ISSN: 2754-8880
Published 00 11 0000
OPEN ACCESS
Edited by
A.Hussain
Submitted 1 July. 2024
Accepted 5 June. 2025
Citation
K Khairuddin, N Afdzillah, D
Melissa, N Azmi, S
Balaganapati. Gracilis
Muscle Neosphincter As A
Surgical Management of
Traumatic Fecal
Incontinence.Editorial
article:BJOSS::2025:(5);149-
152
Gracilis Muscle Neosphincter As A Surgical
Management of Traumatic Fecal Incontinence
K Khairuddin
1*
, N Afdzillah
1
, D Melissa
1
, N Azmi
1
, and S Balaganapati
1
1
Department Of General Surgery, Universiti Kebangsaan Malaysia, KualaLumpur, Malaysia
*
Correspondence author : Khairul Farhan Khairuddin; aan89charlie@gmail.com
O R IGI N A L
Abstract
Faecal incontinence after obstetric trauma is a distressing condition that profoundly impacts pa-
tients’ daily lives. Traditional management approaches often fail to provide satisfactory outcomes,
particularly in cases where the anal sphincter complex is compromised. This abstract summarizes
the challenges and advancements in managing faecal incontinence following obstetric trauma,
highlighting the importance of a multidisciplinary approach involving surgical interventions. We
present a case of a young lady who suffered from faecal incontinence after a traumatic delivery
and opted for corrective surgery as a treatment option for faecal incontinence post-obstetric
trauma. Additionally, we discuss the role of gracilis muscle neo-sphincter reconstruction as a
promising surgical technique in restoring faecal continence in refractory cases. Through a re-
view of pertinent literature and illustrative case reports, we emphasize the importance of early
diagnosis, individualized treatment strategies, and ongoing research efforts aimed at enhancing
outcomes and improving the quality of life for affected individuals.
Introduction
The reported occurrence of faecal incontinence due to overt obstetric anal sphincter injuries
across European countries varies from 0.6 to 4.2% (
1
). Secondary repair of sphincter defects
following obstetric trauma typically yields short-term success rates ranging between 64 and 80%
(
2
;
3
;
4
). Addressing faecal incontinence requires a multidisciplinary approach, wherein surgical
intervention is one of several therapeutic avenues. Neo-sphincter reconstructions are viable
options for individuals who exhibit inadequate improvement with conservative treatments or
have previously experienced unsuccessful sphincter repair attempts. In cases where a substantial
portion of the native sphincter is lost due to trauma, neo-sphincter reconstruction may be
considered as a primary procedure. The utilization of gracilis muscle neo-sphincter creation for
managing obstetric perineal injuries offers numerous potential advantages, primarily focused on
reinstating anal sphincter function to alleviate faecal incontinence resulting from such injuries (
5
).
By significantly enhancing patients’ bowel control, this surgical intervention provides a tangible
improvement in continence, thereby contributing to an enhanced quality of life for women
affected by obstetric perineal injuries. The gracilis muscle transposition technique was originally
introduced by Pickrell et al (
6
). This innovative approach to sphincter substitution was initially
applied to 12 children, predominantly afflicted with congenital causes of incontinence such
as spina bifida, meningocele, or neurogenic malformations affecting the perineum and rectum.
Graciloplasty entails detaching the gracilis muscle from its distal attachment to the tibia and
fashioning it into a muscle wrap around the native or artificially constructed anal canal, configured
in an
α
,
ε
, or
γ
arrangement, with the gracilis tendon affixed to one of the ischial tuberosities.
This technique offers a degree of mechanical obstruction, primarily addressing the retaining
component of continence. Moreover, long-term follow-up studies conducted by Leguit et al(
7
)
demonstrated improved continence outcomes in a series of patients who underwent gracilis
muscle transposition.
(a) (b)
Figure 1. Intra-Operative Clinical Picture - Before (Left) ; After Repair (Right).
(a) (b)
Figure 2. Post-Operative Picture - Perineal Scar (Left) ; Left Thigh Scar (Right)
Case Presentation
A 37-year-old woman suffered from faecal incontinence persisting for three years following a
traumatic obstetric delivery attended by an uncertified midwife. The delivery resulted in a grade
4 perineal injury affecting her sphincters. Although an initial surgical repair of the sphincter
was performed, she was subsequently lost to follow-up. Nearly three years elapsed before
she resumed follow-up care. Endoanal ultrasound revealed distortion of the chronic sphincter
muscle complex. She underwent sphincter reconstruction with a gracilis muscle transposition flap.
Intraoperatively, it was observed that the perineal body was absent, along with a complete absence
of the sphincter complex anteriorly. Additionally, a contracted sphincter complex was identified
at the 3 and 9 o’clock positions, respectively. She was discharged well post-operatively. During
subsequent serial follow-up appointments, the patient demonstrated significant improvement in
her continence status. Through diligent monitoring and supportive care, she gradually regained
control over her bowel movements, achieving a notable enhancement in her quality of life.
Discussion
Gracilis muscle transposition, also known as graciloplasty or gracilis neo-sphincter reconstruction,
constitutes a crucial surgical intervention in the comprehensive management of traumatic faecal
150/152
incontinence. This procedure, indicated for patients with sphincter dysfunction resulting from
obstetric trauma, pelvic injuries, or failed sphincter repair surgeries, involves harvesting the gracilis
muscle from the inner thigh and fashioning it into a neo-sphincter around the anal canal. Through
meticulous surgical technique, including careful preservation of neurovascular structures during
muscle harvest and precise placement around the anal canal, the gracilis muscle serves to restore
continence in individuals plagued by refractory faecal incontinence.
Preoperative evaluation, encompassing clinical assessment, imaging studies, and functional tests,
facilitates appropriate patient selection and surgical planning. Postoperatively, patients undergo
comprehensive monitoring to assess outcomes and manage potential complications. The efficacy
of gracilis muscle transposition in restoring faecal continence and improving quality of life has been
well-documented, with significant reductions in incontinence episodes and sustained benefits
observed in long-term follow-up studies.
However, the procedure is not devoid of risks, as potential complications such as infection, wound
dehiscence, and donor site morbidity necessitate vigilant postoperative care and management.
Furthermore, the success of gracilis muscle transposition hinges on various factors, including
patient selection, surgical technique, and adherence to postoperative protocols.
In general, gracilis muscle transposition stands as a valuable component of the surgical armamen-
tarium for traumatic faecal incontinence, offering hope for patients grappling with the profound
impact of sphincter dysfunction on their daily lives. Through continued advancements in surgical
techniques, patient selection criteria, and postoperative care protocols, the field strives to op-
timize outcomes and enhance the overall efficacy of neo-sphincter reconstruction in restoring
continence and improving the quality of life for affected individuals.
Conclusion
This successful outcome underscores the effectiveness of gracilis muscle transposition flap surgery
in addressing complex cases of faecal incontinence, highlighting the importance of meticulous
surgical techniques and comprehensive postoperative management in achieving favourable patient
outcomes.
Conflict Of Interest
Author declare no conflict of interest and no funding for this study.
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