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Transanal Resection, How to Avoid Fecal Incontinence

from the APSA 2010 Annual Meeting proceedings

TRANSANAL RESECTION, HOW TO AVOID FECAL INCONTINENCE

Author:
Alberto Pena, MD, Andrea Bischoff, MD, Marc A. Levitt, MD
Cincinnati Children Hospital, Cincinnati, OH, USA

Purpose:
Transanal resection of the rectosigmoid is a valuable technique applicable for Hirschsprungâs disease, non-manageable idiopathic constipation, and idiopathic rectal prolapse. However, it represents a risk of producing damage to the continence mechanism. A series of important technical steps are crucial to avoid damage to the anal canal and sphincters. These are shown in a short video.

Methods:
In operations designed to remove the rectosigmoid and pull-through a new portion of colon it is mandatory to preserve the patientâs continence mechanism. This is achieved by avoiding damage to the sphincter and preserving the anal canal for up to 2 centimeters above the pectinate line. Damage to the continent mechanism can result from inadvertently resecting part, or the entire anal canal, leaving the patient without sensation. In addition, the striated sphincter mechanism may be resected or overstretched.

Results:
Over a period of ten years, 13 patients from other institutions were referred suffering from fecal incontinence following a transanal rectosigmoid resection. An examination under anesthesia demonstrated that the anal canal was non-existent or seriously damaged. During the same period of time we have done 125 transanal resections of the rectosigmoid and have made every effort to preserve intact the continence mechanism. As a result, we developed a series of technical recommendations that include: a) use of a Lone-Star retractor, b) placing and then replacing the eight hooks deeper so that the pectinate line is protected and hidden, c) placing multiple fine sutures on the rectal wall to apply uniform traction, d) starting the resection two centimeters above the pectinate line, e) avoiding overstretching of the anus using a three point exposure technique (one narrow malleable, a forceps or suction tip, and rectum; forming a triangle).

Conclusions:
With these technical maneuvers a transanal rectal and rectosigmoid resection can be performed preserving the continence mechanism.

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