HOW TO REPAIR THIRD AND FOURTH DEGREE PERINEAL TEAR: SURGICAL TECNIQUE. - Gynecology and Obstetrics скачать в хорошем качестве

HOW TO REPAIR THIRD AND FOURTH DEGREE PERINEAL TEAR: SURGICAL TECNIQUE. - Gynecology and Obstetrics

HOW TO REPAIR THIRD AND FOURTH DEGREE PERINEAL TEAR After vaginal delivery the vagina, perineum and anorectum are examined to identify and repair significant injuries. Sometimes, it can happen the damage of the anal sphincter and it is important to recognize and repair it, because in case of neglected and not repaired immediately, this can contribute to anal and fecal incontinence for the mother. CLASSIFICATION There are four kinds of obstetric perineal lacerations: 1st degree: involve injury to the skin and subcutaneous tissue. 2nd degree: extend into the musculature of the perineal body, including deep and superficial transverse perineal muscles, pubococcygeus and bulbocavernosus muscles. 3rd degree involve injury of external anal sphincter and/ or internal sphincter. o 3a: less than 50% of external sphincter thickness is torn. o 3b: more than 50% of external sphincter torn. o 3c: both external and internal sphincter are torn. 4th degree: involves both anal sphincter complex and anal mucosa. REPAIRMENT OF 3RD AND 4TH DEGREE TEARS Prepare the patient for shifting to operating room, as this may improve access to appropriate equipment, lighting, anesthesia support and maintenance of aseptic conditions. A single dose of broad spectrum antibiotic should be given prior to repair to reduce wound complications. Third or fourth degree tears should be repaired before 1st and 2nd tears. Muscle fibers of sphincters tend to retract over time, so we must identify and repair this tears immediately after labor. The internal sphincter is responsible of 75% of anal continence, and its repairment is just possible immediately after labor (repairment over the time can be extremely difficult). Sphincter repairment over the time is much more difficult than immediate repairment after delivery, with worsen prognosis of anal incontinence. SURGICAL TECNIQUE The aim of reconstructive surgery is to restore the continuity of both external and internal sphincters. The optimal repair consists in a multilayer closure. It is very important that stitches do not pass through the rectal mucosa, because this could increase the risk of vagino-rectal fistulae. 4th degree tear: repair the torn anal mucosa using a continuous (non locking) suture with vicryl 3/0 no rapid. Absorbable monofilament suture is also acceptable. Interrupted sutures also can be used but being aware that the knot must be always towards the rectal lumen (so knots will be easily spontaneously removed with the pass of stool and also we avoid larger quantity of foreign body in the tissue). In the continuous suture, there will be just two knots, both must be towards the rectal lumen, so the suture needs to start with a knot in-to-out/ out-to-in, and finish the same way. 3rd degree tear: Internal anal sphincter should be properly identified and repaired as a separate layer. It often retracts laterally and superiorly and appears as pale pink shiny tissue just above the anal mucosa. Reapproximation of this layer is important for achieving anal continence. End to end separated stitches or continuous suture can be done with vicryl 2/0. Mattress stitches, as seen in the video help very much to confront the edges. External anal sphincter: if it is 3a tear, then end-to-end technique is required. But if it is injury of the whole external sphincter, then overlap technique is preferred. For overlapping we need to identify external sphincter fibers and hold them with an Allis clamps. If necessary, mobilize of tissue can be done to correctly identify the reddish ends of external sphincter. For Overlap, it is important to follow always same steps: o Start close to edge and up-down direction in first end. o Go to the other end, give the stitch in same line, same direction up-down but further. o Then we do the opposite movement: from down-up direction in second end, closer to the edge. o And the last one down-up, further in first end. Repeat until all fivers are overlap: fist two steps up-down direction closer-further and third forth steps down to up direction, closer-further, to overlap. Hold suture and knot all them in the end, to facilitate further suturing. Practicing in models like this one in foam paper, can help you to improve the practice and prepare better yourself for further perineal repairments.