Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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132 Surgery and Healing in the Developing World
Place a second layer more superficial to these in a running unlocked subcutaneous
fashion from the hymenal ring to the apex of the laceration (here
you can pick up the suture used to close vaginal mucosa, avoiding an additional
anchoring stitch and knot). Finally, continue using the same suture
to complete the closure subcutaneously, sewing up from the caudal apex
until the skin is closed.
3. Third Degree: These lacerations penetrate the overlying tissues to involve
the anal sphincter. The external anal sphincter is composed of three bundles
of muscle fibers, the subcutaneous, superficial, and deep fibers. The subcutaneous
fibers form a ring enclosed in a capsule of tough white connective
tissue which you may often see exposed but undamaged in a deep second
degree laceration. If this capsule is invaded or the muscle incised or ruptured
the laceration is third degree. Place strong single sutures in the anatomical
superior, anterior, posterior, and inferior portion of the muscle. Try
to include a bit of fascia and capsule on each side of the ruptured muscle.
Do not tie until all four sutures are placed and you can test your closure by
pulling them snug (your assistant will be important here in holding the
untied sutures and helping to gently reapproximate prior to tying off the
suture). Ideally, the muscle should overlap slightly when reapproximated.
Place a few careful deep sutures to reapproximate fascia over the sphincter
muscle and avoid tension on overlying sutures. You may then complete the
repair as with a second degree laceration above.
Extreme caution must be exercised to avoid driving the needle through
rectal mucosa. You may encounter bleeding from branches of the inferior
rectal artery. Stop this with interrupted or figure-of-eight sutures in the
usual fashion.
4. Fourth Degree: Exposes the lumen of the rectum. If you have access to your
operating theatre, transfer the patient to the OR and complete the repair
there with support of anesthesia. Obtain good exposure to see the extent of
the tear in the rectum. Close the rectum with a series of interrupted 3-0 or
4-0 suture placed at about 5 mm separation. Perform a rectal exam to confirm
that you have closed the entire defect. Next, approximate a layer of
fascia over your repair. Finally, reapproximate the anal sphincter and complete
the repair as described above.
Your patient may have delivered elsewhere and come to you with a laceration
that is more than 24 hours old. If this is the case, you must delay the repair. Treat her
with BID 2 hour soaks in half normal saline until healing is well begun. She can
continue this treatment until epithelial regeneration is complete and infection has
cleared. King et al recommend waiting three months before attempting repairs and
undertaking them then only if referral is not possible. Minor lacerations will heal by
secondary intention during this period and may require no further attention. For
planned repair of old third and fourth degree lacerations, consult an atlas of gynecological
surgery.
Operative Obstetrics
A. Assisted delivery
B. Symphysiotomy