Repair of Obstetric Anal Sphincter Injury (OASIs)
Table of contents
Operative Note
_ indicates a section that needs to be reviewed or completed.
Third Degree
After informed consent was obtained, the patient was taken to the operating room. After adequate anesthesia was achieved, she was repositioned in the dorsal lithotomy position with her legs in yellow fin stirrups. She was prepared and draped in a normal sterile fashion for vaginal/perineal surgery with 4% cholrhexidine solution. A surgical timeout was performed and a Foley catheter was inserted into the bladder.
A Lone Star retractor was set up to aid in visualization. Copious irrigation was performed and profuse bleeding controlled with figure of eight sutures. Examination of the anorectum and vagina revealed the findings noted above. Specifically, the anal mucosa was intact.
We began the repair by identifying the internal anal sphincter and the extent of injury to this layer.
IAS REPAIR REQUIRED
The IAS was found to be injured and was closed in an end-to-end fashion with a running stitch of 3-0 PDS in a cephalad to caudad fashion.
IAS REPAIR NOT REQUIRED
The IAS was found to be intact so we turned our attention to the external anal sphincter.
COMPLETE EAS LACERATION
The external anal sphincter was then repaired in an overlapping fashion. Approximately 1.5 cm of sphincter was mobilized bilaterally. 3-0 PDS sutures were then placed posteriorly, inferiorly, superiorly and anteriorly. After all sutures were placed, they were sequentially tied in the above order.
PARTIAL EAS LACERATION
The partially lacerated external anal sphincter was then repaired in an end-to-end fashion using *** stitches of 3-0 PDS.
The vaginal muscularis was reapproximated with 2-0 monocryl and the perineum was reconstructed using 0 monocryl. Vagina epithelium and perineal skin were then closed with 3-0 monocryl. Copious irrigation and evaluation for hemostasis was performed with the closure of each layer.
Sponge, lap, and needle counts were correct x2. The patient tolerated the procedure well, and was taken to the recovery room in stable condition.
Fourth Degree
After informed consent was obtained, the patient was taken to the operating room. After adequate anesthesia was achieved, she was repositioned in the dorsal lithotomy position with her legs in yellow fin stirrups. She was prepared and draped in a normal sterile fashion for vaginal/perineal surgery with 4% cholrhexidine solution. A surgical timeout was performed and a Foley catheter was inserted into the bladder.
A Lone Star retractor was set up to aid in visualization. Copious irrigation was performed and profuse bleeding controlled with figure of eight sutures. Examination of the anorectum and vagina revealed the findings noted above.
We began the repair by identifying the margins of the anal mucosa and the apex of the laceration in this layer. It was then closed with a running stitch of 4-0 Monocryl. We then moved anteriorly to identify the internal anal sphincter and the extent of injury to this layer. It was closed in an end-to-end fashion with a running stitch of 3-0 PDS in a cephalad to caudad fashion. The external anal sphincter was then repaired in an overlapping fashion. Approximately 1.5 cm of sphincter was mobilized bilaterally. 3-0 PDS sutures were then placed posteriorly, inferiorly, superiorly and anteriorly. After all sutures were placed, they were sequentially tied in the above order. The vaginal muscularis was reapproximated with 2-0 monocryl and the perineum was reconstructed using 0 monocryl. Vagina epithelium and perineal skin were then closed with 3-0 monocryl. Copious irrigation and evaluation for hemostasis was performed with the closure of each layer.
Sponge, lap, and needle counts were correct x2. The patient tolerated the procedure well, and was taken to the recovery room in stable condition.
Postoperative Considerations
- Voiding trial on postop day #1 to evaluate for urinary retention
- NSAIDs and ice packs decrease opioid use
- Docusate and polyethylene glycol, if needed, for six weeks postpartum.
- Patients should be educated on performing twice daily sitz baths.
- Evaluate in the office 1-2 weeks postop
Supplies
Operating Room
- non-negotiable
Anesthesia
- regional or general
Antibiotics
- 2 g cefazolin (preferred)
- 900 mg clindamycin
Prep & Drape
- 4% chlorhexidine solution
- lithotomy in boots
- Foley catheter
Instruments
- vaginal hysterectomy or pelvic floor set
- EEA sizers or Lucite rods
- 2L NS irrigation
- suction
- foley catheter
Injectables
- bupivicaine with or without epi (whatever concentration is available)
Retraction
- Lone Star 3340G retractor with SHARP hooks
Suture
- Anal Mucosa = 4-0 Monocryl SH x 2
- IAS & EAS = 3-0 PDS SH x 6
- Vaginal Muscularis = 2-0 Monocryl x 3
- Perineal Body = 0 Monocryl CT-2 x 2
- Vaginal Epithelium = 3-0 Monocryl SH x 4