Anal Encirclement Procedure

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In 1891, Thiersch initially described encirclement of the anus with silver wire for treatment of incontinence and rectal prolapse.5'6 It was hoped that the wire would produce an area of fibrosis around the anus that would act as a passive support for the pelvic floor (Fig. 20.1). Unfortunately, not only did the wire fail to provoke the desired fibrosis, but it also produced unwanted complications, including ulceration, erosion, breakage, and fecal impaction.

Surgeons have attempted to modify the encirclement technique by using other materials including fascia, tendon, nylon, polypropylene mesh, Mersilene®, and Teflon®. These materials have shown less of a tendency to break and have had fewer complications than were noted with the silver wire.

The disadvantage of encirclement procedures is that, in most cases, the ring is placed in the

Figure 20.1. Anal encirclement. Also known as the Thiersch procedure, this operation has been performed with the use of many types of material. Note that the ring is placed in the subcutaneous (perianal) tissue and offers no support to the levators. (From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771-832, with permission from Elsevier.)

Figure 20.1. Anal encirclement. Also known as the Thiersch procedure, this operation has been performed with the use of many types of material. Note that the ring is placed in the subcutaneous (perianal) tissue and offers no support to the levators. (From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771-832, with permission from Elsevier.)

Figure 20.2. Notaras variation of the Thiersch procedure. The ring of foreign material is placed around the anorectal musculature at the level of the puborectalis muscle,thus supporting both the anorectal angle and the anal canal. (From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771-832, with permission from Elsevier.)

Figure 20.2. Notaras variation of the Thiersch procedure. The ring of foreign material is placed around the anorectal musculature at the level of the puborectalis muscle,thus supporting both the anorectal angle and the anal canal. (From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771-832, with permission from Elsevier.)

subcutaneous space and does not support the levators. As a result, this technique does not cure prolapse; it merely hides it away from view and should be regarded as a palliative procedure. The advantage of encirclement procedures is that they can be performed under local or spinal anesthesia and they have minimal impact on even the poorest risk patient. The disadvantage is that if the rectum prolapses through the ring, it may incarcerate necessitating an emergency operation.

Notaras7 described one interesting variation of the Thiersch anal encirclement procedure (Fig. 20.2). In this variation, a ribbon of polypropylene mesh is placed around the rectum at the level of the puborectalis. The goal of this procedure is to support both the anorectal angle and the anal canal. Due to the more extensive dissection that was required with this technique, general anesthesia is often required. Limited information is available about recurrence rates with this technique.

One other unusual technique used an Angelchik prosthesis to encircle the distal rectum; this device was at one point in time popular for the treatment of esophageal reflux.8 The technique is no longer performed, because the device was withdrawn from the market when it fell into disfavor due to complications. The device was placed above the levators in a series of eight elderly patients with rectal prolapse. With the exception of this one nuance, it was similar to other encirclement procedures. Results showed one death on postoperative day 10 due to a stroke, and one patient with pelvic sepsis in whom the prosthesis was removed. There were no reports of recurrence, morbidity, or mortality in the six remaining patients.

Another version of anal encirclement is the Gant-Miwa procedure, which has been described in Japan. In this procedure, an absorbable suture is used to create dozens of tags of mucosa and submucosa on the surface of the prolapsed rectum. The rectum is then returned to its normal anatomic position and a nonabsorbable purse-string suture is placed around the anus. A recent review of this procedure lists low complication and recurrence rates, although it is not widely practiced outside of Japan.9

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