Suturing of perineal tears

Classification of Postpartum Perineal Injuries

In clinical practice, the severity of obstetric injuries is conventionally assessed by the depth of the involved anatomical structures. Traditionally, three degrees of rupture are distinguished:

• Grade I: Injuries are superficial in nature. Only the perineal skin and the mucosa of the vaginal walls are affected.
• Grade II: The trauma extends deeper, involving the skin, subcutaneous adipose tissue, the vaginal wall, and the muscular framework of the pelvic floor. The fundamental difference of this grade is that the anal sphincter (m. sphincter ani) remains completely undamaged.
• Grade III: The most severe variant of obstetric trauma. A complete rupture of the external anal sphincter, as well as a breach in the integrity of the intestinal wall itself, is added to the extensive injuries of the second degree.

Anesthesia: Pudendal Anesthesia Technique

During perineal surgeries, in addition to standard local anesthesia, pudendal anesthesia—a targeted block of the pudendal nerve—is widely used.

The execution technique involves several stages. First, the physician performs skin anesthesia, stepping back exactly 2 cm to the right and left of the perineal midline. Then, a long needle is used, which is carefully inserted into the depth of the ischioanal fossa (fossa ischiorectalis). Advancing the instrument through the tissues must be accompanied by the continuous injection of anesthetic solution ahead of the needle—a method known as creating a "creeping infiltrate".

To achieve a lasting effect, 50–60 ml of a 0.25% procaine solution is injected into each fossa. Presacral procaine block can be used as an effective adjunct to this method.

Surgical Treatment of Old Grade III Ruptures

The clinical presentation of a long-standing complete perineal rupture is extremely debilitating for the patient and manifests primarily as fecal incontinence. The goal of the surgical intervention is to re-establish the correct anatomical relationships of the pelvic floor, vaginal walls, and rectum.

The operation begins by stretching the scar tissue in the transverse direction using bullet forceps. Next, a scalpel is used to make an incision strictly along the scar.

The key and most critical step is the sharp dissection of the posterior vaginal wall from the anterior rectal wall. Important: the scalpel blade must be directed strictly parallel to the intestinal wall. This rule is strictly observed to avoid accidental injury to the rectum. The tissues are separated until the contacting walls achieve complete mobility. After this, the scar is split laterally and upward, preparing the surgical field for suture placement.

Layer-by-Layer Tissue Suturing Technique

Anatomical restoration occurs in a strict sequence. The essence of the method lies in the step-by-step conversion of a severe rupture degree into a milder one.

1. Restoration of the rectum and sphincter: Ligatures are carefully passed through the edges of the rectal wound. The main rule is to suture extramucosally, without piercing the mucosa. Threads and knots must be located exclusively outside the organ lumen, embedding into the surrounding adipose tissue. Catgut sutures are placed on the edges of the external sphincter (m. sphincter ani externus). This step allows a grade III rupture to be converted into a grade II rupture.
2. Suturing of muscles and vagina: Using interrupted catgut sutures, the surgeon sequentially joins the vaginal wall, the deep transverse perineal muscle, the medial portions of the levator ani muscle (m. levator ani), as well as the superficial transverse muscle along with the adjacent adipose tissue. Thus, a grade II rupture is converted into grade I.
3. Skin closure: At the final stage, interrupted silk sutures are applied to the perineal skin, completely closing the defect.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographic anatomy of the ischioanal fossa (fossa ischiorectalis).
• Innervation of the perineum and topography of the pudendal nerve.
• Structure and functions of the levator ani muscle (m. levator ani).
• Anatomy of the external anal sphincter (m. sphincter ani externus).
• Technique for performing a presacral procaine block.

Other topics in the section «Pelvic and Perineal Surgery»

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