HYPOGASTRIC ARTERY LIGATION
PERINEAL LACERATION REPAIR
The series of videos presented in this section will review the four steps associated with repairing a 4th degree perineal laceration (see eFigure 1) as covered in Chapter 62. Repairs of this nature require adequate lighting, positioning and pain control. This may require moving the patient to the operating room. A rectal exam should be performed before and after a deep perineal repair. (Illustrations used with permission from Drs. Shayzreen Roshanravan and Marlene Corton.)
Step 1: Repair of the Anal Mucosa
The anal mucosa can be repaired with either running nonlocking or interrupted stitches. The first suture should be placed above the apex. Care should be taken to include the rectal submucosa but not the anal mucosa. Video 03 demonstrates a running, nonlocking repair using 3-0 polyglactin.
Video 3: Repair of the Anal Mucosa (Step 1 of Perineal Laceration Repair)
Step 2: Repair of the Internal Anal Sphincter (IAS)
The most critical and difficult aspect of repairing the IAS is identification. Repair of this layer is critical as it is responsible for 75-80% of anal continence. This layer can be repaired using running or interrupted stitches. Video 04 demonstrates the use interrupted stitches of 2-0 polyglactin.
Identify the internal anal sphincter (IAS)
Imbricate the IAS over the anal mucosa
Can be done with either running or interrupted mattress sutures
Video 4: Repair of the Internal Anal Sphincter or IAS (Step 2 of Perineal Laceration Repair)
Step 3: Repair of the External Anal Sphincter (EAS)
The EAS can be reapproximated in an either an end-to-end or overlapping manner. The end-to-end technique uses simple interrupted or mattress stitches. Sutures are placed in a "PISA" fashion (i.e. proximal, inferior, superior and anterior). With the overlapping style, one end of the EAS is brought over the other which is usually only possible with a full thickness 3b, 3c or 4th degree perineal laceration (see eFigure 2).
(Illustration reproduced with permission from Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM, eds. Williams Gynecology, 3e. New York, NY: McGraw-Hill; 2016. Fig 45-25.4.)