes into view. It is possible to detect the activity and direction of muscle pull and thus incise the pelvic diaphragm as close to the raphe as possible. The coccyx should be split or excised and the supralevator space dissected up under the tip of the sacrum. It is then possible to separate the tissues from the rectum from above down, within and outside the supralevator space. In this way, the pelvic diaphragm is laid open, the rectum is isolated from the levator muscles, and the route that the rectum has taken can be identified.
The nerves to the levator muscles pass from the lateral pelvic wall toward the midline on or in the substance of the levator muscle. Midline operations with expansion of the window thus created should not impair these nerves. It may be necessary at this juncture to insert a metal obturator or gloved finger into the rectum to facilitate isolation of the wall from the surrounding very adherent fibrous and muscular tissues.
The rectum and anus are cleared and thoroughly mobilized from the pelvis and perineum, and replaced in a collapsed and empty state, with the gauze removed, against the urethra or vagina, and the leva-tor muscle, ragged and barely recognizable, partly obscured by fat and fascia, is sutured in the midline as far anteriorly as possible to the indent or, if possible, to occlude temporarily the rectal lumen and thus heal in this position. The remainder of the diaphragm and the fat of the perineum are approximated, and the anus, divested of any cutaneous cuff still adhering to the wall of the rectum, is restored in its original site.
A drain tube is brought out of the incision in the vicinity of the coccyx. A rectal tube is then passed into the rectum through the indented zone and is left in place for several days. Regular saline irrigations of the rectum are recommended to deflate the lumen and wash away fecal matter as it accumulates. The tube may be removed on the 4th day. To reduce residue, the patient should be given fluids by the intravenous route and only water by mouth for at least 3-4 days, and longer if tolerated after surgery. A low-residue diet is continued for 1-2 weeks postoperatively.
At 10 days postoperatively, gentle dilatation of the indented zone of the rectum is then performed daily with the surgeon's or parent's finger until the sling is softened and agile. This may take several weeks.
In a paper describing 29 secondary operations, with "acceptable" continence in three-quarters of the patients, Kiesewetter and Jeffries  described the advantages of the sacral route in revision repairs. Furthermore, it is interesting to note the similarity of this reconstruction to that of Pena's PSARP , even to the use of a muscle stimulator.
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