Colorectal

Sphincteroplasty (Post-Obstetric External Anal Sphincter Repair)

OPERATION: Anterior Sphincteroplasty with Levatorplasty — Post-Obstetric External Anal Sphincter Injury
ANAESTHETIC: General / spinal anaesthesia
POSITION: Prone jack-knife / lithotomy. Urinary catheter inserted.

INDICATION:
Faecal incontinence secondary to obstetric external anal sphincter injury. [3rd / 4th degree perineal tear]. Symptoms: [faecal urgency / incontinence to liquid / solid stool / flatus]. Wexner / St Mark's incontinence score: [value]. Preoperative investigations: endoanal USS — [anterior sphincter defect size, IAS status], anorectal manometry — [squeeze pressure, resting pressure], pudendal nerve terminal motor latency — [bilateral results]. Informed consent including discussion of limitations and realistic expectations.

PROCEDURE:
WHO Checklist performed. Perineum prepared and draped. Examination under anaesthesia confirmed anterior sphincter defect.

Transverse perineal incision overlying the defect, extended laterally to define the ends of the divided sphincter. Dissection deepened through scar tissue. Ends of the external anal sphincter identified — scarred fibromuscular tissue preserved as it improves suture holding. Both ends of the divided external sphincter mobilised sufficiently to allow tension-free approximation.

[LEVATORPLASTY: Levator ani muscles identified on each side. Approximated in the midline anterior to the rectum with two or three 0-Vicryl interrupted sutures to reconstruct the perineal body and narrow the hiatus.]

SPHINCTEROPLASTY: Overlapping repair performed — one end of the sphincter pulled over the other and secured with horizontal mattress sutures of 2-0 Prolene / PDS, incorporating the scar tissue in both passes. [3–4 sutures placed]. All sutures placed before tying. Tied without excessive tension.

[Perineal body reconstructed with interrupted absorbable sutures to the perineal musculature.]

Skin closed with interrupted absorbable sutures. [Wound partially left open posteriorly for drainage.] Dressing applied.

FINDINGS:
Anterior external anal sphincter defect [size / extent] confirmed. Muscle ends identified and mobilised. Overlapping repair performed. Levatorplasty [performed / not required]. Sphincter ring confirmed complete on digital examination at completion.

EBL: Minimal. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Urinary catheter retained for [24–48 hours]. Low-residue diet for 5 days. Stool softeners. Pelvic floor physiotherapy at 6 weeks. Continence assessment at 3 and 12 months. Counsel re: future obstetric delivery — elective caesarean section recommended.