AU2013201412A1 - Method of treating anal incontinence - Google Patents

Abstract

METHOD OF TREATING ANAL INCONTINENCE A method for treating anal incontinence is provided, in which a support member (1) is implanted in a tissue pathway (10) extending from a first location (1Ob) posterior to and adjacent the anus (102), through the perineum (103) anterior to the anus (102) and terminating at a location (1Ob) posterior to and adjacent the anus (102) opposite the first location (1 Oa).

Description

METHOD OF TREATING ANAL INCONTINENCE Field of the Invention The present invention relates to the field of anogential surgery. Background of the Invention Mild anal incontinence, which may present as flatal incontinence and/or mild faecal incontinence, often results from anal sphincter muscle damage that may be associated with damage at childbirth and/or deterioration of the sphincter muscle with age. Patients exhibiting mild anal incontinence resulting from childbirth also often present with pelvic organ prolapse, particularly posterior vaginal wall prolapse, which may result in a descent of the rectum into the vagina, often termed a "rectocele". One current method of treating mild anal incontinence is formal dissection and identification of the external anal sphincter muscle bundle and repair with either end-to-end muscle fibres. This procedure however, is a relatively invasive procedure involving a significant amount of tissue dissection. Significant post-operative pain and relatively lengthy hospital stays are also generally associated with the procedure. An alternate procedure for treating mild anal incontinence is by the injection of bulking agents into deficient or damaged sphincter muscle tissue. This procedure however, is typically of limited effectiveness with generally low success rates and relatively high reoccurrence rates. Object of the Invention It is an object of the present invention to substantially overcome or at least ameliorate one or more of the above disadvantages. Summary of the Invention There is provided herein a method of treating anal incontinence in a patient comprising: forming a first incision in the buttock of the patient posterior to the anus; forming a second incision in the opposite buttock posterior to the anus; 2 forming a vaginal incision in the posterior vaginal wall that extends into the perineum; forming a first tissue pathway between the first incision and the perineum by passing a surgical instrument therebetween; forming a second tissue pathway between the perineum and the second incision by passing the surgical instrument therebetween; and implanting a support member in the tissue pathway such that the support member is positioned around a substantial portion of the circumference of the anal sphincter and passes between the anterior side of the anal sphincter and the posterior side of the vaginal wall within the perineum by: securing a first end of the support member to an elongate surgical instrument at the perineum; extending the elongate surgical instrument and the support member through the first passage; securing a second end of the support member to an elongate surgical instrument at the perineum; and withdrawing the elongate surgical instrument through the second passage. The support member preferably extends about the anal sphincter through an included angle of at least 1800, more preferably at least 2700, measured about an axis extending centrally and perpendicularly through the anus. Brief Description of the Drawings A preferred embodiment of the present invention will now be described, by way of an example only, with reference to the accompanying drawings wherein: Figure 1 is a schematic view of the anogenital area of a patient with an anal sphincter support member in place. Figure 2 is a perspective view of a surgical instrument particularly suitable for use on the left side of a patient. Figure 3 is a plan view of the surgical instrument of Figure 2. Figure 4 is a front view of the surgical instrument of Figure 2.

3 Figure 5 is an end view of the surgical instrument of Figure 2. Figure 6 is a perspective view of an anal sphincter support member. Figure 7 is a perspective view of an anal sphincter support kit comprising left and right elongate surgical instruments as per Figure 2 and an anal sphincter support member as per Figure 6. Figure 8 is a schematic view of the anogenital area of a patient depicting a perineal incision and left and right buttock incisions. Figure 9 is a perspective view of the anogenital area of a patient depicting creation of a right buttock incision. Figure 10 is a perspective view of the anogenital region of Figure 9 depicting insertion of a surgical guide instrument in a left buttock incision. Figure 11 is a perspective view of the anogenital region of Figure 9 depicting further insertion of the surgical guide instrument. Figure 12 is a perspective view of the anogenital region of Figure 9 depicting an anal sphincter support member extending through both buttock incisions. Figure 13 is a perspective view of an Apogee

TM

vault suspension member. Figure 14 is a front elevation view of an Apogee T M surgical guide instrument. Figure 15 is a schematic view of an anogenital region depicting location of an anal sphincter support member and the Apogee

TM

vault suspension system support member. Detailed Description of the Preferred Embodiments Referring to Figure 1, the structure of the ano genital region of a female patient is schematically depicted with an elongate, flexible, anal sphincter support member 1 in place. The support member 1 is located in and extends along a tissue pathway 10 that has been established in tissue of the patient so as to extend about the anal sphincter 10 1, which circumferentially envelops the anal passage extending from the anus 102. The support member 1 is specifically located in a 4 supporting relationship with the anal sphincter 101, so as to provide support for the anal sphincter 10 1, typically the external anal sphincter, in patients suffering from mild anal incontinence, which may present as flatal incontinence and/or mild faecal incontinence. Supporting the anal sphincter 101 will also generally aid in support of the pelvic floor. In the configuration depicted in Figure 1, the support member 1 extends along the entire length of the tissue pathway 10 about the anal sphincter 101 through an included angle of about 3000, as measured about an axis extending centrally and perpendicularly through the anus 102. The support member 1 extends between the 7 o'clock and 5 o'clock positions of a clockface when viewing the patient in a modified dorsal lithotomy position, as depicted in Figure 1. Whilst the particular positioning of the support member 1 depicted extends the support member 1 through an included angle of about 3000, alternate positioning extending the support member 1 through lesser or greater angles about the anal sphincter 101 are envisaged. It is preferred, however, that the support member 1 extends through an included angle of at least 1800, and more preferably at least 2700, so as to provide support around a significant portion of the circumference of the anal sphincter 101. Embodiments are also envisaged where the support member 1 extends a full 3600 about the circumference of the anal sphincter 101. In the configuration depicted in Figure 1, the tissue pathway 10 extends from a left pathway end 1 Oa lateral and posterior to the anus, through the perineum 103 (located between the anterior side of the anal sphincter 101 and the posterior vaginal wall 104) and to a right pathway end l0b located contralateral (i.e., on the patient's right side) and posterior to the anus 102. Other configurations extending about the anal sphincter 101 are also envisaged, including an effectively reverse configuration extending from a left pathway end lateral and anterior to the anus, through a region posterior to the anus, to a right pathway end contralateral and anterior to the anuis 102. Such a pathway might, for example, extend between the 1 o'clock and I11 o'clock positions. Rather than extending along the lateral and contralateral sides of the anal sphincter 101, the tissue pathway 10 might alternatively extend from two pathway ends on the same lateral side of the anus 102, passing posterior and anterior to the anal sphincter 10 1, to a central pathway region on the contralateral side of the anus 102. The general configuration depicted in Figure 1 will, however, generally be preferred given that it is believed that most anal sphincter injuries resulting from childbirth or episiotomy occur between the 10 o'clock and 2 o'clock positions.

5 The surgical procedure to support the anal sphincter 101 may be carried out using any of various known support sling systems as are known in the art, for example, for use with various pubovaginal procedures for stabilising or supporting the bladder neck or urethra. Examples of such slings and sling procedures are disclosed in, for example, US Patent Nos. 5,112,344; 5,611,515; 5,842,478; 5,860,425; 5,899,909; 6,309,686; 6,042,534 and 6,110,101. A particularly suitable sling system is disclosed in US Patent No. 6,911,003, the entire contents of which are hereby expressly incorporated by cross-reference. A commercial embodiment of this system is available from American Medical Systems, Inc. of Minnetonka, Minnesota, United States of America as the MonarcTM subfascial hammock, used for the treatment of stress urinary incontinence. The MonarcTM system comprises a pair of elongate surgical guide instruments each comprising a helically formed needle element attached to a plastic handle, an elongate flexible support member (referred to as a support sling) and dilator/connectors for attaching the ends of the support sling to a tip portion of each needle element. Any of various other known sling systems will, however, also be suitable for use with the present anal sphincter support procedure. Figures 2 to 5 depict an elongate surgical element 20 of the form disclosed in US Patent No. 6,911,003 and used in the MonarcTM system. The surgical guide instrument 20 depicted is particularly suitable for use on the left side of the patient's body. The surgical guide instrument 20 comprises a needle element 21 having a proximal straight shaft portion 22 fixed to a plastic handle 25. A distal helical portion 23 of the needle element 21 extends from the shaft portion 22 in a generally helical configuration to a tip portion 24. A surgical instrument suitable for use on the right side of the patient's body is configured as a mirror image to the surgical instrument 20, with the helical portion extending from the shaft portion in an opposing helix to that of the surgical instrument 20 designed for left side use. Whilst the surgical instrument 20 of the MonarcTM system has been designed to pass between an incision adjacent the anterior side of the pubic bone through the obturator foramen to the posterior side of the pubic bone and to emerge from a vaginal incision, the helical form is also suitable for the present anal sphincter support procedure. Many other configurations of surgical instruments, however, are also envisaged, including, for example, C-shaped needles. The specific configuration of the surgical guide instrument may be dependent on the surgeon's preference and varying anatomical sizes of patients. Any configuration of surgical guide element that enables creation of the necessary tissue pathway 10 for placement of the support member 1 will suffice.

6 The needle portion 21 is typically formed of a durable, biocompatible surgical instrument material such as, but not limited to, stainless steel, titanium, Nytinol, polymers, and other materials including combinations of materials. The needle portion 21 is relatively slender and may have a circular cross-sectional shape having a diameter of less than 3.5mm to allow for relatively easy passage of the needle portion 21 through tissue so as to establish the tissue pathway 10. Figure 6 depicts an example of an anal sphincter support member I suitable for use with the present procedure in the form of a support sling 1 of the MonarcTM system as disclosed in US Patent No. 6,911,003. The support sling 1 is in the form of a tape formed of a flexible mesh material. The flexible mesh material may be of any of many forms as are known for use in surgical support slings. The support sling 1 may be formed as a single monolithic piece, or a composite of different components and/or different materials. Suitable synthetic materials for forming the support sling 1 include polymers and metallic materials and, in the case of the MonarcTM sling mesh, polypropylene. The support sling may alternatively be formed of non synthetic material. Various suitable synthetic and non-synthetic materials are disclosed in US Paten-t No. 6,911,003 and are otherwise known in the art. It is preferred that the sling material is elastically deformable. The support sling 1 may also incorporate any or various coatings, such as anti-bacterial coatings to achieve any or various effects, including to fight bacterial infection or reduce the chance of sling rejection by the body. The support sling 1 may be of a generally elongate rectangular shape, as depicted, or any of various other elongate shapes including, for example, a broader central region. The example MonarcTM system support sling has an unstressed width of approximately 11 mm and length of approximately 350 nm. The support member 1 is provided with a dilator/connector 2 at each of its first and second ends a, lb. As described in US Patent No. 6,911,003, the dilator/connector 2 has an open end with internal surfaces adapted to engage corresponding external surfaces on the tip portion 24 of the surgical instrument 20, allowing the support sling 1 to be readily connected to, and extend between, two surgical instruments 20. The external surface of each dilator/connector 2 tapers toward its free end. This taper acts to dilate the tissue pathway 10 as it passes therethrough, providing for ease of passage of the support sling 1. Various other forms of dilator and/or connector may, however, be utilised as desired.

7 A tensioning suture 3 is woven along the length of the mesh material forming the support sling 1, to assist in tensioning and precise placement of the support sling 1, as will be further described below. The support sling 1 is encased in two protective sheaths 4, extending from the first and second ends 1 a, lb of the support sling 1 respectively, and overlapping in a central region of the support sling 1. The sheaths 4, which are again further described in US Patent No. 6,911,003, are typically formed of plastic material, such as polyethylene. Figure 7 depicts a surgical kit comprising a left surgical guide instrument 20, right surgical guide instrument 20' and support sling 1. The support sling 1 is connected to the tip portion 24 of the left surgical guide instrument 20 by the dilator/connector 2. The sheaths 4 act to protect the support sling 1 during the surgical procedure, and assist in passage of the mesh material of the support sling 1 through the tissue pathway 10. A surgical procedure for supporting the anal sphincter to thereby treat mild anal incontinence will now be described with particular reference to Figures 8 to 12. The procedure can be carried out under local or general anaesthesia. The patient should be placed in a modified dorsal lithotomy position with hips flexed, legs elevated in stirrups, and buttocks even with the edge of the able. Vaginal mucosal retraction using a "lone star" vaginal retractor or other means may be utilised if desired. The tissue pathway 10 for location of the support sling 1 is established by first making three incisions, the locations of which are depicted in Figure 8. A perineal incision 11 is made in the posterior vaginal wall 104, extending into the perineum 103. The perineal incision 11 will typically be a transverse incision of approximately 40 - 50 mm in length, and may appropriately be made in the posterior vaginal wall 104 at or adjacent the posterior vaginal vestibule/hymen ridge 105. The posterior vaginal wall 104 is further dissected superior and inferior from the perineal incision 11 so as to expose the perineal body 106 (the central tendon of the perineum 103). Alternatively, the perineal incision may be made in the superior region of the external skin of the perineum, adjacent the vaginal opening, extending into the perineum.

8 Referring to Figures 8 and 9, a right buttock incision 13 of approximately 3 mm in length is made at a position corresponding to the right pathway end 1 Ob, lateral and posterior to the anus 102, in the right buttock. The right buttock incision 13 may be made approximately 3 cm lateral to the anus 102 and 3 - 4 cm posterior. This position is approximately at the 7 o'clock position when viewing the patient in the modified dorsal lithotomy position. A left buttock incision 12 is made in the corresponding position on the contralateral side, corresponding to the left pathway end I0a. The precise location of the left and right buttock incisions 12, 13 may vary according to surgeon preference. A left passage 14 of the tissue pathway 10 is established between the left buttock incision 12 and the perineal incision 11, using the left surgical instrument 20. The left surgical instrument 20 is inserted into the left buttock incision 12 with the needle tip portion 24 leading, gripping the handle 25 with the right hand. Referring to Figure 10, the left surgical instrument 20 is oriented such that the needle tip portion 24 is oriented generally perpendicular to the skin at the left buttock incision 12. Referring to Figure 11, the needle tip portion 24 is pushed deeper into the left buttock incision 12, puncturing the initial layers of tissue. The needle tip portion 24 should be advanced in this direction, a distance of approximately 2 - 3 cm, into the perianal tissue adjacent to the ischiorectal fossa, however, it is not necessary to extend the incision into the ischiorectal fossa. Advancing the needle tip portion 24 a distance of 2 - 3 cm will generally bring the needle tip portion 24 in line with the transition between the subcutaneous and superficial portions of the external anal sphincter, which will typically be located about em. to 1.5 cm from the anal verge along the anal canal. The depth of 2 - 3 cm into the buttock will typically correspond to a position approximately 1 cm. beyond the anal verge, given that the anal verge is recessed in relation to the buttock at the position of the buttock incision. Whilst the needle tip portion 24 is being advanced, the surgeon's left index finger should be inserted into the patient's anal canal, primarily as a protective mnechanismn, to ensure that the needle tip portion 24 does not puncture the anal canal. The finger can also serve as a guide, palpating the location of the needle tip portion 24 as it advances. The left surgical instrument 20 is then rotated, utilising the helical configuration of the needle element 21 to direct the needle tip portion 24 towards the outside lateral edge of the perineal body 106 and superior to the perineal body 106. The needle tip portion 24 is advanced until it is displayed in the opening created by the perineal incision 11 and dissection. As the left surgical 9 instrument 20 is advanced to this position, the left index finger may be used to gently pull the anal canal away from the advancing needle element 21, thereby further ensuring integrity of the anal canal is maintained. The right surgical instrument 20' is taken by the surgeon and the right passage 15 of the tissue pathway 10 is established by the same procedure as discussed above, guiding the needle tip portion 24' of the right surgical instrument 20' through the right buttock incision 13 to the perineal incision 11, with the surgeon's right index finger inserted in the anal canal. The support sling 1 is then connected to the left and right surgical instruments 20, 20' by snapping the dilator/connectors 2 at each end 1 a, lb of the support sling 1 onto the needle tip portions 24, 24' of the left and right surgical instruments 20, 20' respectively. At this stage, the protective sheaths 4 are left in place over the support sling 1. Both surgical instruments 20, 20' are then pulled back through the left and right passages 14, 15 respectively, drawing the dilator/connector 2 and ends la, lb of the support sling I through the left and right passages 14, 15 and out of the left and right buttock incisions 12, 13. The support sling 1 is thus located extending along the tissue pathway 10 from the left buttock incision 12, through the perineum 103 and out of the right buttock incision 13. Referring to Figure 12, the support sling 1 and overlying protective sheaths 4 are then manually adjusted into the desired position by manipulation of the surgical instruments 20, 20' and/or grasping the projecting end regions of the support sling 1 and protective sheaths 4 directly. The support sling I should have generally firm tension and be located sufficiently close to the anal sphincter 101 to provide support, but should not impart any appreciable load on the anal sphincter 101 that would tend to constrict or kink the anal canal. To draw the support sling 1 taut and closer to the periphery of the anal sphincter 101, tension may be applied to each opposing end of the tensioning suture 3 extending along the length of the mesh tape forming the support sling 1. Use of the tensioning suture 3, however, will typically not be required given that the support sling 1 is located in a generally U-shaped configuration, rather than the relatively straight configuration adopted in the MonarcTM procedure. With the support sling 1 now in the desired position, the surgical instruments 20, 20' and protective sheaths 4 may be removed by firstly cutting through the sheaths 4 and support sling 1 below the point at which the mesh of the support sling 1 is secured to each protective sheath 4.

10 The protective sheaths 4 are then removed by pulling them through the left and right passages 14, 15 respectively, through the left and right buttock incisions 12, 13. Alternatively, if desired, the surgical instruments 20, 20' may first be removed, prior to final positioning of the support sling 1, by cutting through the protective sheaths 4 and support sling 1 adjacent the dilator/connectors 2, above the points at which the mesh of the support sling 1 are secured to the protective sheaths 4. A subsequent cut is then required below this point to remove the protective sheaths 4 once the support sling 1 has been adjusted into the desired position. Once the desired position of the support sling has been achieved, the support sling 1 may be sutured to the perineal body 106, typically at lateral and contralateral positions, so as to securedly fix the support sling 1 in the desired position. The sutures may be absorbable, or alternatively may be non-absorbable. The support sling 1 is trimmed at the level of the subcutaneous tissue at the left and right buttock incisions 12, 13. The left and right buttock incisions 12, 13 and perineal incision 11 and dissection are then closed. Whilst the above described procedure adopts an "outside-in" approach in establishing the passages 14, 15 of the tissue pathway 10, it is envisaged that an "inside-out" approach may alternatively be utilised. In such an approach, a modified form of surgical guide instrument having a detachable handle, an example of which is again disclosed in US Patent No. 6,911,003, may be utilised. The needle elements of these alternate surgical instruments are passed from the perineal incision 11 to the left and right buttock incisions 12, 13 to establish the left and right passages 14, 15 with the handles attached to a first end of the needle element extending through the perineal incision 11. The handles are then removed from the first end of each of the needle elements, and attached to the opposing second end of the needle elements, which at this stage of the procedure extend through the buttock incisions. The support sling is then connected to the first end of the needle elements and drawn through the left and right passages by again drawing the needle elements back through the passages. It is further envisaged that one passage might be established by the "outside-in" approach, with the opposing passage established by the "inside out" approach, as desired by the surgeon. Whilst the above described procedures establish the tissue pathway 10 by way of two separate passages 14, 15, meeting at a central perineal incision 11, it is envisaged that the tissue pathway might be established by a single passage extending from the left buttock incision 12 to the right buttock incision 13, via the perineum 103, utilising a single needle element extending through the entire pathway, without the need for the perineal incision.

11 If the surgeon determines to create the tissue pathway with a different configuration (such as, for example, between the 1 o'clock and 11 o'clock positions), it will be evident that alternate incisions will be required for the passage of the needle elements to establish the tissue pathway. For example, for a 1 o'clock to I1 o'clock configuration, a first incision would be made anterior and lateral to the anus, a second incision contralateral and anterior to the anus and a third central incision made posterior to the anus between the buttocks. Again, it is envisaged that such a tissue pathway may be established by a single passage, omitting the need for the central posterior incision. Given that many patients suffering from mild anal incontinence will also present with pelvic organ prolapse, it will often be convenient to conduct the above described anal sphincter support procedure together with a procedure to treat the pelvic organ prolapse. A particularly suitable system and treatment for pelvic organ prolapse is described in US Patent Application Publication No. US 2005/0245787 Al, the entire contents of which are hereby expressly incorporated by cross-reference. A commercial embodiment of this system is available from American Medical Systems, Inc. as the ApogeeTM Vault Suspension System. The Apogee TM system is also in the general form of a sling support and surgical guide instrument. An example of an ApogeeTM support sling of the form described in US Patent Application Publication No. US 2005/0245787 Al, particularly suitable for the treatment of posterior vaginal wall prolapse, is depicted in Figure 13. The support sling 30 comprises first and second elongate mesh tapes 31 supporting a central support element 32, commonly referred to as a cape, which extends above and below the points of attachment of the mesh tapes 31, forming a superior cape flap 33 and an inferior cape flap 34. The cape 32 is formed of a mesh material, similar to the mesh tapes 31. Versions of the ApogeeTM system are also available without the cape 32, with the support sling being in the form of a continuous mesh tape, and a further version is available utilizing what is referred to as bio-cape. The free ends 3 1a of the mesh tapes 31 are provided with dilator! connectors 35 similar to those described above. Referring to Figure 14, a surgical guide instrument 40 of the Apogee T M system as described in US Patent Application Publication No. US 2005/0245787 Al comprises a curved needle element 41 and a handle 45. The tip portion 44 of the needle element 41 has a cooperating connector structure for engaging the dilator/connectors 35 of the sling support 30. Whilst this Apogee T M system is particularly suitable for treating pelvic organ prolapse, any of various other pelvic organ prolapse repair systems may be utilised as desired.

12 When carrying out the pelvic organ prolapse treatment procedure described in US Patent Application Publication No. US 2005/0245787-Al using the Apogee TM system, in combination with the above described anal sphincter support procedure, the standard Apogee T M procedure as described is carried out with the following described modifications. Firstly, the buttock incisions for establishing the tissue pathway for location of the Apogee T M support sling are described as being located at or adjacent to the above described positions for the left and right buttock incisions 12, 13 used with the present anal sphincter support procedure. Accordingly, if both procedures are being carried out, the buttock incisions for the Apogee T M procedure may be made further lateral and posterior, as indicated in Figure 15. For example, the left and right buttock incisions 52, 53 for the Apogee TM procedure may be located approximately 2 cm lateral and 3-4 cm posterior to the left and right buttock incisions 12, 13 formed for the anal sphincter support procedure. The surgical guide instrument 40 is then used to establish the left and right passages of the tissue pathway for the Apogee TM procedure following the same general path as described in US Patent Application Publication No. 2005/0245787 Al in front of the ischial spine, through the levator muscle and to the incision and dissection to the posterior vaginal incision and dissection created for placement of the cape. This tissue pathway extends lateral and superior to the tissue pathway 10 of the present anal sphincter support procedure. The vaginal dissection for placement of the cape will extend from the initial vaginal incision for the Apogee T M process which is located superior to the perineal incision 11 for the anal sphincter support procedure, down to the perineal incision 11. As the inferior flap 34 of the cape 32 of the Apogee TM support sling 30 will typically extend down to adjacent the perineal body 106, the inferior flap 34 may conveniently be sutured to the perineal body 106 with the same lateral and contralateral suturing performed during the anal sphincter support procedure to secure the anal sphincter support sling 1 to the perineal body 106. This improves the fixation of the Apogee TM cape 32, which would typically otherwise only be relatively loosely located within the soft tissue of the posterior vaginal wall. The person skilled in the art will appreciate that the above described procedures may be varied as desired by the surgeon, depending on personal preferences, anatomical size of patient, and specific patient symptoms. The above described procedures may also be carried out utilising any of various surgical support sling kits apart from the MonarcTM and ApogeeTM systems referred to above. It is also envisaged that the anal sphincter support procedure may be carried out on male patients suffering from mild anal incontinence, and both male and female patients suffering from urge faecal incontinence.

Claims (11)

1. A method of treating anal incontinence in a patient comprising: forming a first incision in the buttock of the patient posterior to the anus; forming a second incision in the opposite buttock posterior to the anus; forming a vaginal incision in the posterior vaginal wall that extends into the perineum; forming a first tissue pathway between the first incision and the perineum by passing a surgical instrument therebetween; forming a second tissue pathway between the perineum and the second incision by passing the surgical instrument therebetween; and implanting a support member in the tissue pathway such that the support member is positioned around a substantial portion of the circumference of the anal sphincter and passes between the anterior side of the anal sphincter and the posterior side of the vaginal wall within the perineum by: securing a first end of the support member to an elongate surgical instrument at the perineum; extending the elongate surgical instrument and the support member through the first passage; securing a second end of the support member to an elongate surgical instrument at the perineum; and withdrawing the elongate surgical instrument through the second passage.

2. The method of claim 1, wherein: the first tissue pathway is formed by passing the surgical instrument from the first incision to the vaginal incision and the second tissue pathway is formed by passing the surgical instrument from the second incision to the vaginal incision.

3. The method of claim 1, wherein said support member extends about the anal sphincter through an included angle of at least about 1800, measured about an axis extending centrally and perpendicularly through the anus.

4. The method of claim 1, wherein said support member extends about the anal sphincter through an included angle of at least about 270*, measured about an axis extending centrally and perpendicularly through the anus. 14

5. The method of claim 1, comprising placing the support member in a supporting relationship with the anal sphincter to provide support for the external anal sphincter.

6. The method of claim 1, comprising placing a finger in the patient's anal canal and palpating a tip of the elongate surgical instrument.

7. The method of claim 1, comprising adjusting the support member with tension to draw the support member to a periphery of the anal sphincter.

8. The method of claim 1, wherein the surgical instrument comprises a helical needle.

9. The method of claim 1, wherein the support member comprises a mesh sling consisting of an elongate mesh strip.

10. The method of claim 9, wherein the support member comprises a connector at a distal end.

11. The method of claim 9, wherein the support member comprises a protective sheath. AMS Research Corporation Patent Attorneys for the Applicant/Nominated Person SPRUSON & FERGUSON