Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

1 1 0 0 S E C T I O N X I V • G Y N E C O L O G Y

The labium majus is incised to obtain the Martius bulbocavernosus fat pad (Figure 99-13).

In this case, the blood supply from the external pudendal artery is ligated.

The internal pudendal artery provides the blood supply inferiorly.

The flap is largely composed of adipose tissue, because the muscle is not very prominent

(Figure 99-14).

1 1 0 4 S E C T I O N X I V • G Y N E C O L O G Y

The rectovaginal fascia is sutured to the center of the perineal body (Figures 99-19 and 99-20).

The transverse perineal and bulbocavernosus (also called bulbospongiosus) muscles join the anal sphincter and rectovaginal septum at the perineal body.

If these muscles are not inextricably bound together, they may be joined end-to-end. If there is excessive perineal laxity, the perineal muscles may also be overlapped, but such overlap may require extensive lateral dissection of the transverse perineal muscles toward the ischial tuberosities (Figure 99-21).

1 1 0 6 S E C T I O N X I V • G Y N E C O L O G Y

A 00 or 000 rapid absorbable suture is used to close the vaginal mucosa and perineal skin

(Figures 99-22 through 99-24).

STEP 4: POSTOPERATIVE CARE

The most common short-term complication is urinary retention, so a urinary catheter may be necessary until the normal micturition reflex recovers.

Postoperative management consists of careful perineal hygiene and stool softeners.

Excessive antibiotic use in the absence of infection may lead to diarrhea and impaired wound healing of the rectal mucosal suture line, in addition to the increased risk of infection with resistant organisms.

Although perineal skin breakdown is common, it does not seem to affect the ultimate success of the repair.

STEP 5: PEARLS AND PITFALLS

Long-term functional outcome of overlapping anal sphincteroplasty may be disappointing, with anal continence rates as low as 50%.

Patients should be counseled that restoration of anatomy does not guarantee restoration of function.

1 1 0 8 S E C T I O N X I V • G Y N E C O L O G Y

SELECTED REFERENCES

1. Martius H: Die Gynäkologischen Operationen. Leipzig, Georg Thieme, 1949.

2. Hankins GDV, Hauth JC, Gilstrap LC, et al: Early repair of episiotomy dehiscence. Obstet Gynecol 1990;75:48-51.

3. Mengert WF, Fish SA: Anterior rectal wall advancement. Technique for repair of complete perineal laceration and rectovaginal fistula. Obstet Gynecol 1955;3:262-267.

4. Noble GH: A new operation for complete laceration of the perineum designed for the purpose of eliminating danger of infection from the rectum. Trans Am Gynecol Soc 1902;27:357-363.

5. Sultan AH, Kahn MA: Perineal and primary anal sphincter repairs. In Cardozo L, Staskin D (eds): Textbook of Female Urology and Urogynecology. London, Isis Medical Media, 2001, pp 628-642.