Steps of Repairing Total Perineal Rupture: Evidenced-based

Steps of Repairing

Total Perineal Rupture:

Evidenced-based

Dr. Gatut Hardianto, SpOG (K)

Divisi Uroginekologi Rekonstruksi,

Dept/SMF Obstetri Ginekologi, RSU Dr Soetomo-FK Unair

Anatomy Superficial Muscle of

Perineum

Anatomy Anal Sphincter

Epidemiology

• Rate of Obstetric Anal Sphincter Injuries (OASIS) in

England has tripled from 1.8% to 5.9% (2000 until 2012)

• Incidence in primiparae is 6.1%, multipara 1.7%

Royal College of Obstetricians and Gynaecologist. A third- or fourth-degree tear during birth:

Information for you. London: RCOG; 2015.

Grade 1 : Laceration of vaginal epitel and perineal skin

Grade 2 : Grade 1 rupture + laceration of perineal muscle

Grade 3 : Grade 2 rupture + laceration of anal sphincter

Grade 4 : Grade 3 rupture + laceration of anal mucosa

Old Classification

Perineal Rupture Classification

New Classification

1st Degree

• Injury to perineal skin and/or vaginal mucosa

2nd

Degree

• Injury to perineum involving perinealmuscles but not involving the anal sphincter

3rd

Degree

• Injury to perineum involving the anal sphincter complex

• 3a: Less than 50% of EAS thickness torn

• 3b: More than 50% of EAS thickness torn

• 3c: Both EAS and IAS torn

4rd Degree

• Injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa

Fernando R, Sultan AH, Kettle C, Radley S, Jones P, O’Brien S, 2006, ‘Repair techniques for

obstetric anal sphincter injuries: a randomized trial’, Obstet Gynecol : 107 : 1261-8.

Fernando RJ, Williams AA, Adams EJ. The management of third-and fourth-degree perineal tears. RCOG Green-top

Guideline 2007; 29: 1-11.

How to identificate anal

sphincter injuries?

• Examined systematically by a digital rectal examinationto assess the severity of damage, particularly prior tosuturing

• NICE perineal care guidance:

• Explain to the woman what thay plan to do and why

• Offer inhalational analgesia

• Ensure good lighting

• Position to the woman so that she is comfortable and so that the genital structures can be seen clearly (lithotomy position)

Evidence Level 2+



How to identificate anal

sphincter injuries?

• Using endoanal ultrasound immediately following

delivery was not significantly increasing the detection

rate of OASIS compared with clinical examination alone.

Evidence Level 3



Repair of Anorectal

Mucosa

• The torn anorectal mucosa should be repaired with

sutures using either the continous or interupted

technique.

• When using catgut it was recommended insert

interrupted sutures with the knot tied within the anal canal

(minimise tissue reaction and infection)

• Using polyglactin it was recommended using continous

techniques (it dissolves by hydrolysis)

• Figure if eight sutures should be avoided during repair

anorectal mucosa because they can cause ischemia

Evidence Level 4

D



Repair Internal Anal

Sphincter

• Where the torn IAS can be identified, it is advisable to

repair this separetely with interrupted or mattress

sutures without any attempt to overlap the IAS

• Using the end-to-end technique, repairing IAS improves the

likelihood of subsequent anal continence

C

Evidence Level 2+



Repair External Anal

Sphincter

• For repair of full thickness EAS tear, either overlapping

or an end-to-end (approximation) method can be used

with equivalent outcomes.

• For partial thickness (all 3a and some 3b) tears, an en-to-

end technique should be used.

A

D



End-to-end Approximation of EASSultan AH. Primary repair of obstetric anal sphincter injuries. Cardozo L, Staskin D, et al, editors. In: Textbook of

Female Urology and Gynecology. 3rd ed. London: Informa Healthcare; 2010. p. 863-9

End-to-End Procedures

Overlap repair of EASSultan AH. Primary repair of obstetric anal sphincter injuries. Cardozo L, Staskin D, et al, editors. In: Textbook of

Female Urology and Gynecology. 3rd ed. London: Informa Healthcare; 2010. p. 863-9

Repair External Anal

Sphincter

• No statistically significant difference in perineal pain (RR

0.08,95%CI 0.00-1.45), dyspareunia (RR 0.77, 95%CI

0.48-1.24), flatus incontinence (RR 1.14, 95%CI 0.58-

2.23) between two repair techniques at 12 months.

• It showed statistically significant lower incidence of fecal

urgency (RR 0.12, 95%CI 0.02-0.86), lower anal

incontinence score in the overlap group, lower risk of

deterioration of anal incontinence symptoms over 12

months (RR 0.26, 95%CI, 0.09-0.79)Evidence Level 4



Suture Materials

• 3-0 polyglactin should be used to repair the anorectal

mucosa as it may cause less irrtitation and discomfort

than polydioxanone (PDS) sutures.

• When repair of the EAS and/or IAS muscle is being

performed, either monofilament sutures such as 3-0 PDS

or modern braided sutures such as 2-0 polyglactin can be

used with equivalent outcomes.

D

B



Evidence Level 4

Suture Materials

Material Brand Name Manufacture

Polyglactin Vicryl® Ethicon

Polydioxanone PDS® II Ethicon

Polyglycolic acid Safil® B Braun

Antibiotics

• The use of broad-spectrum antibiotics is recommended

following repair of OASIS to reduce the risk of

postoperative infections and wound dehiscence.

• A Cochrane review from one randomised controlled trial of

147 participants suggested that prophylactic antibiotics help

to prevent perineal wound complications following third-or

fourth-degree perineal tears, loss to follow-up was very

high.

B

Evidence Level 1-

Steps of Repairing Total Perineal Rupture: Evidenced-based

Health & Medicine

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