Step by Step to Perineal repair .BOY.pptx

Memahami grading ruptur perineum dan teknik repair

1. Perineal repair grade III-IV

2. Introduction Perineal trauma—particularly OASIS—is associated with short- and long-term morbidity including persistent perineal pain, dyspareunia, delayed resumption of sexual intercourse, and depression, and may ultimately interfere with a new mother’s ability to care for her newborn. Furthermore, OASIS is associated with an increased risk of anal incontinence with 29% to 53% of women reporting flatal incontinence and 5% to 10% reporting fecal incontinence in the first 6 months postpartum.

3. Anatomy A, The superficial compartment contains the superficial transverse perineal muscle, the bulbospongiosus , and the ischiocavernosus. These 3 muscles form a triangle on either side of the perineum, with a floor formed by the perineal membrane. B, The left bulbospongiosus muscle has been removed to demonstrate the vestibular bulb and Bartholin’s gland.

4. Diagnosis

5. Perineal laceration repair

6. Third- and fourth-degree laceration repairs

7. Technique For the overlapping technique (Figure 4, A), the torn ends of the sphincter should be evaluated and dissected from the surrounding tissue. This undermining allows overlapping the EAS complex without causing undue tension on the closure. The torn ends are overlapped and reapproximated using 2 to 4 interrupted or mattress sutures. For the end-to-end repair, the EAS is identified and 4 interrupted sutures are placed to reapproximate the posterior, inferior, superior, and anterior portions of the muscle (Figure 4, B). The RCOG recommends against the use of figure-of- 8 sutures.

8. Begin by repairing the anorectal mucosa using 3-0 or 4-0 delayed absorbable sutures such as polyglactin or poliglecaprone. First, anchor the suture with the knot above the apex of the laceration, with the knots tied within the anorectal lumen. Perform a running, nonlocked suture to reapproximate the mucosa to approximately 5 mm past the anal verge. If possible, using 3- 0 or 4-0 delayed absorbable sutures such as polyglactin, close a second layer over the repaired anorectal mucosa by reapproximating the overlying rectovaginal fascia. Next, identify the IAS, which appears as a thin, pale pink layer similar to fascia. Place 2 to 4 interrupted sutures using 3-0 polyglactin or polydioxanone to reapproximate the IAS in an end-to-end fashion.

9. Identify the EAS, which appears as thick, striated, dark red muscle. Grasp each torn end with an Allis clamp. Repair using either 2-0 polyglactin or 3-0 polyglactin or polydioxanone sutures. For a partial EAS tear, use an end to-end technique (Figure 4, A). Ideally, 4 interrupted sutures are placed into the posterior, inferior, superior, and anterior portions of the muscle. Place all 4 sutures first, then tie each down. For a complete EAS tear, when an overlapping technique will be used (Figure 4, B), identify the completely torn ends. Dissect the torn ends from the surrounding tissue by at least 1.5 cm. Overlap the ends by at least 1 to 1.5 cm, then place 2 to 4 full-thickness interrupted or mattress sutures, passing through the full thickness of both overlapped torn ends of the EAS. Place all 4 sutures first, then tie each down.

10. Once the anal sphincter complex has been repaired, perform a seconddegree perineal laceration repair as described above. Ensure that surgical knots from the anal sphincter repair are buried behind the superficial perineal muscles to reduce the risk of knot or suture migration to the skin, which can cause wound dehiscence, perineal irritation, and patient discomfort. Perform another rectal exam to confirm adequate repair and that there are no injuries or suture transgressions.