带阴部神经吻合的动态股薄肌成形术用于肛门直肠重建的解剖学基础

Hikosaka Makoto, Yazawa Masaki, Sakuma Hisashi, Uchikawa Yumiko, Takayama Masayoshi, Kishi Kazuo

1 Department of Plastic and Reconstructive Surgery, National Center for Child Health and Development, Tokyo, Japan 2 Department of Plastic and Reconstructive Surgery, School of Medicine, Keio University, Tokyo, Japan 3 Department of Plastic and Reconstructive Surgery, Yokohama Municipal Hospital, Kanagawa, Japan 4 Department of Plastic and Reconstructive Surgery, Tachikawa Hospital, Tokyo, Japan 5 Department of Plastic and Reconstructive Surgery, Hiratsuka City Hospital, Kanagawa, Japan.

Dis Colon Rectum. 2015 Jan;58(1):104-8. doi: 10.1097/DCR.0000000000000268.

BACKGROUND

Dynamic graciloplasty has been proposed for anal reconstruction, but this method has 2 major drawbacks. First, an electrical device is required for control of the gracilis. The anastomosis with the pudendal nerve will provide more physiological control. Second, the limitation in the mobility of the muscle flap results in wrapping the anal canal with the muscle's distal portion, which is tendonlike and inelastic. Enhancing the mobility of the muscle flap will enable wrapping with the proximal, muscle-like, and extensible portion, possibly providing better sphincteric function. However, the basis for such an operative method is lacking.

OBJECTIVE

The aim of this study is to provide the basis for the refined method of anal sphincter reconstruction by dynamic graciloplasty with pudendal nerve anastomosis and to verify the feasibility of lengthening the nerve to the gracilis muscle flap by dissecting into the muscle belly, detaching the gracilis muscle from its origin, and enhancing the mobility of the muscle flap.

STUDY DESIGN

This is a retrospective, descriptive study.

METHODS

The results from the anatomical study on 9 cadavers are reported.

RESULTS

Tension-free anastomosis of the pudendal nerve and nerve to the gracilis was successfully performed in all the 9 cases: in 2 cases, by lengthening the nerve. The detachment of the muscle origin improved the mobility of the muscle flap, and the more proximal portion could be used for wrapping the anal canal, as confirmed in 4 cases.

LIMITATIONS

The limited number of cases was a shortcoming of this study.

CONCLUSIONS

By lengthening the nerve to the muscle, the gracilis can be used for anal sphincter reconstruction with pudendal nerve anastomosis, negating the need for an electrical device. By detaching the origin of the gracilis muscle, its proximal portion can be used to wrap the anal canal, possibly enabling a longer functional canal with stronger constricting force and better vascularity. These modifications to past methods may improve fecal continence after the operation.

背景

动态股薄肌成形术已被用于肛门重建，但该方法有两个主要缺点。第一，控制股薄肌需要一个电子装置。与阴部神经吻合将提供更符合生理的控制。第二，肌瓣活动度受限导致用肌瓣的远端部分包裹肛管，该部分呈腱样且无弹性。增加肌瓣的活动度将能够用近端的、类似肌肉且可伸展的部分进行包裹，可能提供更好的括约肌功能。然而，这种手术方法缺乏依据。