https://www.youtube.com/watch?v=hiiTz__xU9A&ab_channel=KarenZaghiyan%2CMD%2CFACS%2CFASCRS
- Indications
- Used for faecal incontinence that has not responded to conservative measures such as dietary changes, medications, and pelvic floor physiotherapy.
- Most effective when the sphincter is structurally intact but functionally weak.
- Suitable for patients with post-obstetric nerve injury or idiopathic incontinence.
- Contraindications
- Not suitable if the sphincter is completely destroyed — a primary repair may be needed first.
- Contraindicated in active infections or in patients unable to attend follow-up or operate the device.
- Relative contraindication in pregnancy, as the device is turned off during gestation.
- Caution in patients with spinal deformity or bleeding disorders.
- Mechanism of Action
- Stimulates the sacral nerve roots, usually S3, to modulate reflex arcs.
- Enhances external anal sphincter tone and rectal sensation.
- Can improve coordination of pelvic floor muscles and modulate colonic motility
- Pre-Procedure Preparation
- Assess continence severity using symptom scores and diaries.
- Perform anorectal physiology and endoanal ultrasound to assess sphincter integrity.
- A staged approach is used — the first stage is a trial stimulation to assess response.
- Informed consent is obtained, highlighting the stepwise process and risks.
- Equipment
- Includes a foramen needle, test or tined lead, implantable pulse generator, and a programmer.
- Fluoroscopy may be used for accurate placement of the lead.
- Sterile surgical instruments and local anaesthetic.
- Stage 1: Trial Lead Placement
- Patient is positioned prone or in a modified jack-knife position.
- S3 foramen is identified using landmarks or fluoroscopic guidance.
- A needle is inserted into S3 and a test lead is advanced through it.
- Correct positioning confirmed by bellows response, toe flexion, and anal contraction.
- The lead is secured externally (temporary) or internally (tined) and connected to an external stimulator.
- The patient undergoes a trial period (typically 1–2 weeks) to assess symptom improvement.
- A response is considered successful if there is more than 50% improvement in incontinence episodes.
- Stage 2: Permanent Implantation
- If the trial is successful, the patient proceeds to permanent implantation.
- The permanent pulse generator is implanted in a subcutaneous pocket in the buttock or flank.
- The lead is tunneled subcutaneously and connected to the generator.
- Intraoperative testing confirms function, and the system is programmed post-op.
- Post-Procedure Care
- Patients are monitored for wound healing and pain control.
- Instructions given for care of incisions and use of the remote control device.
- Follow-up includes reprogramming and adjustment of parameters as needed.
- Patients are usually reviewed at 2–4 weeks and then at regular intervals.
- Complications
- Common issues include local pain, lead migration, or infection.
- Some patients experience loss of effect over time or require reprogramming.
- Rare complications include nerve irritation or tissue erosion.