会阴裂伤缝合英文文献含图.docx

会阴裂伤缝合英文文献含图.docx

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会阴裂伤缝合英文文献含图

RepairofObstetricPerinealLacerations

LAWRENCELEEMAN,M.D.,M.P.H.,MARIDEESPEARMAN,M.D.,andREBECCAROGERS,M.D.,UniversityofNewMexicoSchoolofMedicine,Albuquerque,NewMexico

AmFamPhysician.�2003�Oct�15;68（8）:

1585-1590.

Familyphysicianswhodeliverbabiesmustfrequentlyrepairperineallacerationsafterepisiotomyorspontaneousobstetrictears.Effectiverepairrequiresaknowledgeofperinealanatomyandsurgicaltechnique.Perineallacerationsareclassifiedaccordingtotheirdepth.Sequelaeofobstetriclacerationsincludechronicperinealpain,dyspareunia,urinaryincontinence,andfecalincontinence.Withlacerationsinvolvingtheanalsphinctercomplex,particularattentionmustbegiventoanatomyandsurgicaltechniquebecauseofthehighincidenceofpoorfunctionaloutcomesafterrepair.Anoverlappingtechniquetorepairtheexternalanalsphincter,ratherthanthetraditionalend-to-endtechnique,isbeinginvestigatedtodetermineifitmightdecreasetheincidenceofanalincontinence.Minimizingtheuseofepisiotomyandforcepsdeliveriescandecreasetheoccurrenceofsevereperineallacerations.

Perinealrepairafterepisiotomyorspontaneousobstetriclacerationisoneofthemostcommonsurgicalprocedures.Potentialsequelaeofobstetricperineallacerationsincludechronicperinealpain,1dyspareunia,2andurinaryandfecalincontinence.3–5Fewstudiesoflacerationrepairtechniquesexisttosupportthedevelopmentofanevidence-basedapproachtoperinealrepair.Thisarticlediscussesarepairmethodthatemphasizesanatomicdetail,withtheexpectationthatananatomicallycorrectperinealrepairmayresultinabetterlong-termfunctionaloutcome.

PerinealAnatomy

Theperinealbody,locatedbetweenthevaginaandtherectum,isformedpredominantlybythebulbocavernosusandtransverseperinealmuscles（Figure1）.Thepuborectalismuscleandtheexternalanalsphinctercontributeadditionalmusclefibers.

FIGURE1.

Musclesofperinealbody.

UsedwithpermissionfromCin�-Med,Inc.,127MainSt.N,Woodbury,CT06798-2915.Copyright�Cin�-Med,Inc.

Theanalsphinctercomplexliesinferiortotheperinealbody（Figure2）.Theexternalanalsphincteriscomposedofskeletalmuscle.Theinternalanalsphincter,whichoverlapsandliessuperiortotheexternalanalsphincter,iscomposedofsmoothmuscleandiscontinuouswiththesmoothmuscleofthecolon.Theanalsphinctercomplexextendsforadistanceof3to4cm.6

FIGURE2.

Analsphinctercomplex（cadaverdissection）.

Theinternalanalsphincterprovidesmostoftherestinganaltonethatisessentialformaintainingcontinence.Lacerationofthissphincterisassociatedwithanalincontinence.4Interestingly,repairoftheinternalanalsphincterisnotdescribedinstandardobstetrictextbooks.7,8

SurgicalPrinciples

Obstetricperineallacerationsareclassifiedasfirsttofourthdegree,dependingontheirdepth.Arectalexaminationishelpfulindeterminingtheextentofinjuryandensuringthatathird-orfourth-degreelacerationisnotoverlooked.

Repairoftheperineumrequiresgoodlightingandvisualization,propersurgicalinstrumentsandsuturematerial,andadequateanalgesia（Table1）.Comparedwithsurgicalrepairusingcatgutorchromicsuture,repairusing3-0polyglactin910（Vicryl）sutureresultsindecreasedwounddehiscenceandlesspostpartumperinealpain.9–12[Reference9—EvidencelevelA,randomizedcontrolledtrial（RCT）;Reference10—EvidencelevelB,uncontrolledtrial;Reference11—EvidencelevelA,meta-analysis;Reference12—EvidencelevelB—systematicreviewofRCTs]Useofrapidlyabsorbedpolyglactin910（VicrylRapide）suturedecreasestheneedforpostpartumsutureremovalafterrepairofsecond-degreelacerations.13

TABLE1

EquipmentforRepairofObstetricPerinealLacerations

Steriledrapesandgloves

Irrigationsolution

Needleholder

Metzenbaumscissors

Suturescissors

Forcepswithteeth

Allisclamps

GelpiorDeaverretractor（foruseinvisualizingthird-orfourth-degreeperineallacerations,ordeepvaginallacerations）

10-mLsyringewith22-gaugeneedle

1%lidocaine（Xylocaine）

3-0polyglactin910（Vicryl）sutureonCT-1needle（forvaginalmucosasutures）

3-0polyglactin910sutureonCT-1needle（forperinealmusclesutures）

4-0polyglactin910sutureonSHneedle（forskinsutures）

2-0polydioxanonesulfate（PDS）sutureonCT-1needle（forexternalanalsphinctersutures）

Localanesthesiacanbeusedforrepairofmostperineallacerations.However,generalorregionalanesthesiamaybenecessarytoachieveadequatemusclerelaxationandvisualizationforsurgicalrepairofsevereorcomplexlacerations.

Severeperineallacerationsinvolvingtheanalsphinctercomplexposeasurgicalchallenge.Recentstudies3,14havedemonstrateda20to50percentincidenceofanalincontinenceorrectalurgencyafterrepairofthird-degreeobstetricperineallacerations.Theseinjuriesdonotrequireimmediaterepair;hence,aninexperiencedphysiciancandelaytheprocedureforafewhoursuntilappropriatesupportstaffareavailable.

Withsevereperineallacerationsinvolvingtheanalsphinctercomplex,weirrigatecopiouslytoimprovevisualizationandreducetheincidenceofwoundinfection.Becausetheselacerationsarecontaminatedbystool,asingledoseofasecond-orthird-generationcephalosporinmaybegivenintravenouslybeforetheprocedureisstarted.

RepairofSecond-DegreePerinealLacerations

Repairofasecond-degreelaceration（Figure3）requiresapproximationofthevaginaltissues,musclesoftheperinealbody,andperinealskin.Thestepsintheprocedureareasfollows:

FIGURE3.

Second-degreeperineallaceration.

UsedwithpermissionfromCin�-Med,Inc.,127MainSt.N,Woodbury,CT06798-2915.Copyright�Cin�-Med,Inc.

Theapexofthevaginallacerationisidentified.Forlacerationsextendingdeepintothevagina,aGelpiorDeaverretractorfacilitatesvisualization.

Ananchoringsutureisplaced1cmabovetheapexofthelaceration,andthevaginalmucosaandunderlyingrectovaginalfasciaareclosedusingarunningunlocked3-0polyglactin910suture.Iftheapexistoofarintothevaginatobeseen,theanchoringsutureisplacedatthemostdistallyvisibleareaoflaceration,andtractionisappliedonthesuturetobringtheapexintoview.Therunningsuturecanbelockedforhemostasis,ifneeded.

Thesuturesmustincludetherectovaginalfascia（Figure4）,whichprovidessupporttotheposteriorvagina.Therunningsutureiscarriedtothehymenalringandtiedproximaltothering,completingclosureofthevaginalmucosaandrectovaginalfascia.

FIGURE4.

Vaginalmucosaandunderlyingrectovaginalfascia.

UsedwithpermissionfromCin�-Med,Inc.,127MainSt.N,Woodbury,CT06798-2915.Copyright�Cin�-Med,Inc.

Themusclesoftheperinealbodyareidentifiedoneachsideoftheperineallaceration（Figure5）.Theendsofthetransverseperinealmusclesarereapproximatedwithoneortwotransverseinterrupted3-0polyglactin910sutures（Figure6）

FIGURE5.

Second-degreeperineallacerationwithunderlyingmusclesexposed.

UsedwithpermissionfromUniversityofNewMexicoSchoolofMedicine,DepartmentofFamilyandCommunityMedicine,Albuquerque,N.M.

FIGURE6.

Repairoftransverseperinealmuscleswithsingleinterruptedsuture.

UsedwithpermissionfromUniversityofNewMexicoSchoolofMedicine,DepartmentofFamilyandCommunityMedicine,Albuquerque,N.M.

Asingleinterrupted3-0polyglactin910sutureisthenplacedthroughthebulbocavernosusmuscle（Figure7）.Thetornendsofthebulbocavernosusmusclearefrequentlyretractedposteriorlyandsuperiorly.Useofalargeneedlefacilitatespropersutureplacement.

FIGURE7.

Repairofbulbocavernosusmusclewithsingleinterruptedsuture.

UsedwithpermissionfromUniversityofNewMexicoSchoolofMedicine,DepartmentofFamilyandCommunityMedicine,Albuquerque,N.M.

Ifthelacerationhasseparatedtherectovaginalfasciafromtheperinealbody,thefasciaisreattachedtotheperinealbodywithtwoverticalinterrupted3-0polyglactin910sutures（Figure8）

FIGURE8.

Reattachmentofrectovaginalseptumtomusclesofperinealbody.

UsedwithpermissionfromUniversityofNewMexicoSchoolofMedicine,DepartmentofFamilyandCommunityMedicine,Albuquerque,N.M.

Whentheperinealmusclesarerepairedanatomicallyasdescribedabove,theoverlyingskinisusuallywellapproximated,andskinsuturesgenerallyarenotrequired.Skinsutureshavebeenshowntoincreasetheincidenceofperinealpainatthreemonthsafterdelivery.15[EvidencelevelB,uncontrolledtrial]Iftheskinrequiressuturing,runningsubcuticularsutureshavebeenshowntobesuperiortointerruptedtranscutaneoussutures.16The4-0polyglactin910suturesshouldstartattheposteriorapexoftheskinlacerationandshouldbeplacedapproximately3mmfromtheedgeoftheskin.

Analternativeapproachtorepairoftheperinealbodymusclesisarunningsuturethatiscontinuedfromthevaginalmucosarepairandbroughtunderneaththehymenalring.However,weprefertheinterruptedapproachbecauseitfacilitatesamoreanatomicrepair,allowingreapproximationofthebulbocavernosusmuscleandreattachmentofthevaginalseptumwithminimaluseofsutures.

RepairofFourth-DegreePerinealLacerations

Repairofafourth-degreelacerationrequiresapproximationoftherectalmucosa,internalanalsphincter,andexternalanalsphincter（Figure9）

FIGURE9.

Fourth-degreeperineallaceration.

UsedwithpermissionfromCin�-Med,Inc.,127MainSt.N,Woodbury,CT06798-2915.Copyright�Cin�-Med,Inc.

AGelpiretractorisusedtoseparatethevaginalsidewalls