Obstetrics Anal Sphincter Injuries

Alfa P. Meutia, MD
Division of Urogynecology and Reconstructive Surgery Department of Obstetrics and Gynecology
Faculty of Medicine University of Indonesia-Dr. Cipto Mangunkusumo Tertiary Hospital, Jakarta

Jakarta UrDate, Nov 4-6 2018

 Alfa Putri Meutia, MD

• Medical staff of Division of Urogynecology and Recontruction, Department of Obstetrics and

Gynecology, Faculty of Medicine University of Indonesia
• 2017-2018 :
Fellowship on Advanced Pelvic Organ Prolapse Surgeries Kameda Medical Center, Japan
• 2014-2016:
Urogynecology Subspecialty Program, Division of Urogynecology and Reconstructive
Surgeries, Faculty of Medicine University of Indonesia-Dr. Cipto Mangunkusumo Tertiary
Hospital, Jakarta
• 2009-2013:
Obgyn Specialty Program, Department of Obstetrics and Gynecology Faculty of Medicine
University of Indonesia-Dr. Cipto Mangunkusumo Tertiary Hospital, Jakarta
• 2001-2007:
Faculty of Medicine University of Indonesia, Jakarta
• Introduction
• Anatomy of perineum
• Classification of OASIS
• How to diagnose OASIS?
• How to repair?
• Take home messages
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Anatomy

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Anatomy

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Anatomy

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Classification

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Classification

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How to diagnose?

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How to diagnose?

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 How to diagnose?
• Making an accurate clinical diagnosis:
• Good exposure of the perineal injury
• Good lighting is essential
• Adequate analgesia may be given prior to examination, if necessary
• A vaginal and rectal examination should be performed to establish
the full extent of vaginal tear and exclude injury in the anorectal
mucosa
• If there is still uncertaintycontract the anal sphincter, a distinct
gap will be felt anteriorly
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How to diagnose?

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How to diagnose?

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• 1 RCT, 752 primips with clinically detectable 2nd degree perineal tears
• Assessment with EAUS prior to perineal repair
• The trial reported women’s AI at 3 (n=719) and 12 months (n=684)
• Primary outcome: Compared with clinical examination EAUS prior to
repair was associated with a reduction in the rate of severe AI (RR: 0.48,
95%CI 0.24 to 0.97)
• Severe anal incontinence at less than 6 months was also reduced
(RR 0.38, 95% CI 0.20 to 0.72)
• However, increased perineal pain at 3 months was associated with the
use of EAUS (RR 5.86, 95% CI 1.74 to 19.72)
Walsh KA, Grivell RM, Cochrane Database of Systematic Reviews 2015 Jakarta UrDate, Nov 4-6 2018
 3D TPUS vs 2D EAUS

• Prospective observational study comparing 2D EAUS & 3D TPUS

• 55 women with FI
• EAS defects were observed in 27 (49%) vs 19 (35%) patients
• IAS defects were observed in 15 (27%) vs 16 (29%) patients
• Cohen κ coefficient for the detection of external (κ = 0.63) and internal (κ = 0.78)
anal sphincter defects was good.
• Based on these data, 3D TPUS might be considered as a valuable alternative
noninvasive investigation method

Oom DM Dis Colon Rectum 2012 Jakarta UrDate, Nov 4-6 2018
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Anal mucosa

Sfingter ani
interna

Sfingter ani
eksterna

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 Transperineal US

External Anal Anal

Sphincter (EAS) mucosa

Internal Anal Pubo Rectalis

Sphincter (IAS) Muscle (PRM)

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 Anal sphincter abnormalities on TPUS

- EAS interruption

GUZMAN ROJAS RA, Ultrasound Obstet Gynecol 2013 Jakarta UrDate, Nov 4-6 2018
 Anal sphincter abnormalities on TPUS

- IAS interruption
- Thickness variation
- «Half-moon» sign:
- ↓ of thickness in rupture part
- and ↑ in the opposite side

- Interobserver reliability: 0.8-0.95

IAS

Weinstein MM. Clin Gastroenterol Hepatol 2009

Valsky DV. Ultrasound Obstet Gynecol 2012 Jakarta UrDate, Nov 4-6 2018
 72 hrs pp

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 3 months pp

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 How to repair?
• Know the anatomy and classification of perineal
tear
• Good lighting, adequate instruments and suture
materials
• Proper technique of repair
• Postoperative care and follow up

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 OR setting

Sterile area

Adequate
lighting

Adjustable Op
Adequate
Table instruments

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 Instruments needed?
• Retractor Weislander’s
• Forceps gigi (fine & strong)
• Needle holder (small and
large)
• Forceps Allis (4)
• Forceps arteri (6)
• McIndoe Scissors
• Scissors for suture
• Sims Specula
• Forceps for gauze
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Which suture material to use?

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 Which suture material to use?
SUTURE TYPES TENSILE STRENGTH ABSORPTION RATE TISSUE
RETENTION in vivo REACTION
Surgical Gut Chromic Individual patirent characteristics can Absorbed by proteolytic Moderate
affect rate of tensile strength loss enzymatic
Suture process.

Coated rapid Braided Approximately 50% remains at 5 Essentially complete Minimal to moderate
days. All tensile strength is lost at between 42 days. acute inflammatory
(polyglactin 910) approximately 14 days. Absorbed by hydrolysis reaction
Suture
poliglecaprone 25 Monofilament Approximately 50-60% (violet: 60-70%) Complete at 91-119 Minimal acute
remains at 1 week. Approximately 20-30% days. Absorbed by inflammatory reaction
Suture remains at 2 weeks.Lost within 3 weeks hydrolysis.

polyglactin 910 Braided Approximately 75% remains at 2 Essentially complete Minimal acute
weeks. Approximately 50% remains at 3 between 56-70 days. inflammatory reaction
Suture weeks, 25% at 4 weeks. Absorbed by hydrolysis

polydioxanone Monofilament Approximately 70% remains at 2 weeks. Minimal until about 90th Slight reaction
Approximately 50% remains at 4 weeks. day. Essentially complete
Suture Approximately 25% remains at 6 weeks within 6 months Absorbed
by slow hydrolysis.
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 Which suture material to use?
Tissue Suture material
Anal mucosa tear Polyglactin 910 no. 3.0
Internal Anal Sphincter Polyglactin 910 no. 3.0
Polydioxanone no. 3.0
External Anal Sphincter Polyglactin 910 no. 2.0
Polydioxanone no. 2.0

Vaginal mucosa and perineal Polyglactin 910 no. 3.0 (rapid

muscle absorption)

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End to end vs overlapping?

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How to repair?

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End-to-end vs overlapping technique

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How to repair?

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How to repair?

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 Postoperative care
•Antibiotics
•Analgesia
•Dietary advice and stool softener
•Patient information
•Follow up
• Management of subsequent delivery??
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 Take home messages
•Perineal trauma is the most common complication
during vaginal delivery
•Adequate lighting is essential to determine degree
of perineal tear properly and manage it correctly
•OASIS repair should be done in operating room to
have optimal result
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Thank You

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How to repair?

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