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A biomechanically based concept for a stronger obstetric anal sphincter repair

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Abstract

Introduction and hypothesis

This study emanates from the ISPP OASIS and fecal incontinence study group at the 2018 annual meeting of the International Society for Pelviperineology (ISPP) in Bucharest, Romania. The aim was to analyze the biomechanical factors leading to the breakdown of anal sphincter repair and to suggest a more robust technique for external anal sphincter (EAS) repair.

Methods

Our starting point was what happens to the EAS wound repair site during defecation following EAS repair, with special reference to the process of wound healing.

Results

We concluded that a graft no more than 1 × 1.5 cm sutured across the EAS tear line would mechanically support the tear line, vastly reduce the internal centrifugal forces acting on it during defecation, thereby giving the wound time to heal. Three different grafts were discussed, autologous, biological, and mesh. Also analyzed were the effects on EAS muscle contractility of overly tight repair and overly loose sphincter repair, the latter occasioned by the tearing out of sutures and repair by secondary intention.

Conclusions

We have analyzed causes of sphincter repair failure, introduced a graft method, preferably autologous, for the prevention thereof and supported ultrasound assessment, rather than the absence of fecal incontinence as the criterion for success of EAS repair. Although based on well-established biomechanical principles, our proposal at this stage remains unproven. Our hope is that these concepts will be challenged, clarified, and tested, preferably in a randomized controlled trial.

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References

  1. Beale RM, Petros PE. Passive management of labour may predispose to anal sphincter injury. Int Urogynecol J. https://doi.org/10.1007/s00192-019-04183-6.

  2. Pinta TM, Kylanpaa ML, Salmi TK, Teramo KA, Luukkonen PS. Primary sphincter repair: are the results of the operation good enough? Dis Colon Rectum. 47:18–23.

  3. Sultan AH, Thakar R. Posterior compartment disorders and management of acute anal sphincter trauma. In: Santoro GA, Wieczorek AP, Bartram CI, editors. Pelvic floor disorders. Milan: Springer; 2010.

    Google Scholar 

  4. Oliva F, Via AG, Kiritsi O, Foti C, Maffulli N. Surgical repair of muscle laceration: biomechanical properties at 6 years follow-up. Muscles Ligaments Tendons J. 2013;3(4):313–7.

    Article  PubMed  Google Scholar 

  5. Gordon AM, Huxley AF, Julian FJ. The variation in isometric tension with sarcomere length in vertebrate muscle fibres. J Physiol. 1966 May;184(1):170–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Douglas DM. The healing of aponeurotic incisions. Br J Surg. 1952;40:79–84.

    Article  CAS  PubMed  Google Scholar 

  7. Kragh JF Jr, Svoboda SJ, Wenke JC, Ward JA, Walters TJ. Epimysium and perimysium in suturing in skeletal muscle lacerations. J Trauma. 2005;59:209–12.

    Article  PubMed  Google Scholar 

  8. Yamada H. Aging rate for the strength of human organs and tissues. In: Evans FG, editors. Strength of biological materials. Baltimore: Williams & Wilkins;1970. p. 272–280.

    Google Scholar 

  9. Wagenlehner F, Andrei Muller-Funogea I-A, Perletti G, Abendstein B, Goeschen K, Inoue H, et al. Vaginal apical prolapse repair using two different sling techniques improves chronic pelvic pain, urgency and nocturia—a multicentre study of 1420 patients. Pelviperineology. 2016;35:99–104.

    Google Scholar 

  10. Abdool Z, Sultan AH, Thakar R. Ultrasound imaging of the anal sphincter complex: a review. Br J Radiol. 2012;85(1015):865–75. https://doi.org/10.1259/bjr/27314678.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Petros PE, Swash MA. The musculoelastic theory of anorectal function and dysfunction in the female. J Pelviperineol. 2008;27:89–93.

    Google Scholar 

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Authors and Affiliations

  1. School of Mechanical and Biomechanical Engineering, University of Western Australia, Perth, Australia

    Peter Petros

  2. Department of Obstetrics and Gynecology, Muğla Sitki Kocman University, Mugla, Turkey

    Akin Sivaslioglu

  3. Department of Obstetrics and Gynecology, University of Bucharest, Bucharest, Romania

    Elvira Bratila & Petre Bratila

  4. Department of Obstetrics and Gynecology, Landeskrankenhaus Feldkirch, Feldkirch, Austria

    Burghard Abendstein

Authors
  1. Peter Petros
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  2. Akin Sivaslioglu
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  3. Elvira Bratila
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  4. Petre Bratila
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  5. Burghard Abendstein
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Contributions

All authors: conceptualization, planning, writing; P.P.: figures.

Corresponding author

Correspondence to Peter Petros.

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From the International Society for Pelviperineology (ISPP) OASIS and fecal incontinence study group

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Petros, P., Sivaslioglu, A., Bratila, E. et al. A biomechanically based concept for a stronger obstetric anal sphincter repair. Int Urogynecol J 31, 2399–2403 (2020). https://doi.org/10.1007/s00192-020-04350-0

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  • DOI: https://doi.org/10.1007/s00192-020-04350-0

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