Anal incontinence is a prevalent condition affecting approximately 7% of women in the United States. Surgical management of anal incontinence has centered on anal sphincteroplasty, although recent studies indicate that long-term success rates with this approach are poor. The posterior pelvic support sling procedure is a novel approach to anal incontinence that provides support to the posterior anal rectum, recreating the natural sling of the puborectalis muscle. The procedure utilizes a trans-opterator approach for the sling arms in a manner similar to the trans-opterator suburethral sling for urinary incontinence. The procedure may be performed under local, regional, or general anesthesia, although an anesthetic and hemostatic solution is always injected into the medial thigh, as well as between the anus and coccyx. A betadine soak sponge has been placed in the rectum to prevent contamination of the surgical site. An anesthetic solution is injected into the ischiorectal fossa, lateral to the levator ani muscles. Two stab incisions are made in the buttocks approximately 1.5 cm lateral and 3 cm inferior to the anus, and a curved clamp is used to create a tunnel between the incisions with an over-gloved finger in the rectum to guide the dissection. The clamp is used to grasp the connector that is attached to a Type I polypropylene mesh, and the wide belly of the mesh is drawn into the tunnel and positioned under the anorectum. A curved introducer needle is inserted through a stab incision in the medial thigh at the level of the urethra, and the needle is placed into the ischiorectal fossa, lateral to the levator ani muscles, guiding the tip of the needle at first with the surgeon's hand in the vagina, and then by palpating the tip by pushing up on the buttock incision. After the needle tip exits the buttock incision, the connector is snapped onto the needle and the needle is withdrawn through the ischiorectal fossa to the thigh incision. The procedure is repeated on the opposite side, which creates a synthetic sling posterior to the anorectum. The forceps are used to prevent puckering, and vigorous irrigation is performed at the buttock incisions. At this point, the buttock incisions are closed with interrupted 3-0 absorbable sutures. Adjustment of the sling is performed with the surgeon's finger placed in the rectum. The sling arms are elevated until minimum tension is felt posterior to the rectum. At this point, the plastic sleeves are removed and the excess mesh is cut at the level of the skin. The medial thigh incisions are also closed with absorbable suture. Patients are maintained on a high-fiber diet with stool softeners for 2 months after surgery. Although long-term follow-up is needed, our initial results with this procedure are encouraging. The posterior pelvic support sling procedure may offer patients a minimally invasive and effective long-term treatment of this socially and medically debilitating problem.

anal incontinence

surgical management

anal sphincteroplasty

posterior pelvic support sling procedure

puborectalis muscle