EPISIOTOMY & PERINEAL TEARS Anatomy &Functionality May Dr. Annie Leong MBBS, FRANZCOG, CU

Transcription

1 EPISIOTOMY & PERINEAL TEARS Anatomy &Functionality May 2011 Dr. Annie Leong MBBS, FRANZCOG, CU

2 Restore normal perineal anatomy Achieve good haemostasis Avoid infection and wound breakdown Avoid coital and bowel dysfunction

3 Superficial : Bulbospongiosis m Ischiocavernosus m Superificial transverse perineal m Deep Deep transverse perineal m External urethral sphincter m

4 Muscle attachments External anal sphincter External urethral sphincter Pubovaginalis Bulbospongiosis Superficial & deep transverse perineal m * Stabilises pelvic & perineal structures

5 Internal anal sphincter Longitudinal smooth muscle layer External anal sphincters Anal canal Ischiorectal Fossae

6 Puborectalis mainly continence of solid stool EAS dysfunction faecal urgency &/or UI IAS continence at rest, esp liquid & flatus dysfunction passive soiling &/or flatal AI

7 * - of tear in rectum

8 Repair by experienced registrar, consultant or under direct supervision Ideally in theatre, under GA or regional Torn anal / rectal mucosa repaired with interrupted 3/0 vicryl or S- C continuous 3/0 PDS

9 IAS identified and if torn, repaired separately with interrupted 3/0 PDS EAS repaired with overlapping technique with interrupted mattress sutures 2/0 PDS

10 Secure apex of the tear or incision Repair posterior vaginal epithelium with continuous non- locking absorbable suture (eg. 2/0 vicryl) Ensure hymenal remnants & fourchette aligned

11 * Regard as a SURGICAL procedure aseptic technique good lighting and exposure appropriate surgical instruments assistant if available good haemostasis avoid tension on tissues

12 Reconstruct the perineal muscles in layers with absorbable suture 2/0 vicryl Perineal skin closed with subcuticular suture 3/0 vicryl rapide Vaginal & rectal examination at completion

13 End-to-End Overlap

14 Parks Secondary repair Sultan Primary repair Reduced AI (8% vs 40%) Reduced persistent EAS defects (15% vs 85%) Higher maximum resting and squeeze anal pressures Sultan AH et al. BJO G 1999;106:

15 GA or regional in OT If torn anal mucosa a. interrupted sutures 3-0 vicryl? knots tied in anal canal b. submucosal continuous 3-0 PDS

16 IAS identified and if torn, repaired separately with interrupted 3-0 PDS Overlap vs End-to-end for IAS? Needs further dissection Smooth muscle more likely to tear?

17 Ensure PDS sutures are short and buried Perineal m reconstructed 2-0 vicryl 3-0 vicryl s/c suture to perineal skin IV antibiotics intra-op and oral for 1/52 Stool softener and bulking agent 14 /7

18 Full length & width of torn sphincter ends identified Greater surface area of contact Allows for retraction while maintaining apposition Longer anal length

19 Fitzpatrick et al 2000 Williams et al 2006 Fernando et al 2006

20 Women with 3 rd or 4 th degree (>3b) tears 32 each arm 1 outcome: FI at 12m 2 outcomes: faecal urgency, flatus incontinence, perineal pain, dyspareunia, QOL, improvement of AI symptoms

21 Reduced risk of faecal urgency, AI score and deterioration of AI symptoms with overlap repair Majority of results based on one RCT Effect of surgeon experience?

22 PDS suture recommended for sphincter repair Delayed absorbable monofilament sutures with longer half-life and less likely to precipitate infection than braided sutures Non-absorbable sutures (eg. prolene) effective but risk suture abscess + sharp ends may need removal

23 Anal mucosa vicryl Perineal m vicryl Perineal skin SC vicryl rapide

24 Cochrane review. Buppasiri et al 2005 Insufficient data to support routine prophylactic antibiotics in 4 th degree tears BUT Infection may predispose to repair breakdown, AI and fistula development Recommend broad-spectrum antibiotics

25 Bowel confinement to avoid passage of formed stool? o Nessim et al 1999 o o Mahony et al 2003 o o o outcome not adversely affected by omission of bowel confinement and associated with less faecal impaction bowel confinement vs laxatives after 3 rd degree tear earlier & less painful b.a in laxative group no difference in functional outcome

26 Straining and passage of hard stool may disrupt repair Recommend laxatives to maintain soft stool Avoid constipating agents

27 Clear documentation of the anal sphincter injury and subsequent management essential. Full understanding of the nature and implications of the injury sustained Follow-up in a multi-disciplinary perineal clinic is recommended.