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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 14-23 The anorectal mucosa is closed first.
The anal sphincter muscle is overlapped (as if doing an overlapping
sphincter repair) in a vest over pants-type manner. We prefer to use 2-0
polydioxanone (Figs. 14-24 to 14-26).
FIGURE 14-24 The anal sphincter is overlapped in a vest over pants-type manner.
FIGURE 14-25
FIGURE 14-26 First row of sutures in sphincter repair tied down.
An important step is to ensure that all dead space is taken up in the most
proximal portion of this overlap. If this is not done, a cavity can form,
which may lead to recurrence at the very proximal extent of the dissection.
The free end is tacked down in a similar manner with 2-0 polydioxanone
(Fig. 14-27).
FIGURE 14-27 Second row of sutures is placed along the overlapping muscle and
scar.
Closure of the vaginal mucosa and perianal body is done with simple or
mattress sutures of 2-0 or 3-0 polyglactin (Fig. 14-28).
FIGURE 14-28 Closure of the vaginal mucosa.
Finally, the skin over the perineal body is closed (Figs. 14-29 and 14-30).
FIGURE 14-29 Drawing of the perineal body closure.
FIGURE 14-30 Intraoperative photograph of the perineal body closure.
We sometimes do not close the skin tightly at the perineal body/vagina
junction to allow for drainage.
It is important to line up the hymnal ring when closing the vagina.
Tissue Interposition
When the sphincter is intact, particularly when there is a lot of scar in the
rectum, tissue interposition may be chosen. We use either the
bulbocavernosus (Martius) or gracilis muscle as the interposed tissue of
choice. We typically consider the bulbocavernosus first as the postoperative
problems due to mobilization of the gracilis can be significant.
For the Martius flap, we typically utilize the lithotomy position. The hair
is clipped over each labia, and the Foley is taped in the midline (Fig. 14-
31).
FIGURE 14-31 In the lithotomy position, the hair has been clipped and the Foley is
taped in the midline. This patient already has a stoma.
The entire perineal region is prepped and draped to allow access to both
areas of the labia. A probe is placed in the fistula, and a transverse incision
is made over the perineal body. The probe remains in place (Fig. 14-32).
FIGURE 14-32 The patient is prepped and draped so there is access to each labia. A
probe is placed through the tract.
A transverse incision is made over the perineal area (Fig. 14-33).
Dissection is carried in the rectovaginal plane utilizing a finger in the anus
or vagina to ensure you do not button hole during the mobilization.
FIGURE 14-33 A transverse incision is made.
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