On the basis of anatomical and clinical studies on the vascular supply to the gracilis muscle, Williams advocated interruption of distal small arteries to the gracilis muscle 4 weeks before the muscle transposition to enhance the intramuscular anastomosis and prevent necrosis , but this is not considered mandatory by other Authors (like Baeten and Cav-ina) based on their large clinical experience.
The patient is placed in a modified Lloyd-Davis position with the dominant leg abducted and extended. The position of the thigh will be changed (adduct-ed) during the muscle wrapping around the anus to favour this manoeuvre. Under systemic antibiotic prophylaxis, after positioning the urinary catheter, the gracilis muscle is isolated by means of 2 or 3 longitudinal incisions on the medial surface of the thigh and the tendon is cut as distally as possible, at the medial shaft of the tibia. Attention should be paid to prevent damage of the main saphenous vein. The main vascular and nerve pedicle is carefully checked under the abductor longus muscle with the help of a disposable nerve stimulator. This procedure enables full mobilisation of the muscle which is then passed through a previously prepared subcutaneous tunnel between the perineum and the incision on the thigh (passing Scarpa's fascia) and around the anus through another tunnel created anteriorly and posteriorly with two lateral peri-anal incisions. Care should be taken at this stage to prevent any twisting of the muscle. The shape of the gracilis loop around the anus varies from an alpha to a gamma or epsilon configuration, depending on the length of the muscle and the surgeon's preference.
A "split sling technique" version of the electro-stimulated gracilis was proposed by Rosen et al.  to obtain an optimal muscle wrap around the anus. In this technique, the tendon of the gracilis is passed through the distal part of the muscle before its insertion into the ischial tuberosity.
The distal tendon is fixed to the medial side of the homolateral or controlateral ischiatic spine with 2-3 non-absorbable stitches using a J needle. Direct fixation to the skin is preferred by Cavina et al. . The thighs are kept adducted for at least 3 days after the procedure and antibiotic prophylaxis (metronida-zole+cephalosporin) can be continued for 3-5 days post-operatively.
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