Levator Plate Research Articles

Jeddah Experience in the Management of High Anal Fistula

Twenty-six (26) transsphincteric anal fistulate with secondary high extension and sixteen (16) suprasphincteric anal fistulate with secondary high extensions have been treated successfully over a period of 3 years. The operative technique depends on exploration of the intersphincteric plane with removal of the primary source of the infection, together with excision of the primary tract, and drainage of he secondary high extensions. The patients have been followed for 2 years without recurrence. Continence for flatus and liquid feces was 92.1% and 96.15%, respectively, in the transsphincteric and 75% and 93.75%, respectively, in the suprasphincteric group but the continence for solid feces was 100% in both. Thus, the so-called excision technique for treatment of high fistula is safe and results are excellent.

Anatomy of Anal Sphincters and Related Structures in Continent Women Studied With Magnetic Resonance Imaging

Five anally continent nulliparas of reproductive age were studied with magnetic resonance imaging. The internal and external anal sphincters could be easily delineated, as could the intervening longitudinal musculature, puborectalis muscle, anococcygeal raphe, anorectal lumen, vagina, uterus, bladder, urethra, coccyx, and pubis. The shape of the sphincters was nearly cylindrical, with an anterior component averaging 18.3 mm thick and 28.0 mm long. Fifty-four percent of this anterior thickness was attributable to the internal sphincter. The anorectal angle varied considerably, with a mean of 86.8 +/- 19.1 degrees (range 60-112). The angle between the portion of the rectal lumen supported by the anococcygeal raphe, or levator plate, and the plane of the puborectalis muscle was consistent at 149.0 +/- 6.3 degrees (138-154). The finding of anterior anal sphincters with substantial thickness and length contrasts markedly with a view often pictured in the literature of a female anal sphincter that narrows anteriorly to half its posterior length and forms a small bundle of muscle rather than a broad band. Knowledge of these relationships is important in primary repair of obstetric sphincter lacerations as well as in surgical correction of anal incontinence.

Female stress urinary incontinence and the pelvic floor

Damage to the pelvic floor muscles leads to an altered relationship of the uterus and the urethrovesical unit to the levator plate and creates conditions predisposing to pelvic relaxation associated with stress incontinence. Morphological changes of pelvic floor muscles are age dependent and associated with deterioration of the urethral closure mechanism. Urodynamic assessment and knowledge of the morphology of pelvic floor muscles improves the understanding of pelvic floor function as it relates to the support of the pelvic viscera and the urethral mechanism that maintains continence of urine.

THE TETHERED VAGINA SYNDROME, POST SURGICAL INCONTINENCE AND I‐PLASTY OPERATION FOR CURE

Urinary incontinence was observed in 19 patients after bladder neck elevation or vaginal repair operations. Characteristically, patients could not suppress their urge to micturate on getting up in the morning, and they wet before arrival at the toilet. Urodynamically, a high posterior cough transmission ratio was noted. A 1.5 cm longitudinal incision in the vagina, dissected free and resutured horizontally (I-plasty), immediately cured this particular condition, but ultimately failed in 1/3 cases. Most of these failed patients were subsequently cured by further adjustment of vaginal tension under local anaesthesia (Tuck procedure). These findings confirm the emphasis given by the Integral Theory of Female Urinary Incontinence as to maintain adequate elasticity in the zone of critical elasticity (ZCE) of the supralevator vagina. The ZCE acts as an elastic hinge, allowing (i.e. facilitates) the separate and opposite contractile forces of anterior pubococcygeus, and levator plate which are necessary to close off urethra and bladder neck respectively. Inadequate elasticity at the ZCE converts the ZCE's role from facilitation to opposition. The stronger levator muscle contraction counteracts the forward section of the weaker anterior part of pubococcygeus muscle, preventing bladder neck closure.

The levator ani muscle and the nerve supply of its puborectalis component

AbstractThis study of 50 embalmed and 4 unembalmed cadavers was undertaken to try to better understand the rationale for the varied descriptions of the levator ani muscle and its components. Our findings are in harmony with those which have determined M. puborectalis to be the caudal component of the levator ani and to have superior and inferior laminae. The inferior lamina contributes significantly to the mass of the puborectalis, forming the major part of its so‐called sling component that angulates the anorectal junction. The more superficial of the anterior fibers of both the M. pubococcygeus and M. puborectalis insert prerectally and contribute to what is called M. levator prostatae (pubovaginalis). Their fused borders bound the levator (urogenital) hiatus. The deeper fibers insert into the posterolateral wall of the vagina in the female. Both M. pubococcygeus and M. puborectalis also insert between the Ms. sphincter ani externus and internus, and both contribute to the postanal levator plate. The nerve supply of M. puborectalis is from the nerve to the levator ani (S 3,4) on its superior aspect, but it frequently receives an auxiliary supply from the inferior rectal and perineal branches of the pudendal nerve on its inferior aspect. The surgical significance of M. levator ani is commented on.

Pararectal Abscess with Pelvic Extension Simulating Gynecological Disease

An anal fistula sometimes takes a high intersphincteric course eventually forming a pelvic extension, with abscess formation above the levator plate. Such a case, simulating gynecological disease, is presented and the differential diagnostic procedures are discussed.

Retrorectal levatorplasty with colporrhaphy.

There is an uncommon type of genital prolapse characterized by descent of the anus and rectum and sagging of the normally horizontal levator plate. When this is associated with long-standing severe constipation and marked decrease in the diameter of the stool while straining, retrorectal levatorplasty with colporrhaphy may be curative.

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. VIII. Levator hiatus and tunnel: anatomy and function.

The anatomy of the levator hiatus and tunnel has been studied, aiming at the elucidation of their functional role in mechanisms of defecation, urination, and continence. The material comprised 25 cadavers studied by dissection and serial histologic sections. The levator hiatus occupies the anterior portion of the levator plate which consists of two "crura," that bound the hiatus, and two "lateral masses." Three crural patterns could be identified: classic, crural overlap and crural scissor. The levator tunnel is a muscular tube which surrounds the intrahiatal organs along their way down from the levator hiatius to the perineum. It is double sheathed, with an inner coat of the suspensory sling and an outer of the puborectalis. Both coats are of striped muscle bundles. The inner coat is a tunnel "dilator," whereas the outer is a tunnel "constrictor." The puborectalis not only acts as a "common tunnel" sphincter but provides an "individual" sphincter for each intrahiatal organ. A detailed study of the hiatal ligament which firmly binds the levator plate to the intrahiatal organs is presented. A "tunnel septum" could be identified to line the levator tunnel, and separate it from the intrahiatal organs. Its surgical significance as a landmark for mobilizing the intrahiatal organs from within the tunnel is stressed. The levator plate consists of two functionally separate zones: a lateral "visceral support" zone and medial "dilator" one. The double sphincteric control provided to each intrahiatal organ by the "individual" and "common" sphincters would suggest that unless both sphincters are destroyed, continence could be maintained by either. The role of the "levator complex" which comprises levator crura, tunnel and hiatal ligament in fixation of intrahiatal structures, as well as in mechanisms of defecation, urination, and continence, is discussed. The understanding of the anatomic details of the levator hiatus and tunnel could be of value in mobilizing the intrahiatal structures from within the levator tunnel with preservation of their voluntary sphincteric mechanism.

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. VII. Anal fistula: a simplified classification.

The pathology of anal fistulas was studied in 300 patients and a simple classification is put forward. Two main types of fistula are recognized: intrasphincteric and extrasphincteric, according to the relation of the track to the external sphincter. All fistulas start as a central space infection which either remains confined to the intrasphincteric compartment or spreads extrasphincterically. Intrasphincteric fistulas include both central and intersphincteric fistulas. The latter fistula, as well as the extrasphincteric, are either low or high according to the relation of the track to the levator plate. The classification is simple and practical. It clearly demonstrates the precise anatomic position of fistulas as related to anal musculature so proper planning for the treatment can be safely achieved.