Int. J. Gynaecol. Obstet., 1983, 21: 481-484 International Federation of Gynaecology & Obstetrics
PUERPERAL PEDRO
PERINEAL
REPAIR
A. POMA
Department (Received (Accepted
of Obstetrics and Gynecology,
Mount Sinai Hospital Medical Center, and Rush Medical College, Chicago, ii.
l%S.A.
July 20th, 1981) May 20th, 1983)
Abstract Poma PA (Dept of Obstetrics and Gynecology, Mount Sinai Hospital Medical Center and Rush Medical College, Chicago, IL, U.S.A. I. Puerperal perineal repair. Int J Gynaecol Obstet 21: 481-484, 1983 Perineal lacerations, which may or may not include the rectal sphincter and mucosa, commonly result from birth trauma. The surgical treatment of these complications is commonly performed during a period not associated with pregnancy - usually in the perimenopausal years or after the patient has achieved her ideal family size. Puerperal perineal repair, described here, has not been associated with a higher incidence of morbidity or recurrences. The technique is well known to gynecologists, and it can be safely employed during the immediate postpartum period. At this time, it is economically advantageous and prevents a longer period of distress caused by patient disability. Perineal Key words: sphincter and mucosa; nancy; Perimenopausal period
lacerations; Rectal Birth trauma; Pregyears; postpartum
Introduction Individual predisposition and obstetrical trauma are considered causative factors for relaxed vaginal outlet, including cystocele, 0020-7292/83/$03.00 0 1983 International Printed and Published
rectocele, perineal and rectal sphincter lacerations and rectovaginal fistulae. However, other iatrogenic factors may have a more significant role in the latter three complications. For instance, incomplete or inadequate episiorrhaphy, undiscovered rectal mucosa penetration, and prolonged second stage of labor are commonly associated factors. Pelvic floor repairs usually require hospitalization and involve expenses for the general anesthesia and operating room, recovery room. These repairs are usually done in the patient’s reproductive years often associated with vaginal hysterectomy. (During 1975, 0.23% of women admitted to hospitals had vaginal hysterectomies; 0.18% had pelvic floor repairs [ 11 .) Pelvic floor repairs are also done when the patient has achieved what she considers as her ideal family size. Often physicians are concerned that further perineal trauma, including new lacerations which may occur if the patient has another vaginal delivery, may damage previous pelvic floor plasties beyond repair. With the technological explosion and worldwide economic inflation, the expenses of hospital care have increased continuously. Emphasis is now placed on early discharge, same-day surgery and office surgery in order to decrease the cost of hospitalization. Still, most women in this country deliver at hospitals, and their expulsive period is commonly under bilateral pudendal block. Women with relaxed vaginal outlet (Fig. lB), especially those with fecal incontinence due to sphincter laceration or rectovaginal fistula (Fig. lC), may benefit from perineal Int J Gynaecol Obstet 21
Federation in Ireland
of Gynaecology
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Fig, 1. (A) Normal appelring vaginal outlet;(B) relaxed vaginal outlet, with or without rectal sphincter tear; and (C) rectovaginal fistula
plastic procedures before the termination of their reproductive function by normal aging or choice. Today, if the patient with fecal incontinence is first seen during pregnancy, probably because of the concern with anesthesia, fetal loss and bleeding, the repair will probably be deferred until a few months after delivery. The purpose of this communication is to report the technique we have used for the last 10 years on patients with symptomatic relaxed vaginal outlet (including fecal incontinence) who were first seen while pregnant. Procedure After an uncomplicated labor, the delivery was accomplished under bilateral pudendal block using a long-acting agent (such as 0.5% Long-acting bupivacaine hydrochloride). agents benefit the patient even into the postoperative period. Depending on the patient’s condition, the repair may be started before the placenta is expelled to gain some time. While the repair is performed, the patient may hold her newborn at her breast and visit with her husband. Besides facilitating parentalinfant bonding, it also distracts the mother from the procedure. Figure 2 shows the preliminary steps used Int J Gynaecol Obstet 21
Relaxed vagin: outlet. (A) New fourchette level is Fig. 2. determined; (B) vaginal epithelium is separated from the perineal skin; and (C) posterior vaginal muwsa is separated from rectum.
on women with relaxed vaginal outlet, with or without anal sphincter incomplete or complete lacerations. The Kochers holding the edges of the introitus should be apprcximated in the midline before the incision is made because that will be the level of the new fourchette. An extremely tight introitus must be avoided, especially on women who already have some serious concern about their genitalia due to their symptoms. After the edge of the introital skin was removed by sharp dissection (Fig. 2B), the vaginal mucosa was separated from the rectum (Fig. 2C). Figure 3 illustrates a similar sharp dissection used on women with old third-degree perineal tears and/or rectovaginal fistulae. After the edge of the vaginal mucosa was separated from the rectal tissues (Fig. 3A,B), the rectal mucosa was approximated in a subcuticular fashion (without perforating the mucosa) with an interrupted or continuous atraumatic GI 000 chromic suture (Fig. 3C). A second layer, which included the pararectal tissues with GI 00 chromic, was commonly employed. The rectal sphincter stumps were found and brought toward the midline with the assistance of Allis forceps (Fig. 4A). The sphincter was sutured with either 0 or 1
Puerperal perineal repair
.A.
B
Rectovagindl fistula; (A) vaginal mucosa separated Fig. 3. from the rectal mucosa; (B) Further dissection separates the vagina from the rectum; and (C) Subcuticular stitch approximating the rectal mucosa
chromic or silk. Next the levator muscles were identified. Placing a finger in the rectum was helpful. Interrupted 0 chromic stitches were placed (Fig. 4B,C). A continuous subcuticular 00 chromic stitch was placed on the vaginal mucosal edge (Fig. SA). A coronal stitch with 00 chrcmic brought the vulvocavernous muscles to the midline, concluding the perineal body recon-
483
B
(A) Continuous subcuticular stitch approximates Fig, 5. the vaginal edge. (B) The vaginal mucosa is approximated in the midline; and (C) coronal stitch brings the vulvocavernous muscles to the midline.
struction (Fig. 5C). The superficial layers of the new perineal floor were sutured in a subcuticular fashion with 00 chromic continuous, returning the appearance of the vaginal outlet to close to normal (Fig. 1A). Hemostasis was reviewed. Clots were removed from the lower uterine segment and vagina. The anal sphincter was dilated with two fingers to facilitate later evacuation. A stool softener is commonly added to the routine postpartum orders. Results
Fig. 4. (A) Rectal sphincter reconstruction in the midline. (B) Levator muscles are identified; and (C) levator muscles have been approximated
Twenty-three patients have had surgery following delivery by means of the technique described here. Twenty women presented old perineal lacerations (Fig. lB), with different degrees of anal sphincter preservation. Two of them had fecal incontinence. Three of the 20 women have had subsequent spontaneous deliveries without further sequelae. The other three women had a rectovaginal fistula when first seen (Fig. 1C); their symptoms had begun following their last deliveries. After the repairs, these women were continent for the first time in several years and were most satisfied. Following the repair, these women Int J Gynaecol Obstet 21
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remained hospitalized until their first spontaneous bowel movements. Their followup was satisfactory, one of them having delivered vaginally over a midline episiotomy without further complications. In these patients, maybe because of the physiological edema of pregnancy, the surgical dissection was easier and the blood loss surprisingly small when compared to perimenopausal and postmenopausal women. The repair on the women of this report healed faster with no evidence of infection and with no cases of dehiscence. Except for the women admitted with rectovaginal fistulae, these patients had lengths of stay in hospital similar to the women who had regular episiotomies. All the patients were satisfied with the results. Comments
The patients reported in this study were migrant workers, women who previously did not have prenatal care, whose previous deliveries had occurred almost unattended in rural areas. Fecal incontinence creates such a personal handicap that one often wonders how these affected women were able to tolerate it for such a relatively long time even though most of them did not want to wait any longer for alleviation. The technique described here has not been immediately following commonly used delivery. Probably, concerns about excessive bleeding, dehiscence, infection and possible
Int J Gynaecol Obstet 21
recurrences following further deliveries have prevented the more common use of puerperal perineal repairs. The results presented here emphasized the fact that those common concerns are not well founded. Puerperal perineal repairs did not unduly prolong the length of hospitalization. As a matter of fact, the more recent patients have been discharged at intervals comparable to those women with no repairs. Even if one does not consider the emotional benefits of the early performance of this type of repair, the economic advantages are self evident. The performance of postpartum repairs prevents a new hospitalization. Puerperal perineal repairs as an elective procedure is not intended for routine use, but it offers an economic and safe alternative for some patients. The technique and the materials used are within the reach of any gynecologist throughout the world. References 1 Poma PA: Hysterectomy: Indications tions Ill Med J 158: 13, 1980.
Address for reprints: Pedro A. Poma, M.D. 1200 Superior Street Suite 402 Metrose Park IL 60160, USA
and
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