Welcome to today's webinar. I'm Dr. Ludmila Lipetskaya, the moderator of today's webinar. Before we begin, I'd like to share that we will take questions at the end of the webinar, but you can submit them at any time by typing them in the question box on the left-hand side of the event window. Today's webinar is titled Pediatric Anal Sphincter Injuries and Rectal Vaginal Special Repair. What is the best approach for repair? And it's being presented by Dr. Christina Luyke-Gapp. Dr. Luyke-Gapp is OB-GYN and CPMRS certified and graduated from University of Michigan. She's an Associate Professor as well as a Director of Research for Gynecologic Surgical Simulation and Assimilation in the Department of Obstetrics and Gynecology at Northwestern University. Dr. Luyke-Gapp is a passionate and gifted surgical educator, receiving the Residence Excellence Teaching Award for three consecutive years, and she recently completed a very prestigious competitive surgical scholars program at APCO. Her research and clinical interests include prevention and treatment of childbirth-related pelvic floor injuries and the relationship between anatomic defects on pelvic floor imaging and pelvic symptoms. She is a Medical Director of Perry Park Home Assessment and Evaluation Clinic, and she has ongoing funded research, which includes prospectively following a large cohort of women with obstetric and sphincter lacerations. She has authored and coauthored many, many, over 25 scientific papers and currently serves as a reviewer for several journals. Dr. Luyke-Gapp's clinical interests include childbirth-related pelvic floor injuries, uterine fecal incontinence, and pelvic organ prolapse. So, without further ado, please welcome Dr. Luyke-Gapp. Thanks, Ludmila. I want to thank AUGS and the Education Committee, for which I sit on, for having the opportunity to give this talk. So, I have no disclosures. So, why do we care about, you know, anal incontinence after birth, and how common is the problem? Well, on the left side, you can see our statistics at Prentice Women's Hospital, which is a women's hospital affiliated with Northwestern. We have about 12,000 live births a year, 8,000, almost 9,000 of those are vaginal deliveries. About 3.7% of the time, there's a sphincter disruption, and as we know, anal incontinence as a sequelae of these is about 25% of the time, which translates into two new cases every week, just at Northwestern alone. In comparison to the United States, you can see that we have about one new case every 14 minutes. So, I would argue that, you know, recognizing oasis and rectal vaginal fistulas and anal incontinence is not an uncommon issue. So, prevention is all about modification of risk factors, right? So, there's certain things that we can modify when it comes to the development of obstetric anal sphincter injuries, and other things that we cannot. Similarly, I think there's stuff that we can do to decrease our risk of wound complications when it comes to these injuries, and hopefully prevent the long-term sequelae. So, in 2015, we published a large prospective cohort in the Green Journal, which we affectionately called the Forecast Study for Optimal Recovery Care After Severe Tears, where we hope to estimate the incidence of and risk factors of wound complications in women who sustained obstetric anal sphincter injury. This was a prospective cohort study over the span of about two years, and what we did was have every woman who sustained an oasis be seen in the FPMRS, or urogyne clinic, the peripartum clinic that Lyudmila mentioned before, within a week of delivery. We saw them again at two, six, and 12 weeks postpartum, and at each of these visits, not only would they fill out numerous questionnaires about their quality of life and incontinence symptoms, but we also had them, their wounds assessed, and assess their pain scores as well. Total, we had about 615 women who sustained oasis, about 502 met inclusion criteria. We had, you know, these are new moms, so we did have some other exclusions, and ultimately, we looked at 268 women. The demographics of the patient population pretty much reflect what we see at Prentiss Women's Hospital, which is, you know, a fairly young population, mostly Caucasian, mostly noliparous. The majority that came to the clinic with oasis had an operative vaginal delivery, and it should be noted that we're one of the few institutions in the country where forceps-assisted vaginal delivery is far more common than vacuum-assisted delivery. So, not surprisingly, 66% of the cohort had a forceps- assisted delivery. The majority had a third-degree laceration, 20% about had a fourth degree. Fifty-four, almost 55% were given antibiotics during their admission for some sort of an indication, and at that time, about 34% were given antibiotics for the sole indication of having a severe laceration, and what we found was that operative vaginal delivery in and of itself was associated with an increased risk of wound complications with an adjusted odds ratio of over two and a half, and that if they received intrapartum antibiotic therapy for any indication, that, not surprisingly, was associated with a decreased risk of wound complication. The two things already there that we can do is modify our obstetric practices with, you know, hopefully not doing as many forceps deliveries, and also being cognizant about antibiotic therapy when these wounds are repaired in postpartum, and we're going to talk more about that in a little bit. So, let's say you do everything right, and instead, this happens. So, here we have a good example of a rectovaginal fistula in the setting of an obstetric anal sphincter entry. You can see the finger going through the rectal mucosa into the vagina, the lack of the external and internal anal sphincters. So, what do you do? Well, I think there's just basic rules of engagement. You know, disclose it to the patient, move to the operating room. I can't tell you guys how many times we see patients in the PPOD clinic, and they say, I don't know why I'm here. I had a third degree. What does that mean? Now, whether or not it's because patients don't remember, they're being told what's happened in an inopportune time, delivery is overwhelming, or whether or not we're even disclosing these injuries and kind of why we would be disclosing these injuries, you know, remains to be figured out. But that being said, you know, good lights, appropriate equipment, retraction, treat it like a surgery. You know, this self-retaining retractor, the Lone Star, is one of my favorite tools to use. Alice clamps are necessary. Those are usually not on the delivery tray. Ask for it ahead of time. Dose the epidural. Give them good anesthesia. It not only allows the external anal sphincter to relax so you can access it better, but it also relaxes the patient and makes the experience a lot less traumatizing. Grade it. Document it as an injury. And I'm sure everybody who's in the urogyne world is up to date on, you know, the latest and greatest classifications with 3A, 3B, and 3C. So, I'm not going to go into that, but I think it's important to know because as you guys probably know from, you know, reading and studies that, you know, our field has put out that the consequences of the 3A versus the 3C oasis can be very different, especially in the long term. So, what kind of suture? Well, why not chromic? This is pretty well known and even the general surgery literature that chromic is associated with an increased risk of wound infection and dehiscence. It causes a much more significant tissue reaction because you need enzymes to break it down. And there's studies that show that it's particularly painful in the first three days postpartum. Generally, at Northwestern, we've gotten chromic removed from all of the delivery trays. I think there's still one provider that uses it, but that's a lot better than what it used to be. And we have over 200 practicing OB-GYNs in labor and delivery. And PDS, this is what we always recommend for the internal and the external anal sphincters. They're monofilament, so there's less of an infection risk and they retain their tensile strength over 50% of it even at three months, which when it comes to healing something like muscle rather than mucosa, which heals very quickly, I think serves its purpose. Vicryl, we use this for the vaginal mucosa, the transverse perineal and the bulbocavernosis muscles if you can. This is stronger than monocryl, so you still have some tensile strength at three weeks, but there's definitely less effects from retained suture at the postpartum visit and less analgesic use when you use something like Vicryl. And monocryl is our go-to for the anal mucosa. As you guys know, mucosa heals very quickly, so retaining tensile strength for long periods of time is not as important when it comes to the anal mucosa. So, you know, when I was training as a resident, you know, we put all this emphasis on, you know, where the knots are, where, you know, where do we put things when it comes to the anal mucosa, don't go through and through. I think all of that's pretty much been debunked. Running or interrupted sutures going through and through the anal mucosa with 3L or 4L monocryl is very acceptable. If there is a concurrent fistula at the time of the repair, which we'll look at in a little bit too, I still, you know, was trained and often do excise the tract in order to really get those edges to be fresh. Less important than if this isn't within the first week or two postpartum, but certainly once the tract has been epithelialized, I know some people just, you know, close over and don't excise it. I traditionally do. The internal anal sphincter complex, I think is very important. We know that it provides 80% of resting tone of the sphincter complex as a whole. It can be challenging to identify, but it is important because we know that if you don't repair the internal anal sphincter, those women have a much greater risk of having bowel symptoms compared to those who have an intact internal anal sphincter. Interestingly, as a kind of anecdotal surprise, we cover three different hospitals as urogynecologists in our system here at Northwestern. And there was one night where I was covering a call downtown and was doing some C-section disaster, not the obstetric part of it, but, you know, VBAC, ruptured uterus, ruptured bladder. And at the same time, I got called to one of our community hospitals to help repair a woman who had a C-section. And so, you know, help repair a third or a complicated third degree tear. I couldn't come since I was scrubbed. And what I said is, why don't we do what they do in most of Europe? I said, if the patient is hemodynamically stable and not bleeding, just pack her. And as soon as I'm done here, I'll come. Well, I ended up coming the next morning, just given the disaster that I was attending to downtown. And it turned out with, you know, just six hours of being packed, a lot of the edema was gone. And I was, for the first time, I think, in a long time, able to clearly identify the internal anal sphincter. So, just a fun story, but it made the repair much easier and very satisfying to be able to separate the two structures and fix them separately. So, the external anal sphincter, I mentioned the Alice Clamps to identify the torn edges, bring them in the midline, try to identify the fascial sheets surrounding the muscle. For this, really, if you can get some PDS, I think, again, it can make a difference with healing. That being said, there's a few studies on this, but, you know, there was a study out of B-Jog in 2006 that showed really no difference in fecal incontinence symptoms at six weeks postpartum in women whose sphincter was closed with PDS versus a delayed absorbable like Vicryl. Overlapping versus end-to-end. Now, in the delivery room, it's very difficult to do an overlapping. You know, the tissue is edematous, the patient's not comfortable necessarily. So, I think most of the time, at least our providers, just do an end-to-end. There was a Cochrane Review in 2013 looking at whether or not overlapping versus end-to-end was better than the other with various outcomes, and I'll show you those in a minute. But essentially, this Cochrane Review included over 580 women that had at least a grade 3C laceration or greater. So, this really was OASIS, you know, 3C being the internal anal sphincter was torn as well, and, you know, obviously, fourth degrees were included, and that's with the rectal mucosa being torn. And what they found was that actually there was no difference in many outcomes at 12 months with perineal pain, dyspareunia, flatal incontinence. There were some lower fecal urgency rates with the overlapping and lower overall anal incontinence scores with the overlapping, but all of that sort of disappeared in the long run. Because at three years, there was no difference in flatal incontinence or fecal incontinence symptoms in these women. So, what about antibiotics? Are they protective? Well, unfortunately, there's only been really one good study looking at this. Dougal et al. did a RCT placebo-controlled study that was published in The Green a few years ago, where over 140 women were given ANSEF, basically, or placebo at the time of repair. Everybody got a pretty standard repair, and this, again, was women who had a third degree or higher. And then afterward, everybody was counseled on good, you know, perineal care measures, et cetera. And their primary outcome was wound complication, which included breakdown or infection, and it was a relatively short follow-up period. It was about two weeks, postpartum. So, what they found was that there was no difference in the two groups with respect to wound disruption, but they did see less purulent discharge in women who were treated with the cephalosporin at the time of repair. And overall, they had lower wound complications in women who were given the antibiotic. Unfortunately, the study had a pretty high no-show rate. It was clearly underpowered, and so I think this wasn't widely adapted. And sadly, you know, there's been no studies in this country or elsewhere looking at the efficacy of postpartum antibiotic regimens and the rates of wound infection or breakdown in women with OASIS. So, we actually, where I trained in Ann Arbor under the auspices of Dr. Funner, followed RCOG guidelines, and I've sort of brought that to Northwestern. And basically, you know, looking at expert opinion, level B evidence, RCOG recommends broad-spectrum antibiotics at the time of repair and also for one week postpartum. So, our model in the PPOD clinic is that women receive cefazolin at the time of their repair and then augmentum flagellum or levoflagellum for seven days after OASIS. I can tell you when we first started the clinic and the forecast data came out with looking at the high rates of wound complications with OASIS, we now probably have an over 95% rate of cefazolin at the time of repair and probably about 70% of our OASIS patients get postpartum antibiotics. I can tell you, while it's anecdotal, we're hoping to share, you know, some data at our next couple of meetings. Essentially, PPOD has become very boring. We're seeing much less wound complications, much less wound breakdown, much less infection, much less perineal revision. So, in our study, we concluded that women with OASIS are at high risk of wound complications in the early postpartum period, that immediate and consistent follow-up was warranted, and ultimately we saw decreases in hospital readmission rates for wound complications. And now, you know, we consistently in our peripartum clinic see upwards of anywhere from 10 to 20 patients each week that are new with OASIS. And, you know, I'll talk a little bit about what we do for them, but in summary, we need to identify each layer separately and use the appropriate feature type. End-to-end repairs of the external anal sphincter are comparable in the setting of OASIS to overlapping repairs, and intrapartum antibiotics are protective against wound complications. And, like I mentioned, we generally do see that most women are getting one week of antibiotics after delivery. So, early surgical intervention, there's really no level one evidence looking at someone who comes in with a OASIS rectovaginal fistula on immediate versus delayed repair. It's really based on expert opinion. There's one study in the literature of 22 women who had immediate repair within 14 days, and they found versus after a year, and they found no difference in their outcomes and quality of life. But, again, this is only 22 women. Generally, what our expert opinion suggests is that for chronic sphincter disruptions three months out, you know, PT, medications, interstim. So, with our patients, we looked at our data, and, again, it's only an N of 18, but this was in patients who presented in less than two months postpartum. We looked retrospectively at those who ultimately underwent surgical repair, and we looked to see, based on CPT code, how many of these patients we had. We ended up with an N of 18, and, you know, these surgeries were all done by the four attendings that are in our division. We now have six. Fellowship trained, we looked at postoperative complications using the clavigendo system and followed them through the first three postoperative months. Most were primiparous. Most were in their, you know, mid-30s. The majority were Caucasian, not surprisingly. Fifty percent had forceps assisted vaginal delivery. Shockingly, 50 percent of them had spontaneous deliveries complicated by OASIS. Babies were of good size. You know, over half had a third-degree tear. We had two that were identified as a second-degree laceration at delivery, but actually did have an OASIS, and we saw them within 10 days of their injury. They were all diagnosed with wound breakdown. 33 percent had a concomitant perineal infection and were cooled down with amoxicillin, clamulonate, and flagyl. Seven of these patients, almost 40 percent, had a concomitant rectovaginal fistula. Two of these were in the setting of an infection, and the median time to diagnosis of a wound complication to the time when we took them back to the OR was only about three weeks. So, relatively quick turnaround and take back to the operating room. All of these women we operated on under the ERAS protocol, which basically involves, as you may or may not know, the same kind of rules of engagement of gynecologic surgery. So, we weren't bowel prepping anybody, which was, again, contrary to how I was trained. We did not give them narcotics if we could. We did, you know, fed them up until two hours before with Gatorade, all these things. We discharged them with the antibiotic regimen that I mentioned, and I actually think that aggressive perineal care is just as important as antibiotics. Everybody was instructed on BID sips baths, as well as good drying techniques. We did not go overboard with bowel regimens afterward. I think we err a lot on kind of putting patients into diarrhea, and in my opinion, having diarrhea going through a newly repaired fistula with a sphincter tear is probably worse than having a little bit harder stool. So, we generally say keep your stool at the consistency of something harder than toothpaste, and give them the option of using, you know, anything, whatever it takes to get them there, whether that's Miralax and Colace if they're particularly constipated, or sometimes even Imodium if we do see some, you know, GI upset with the antibiotics, then we tell them to do half an Imodium a day if necessary. So, of these women, 94% had an overlapping external anal sphincter aplasty, and again, this is because this is not in the delivery room. So, these women are a couple weeks out of delivery. Forty-one percent of them had a concurrent rectovaginal fistula repair. One just had a peroneoraphy. We had only five minor complications, two of which were urinary retention, which required intermittent self-catheterization, and two which were superficial wound separations, and that was just the peroneal skin kind of separating, but all that required was aggressive peroneal care. We had one grade two complication, which was a wound infection with a breakdown, and unfortunately, this woman ended up with an extra week of antibiotics and some packing, but ultimately granulated and well. At three months, we had no evidence of wound breakdown in anyone. Everyone underwent physical therapy for at least three months, and so from this, we were really excited to see that early repair in these women who have complicated oasis in the setting of a rectovascular fistula as well. You can fix them early, and it's feasible and successful. So, I wanted to just go through some kind of anatomic drawings with you guys, and then ultimately, we're going to look at some videos together. So, this is sort of step-by-step how you can repair transperineally a rectovaginal fistula. So, this is from the Wheelis Atlas, and you can see in figure one that the fistula tract has been removed down to the rectal mucosa. This is that circumferential excision, and then the margins of the vagina you elevate and really dissect and mobilize around the fistula. I think this is of paramount importance. The more you can mobilize, the better. Here, it looks like we're dealing with an intact anal sphincter, so I would highly recommend not disrupting an intact sphincter that's functioning, but let's pretend I'll show you the next picture that the patient actually looked like this. So, I don't know if you guys can see my arrow, but this is essentially almost like a cloaca. There's a dovetail sign here. This is not a functioning sphincter, and I think this is the type of repair with the fistula in here that you would come through and transect that in order to, A, better access your fistula, and B, be able to fix the sphincter itself. So, if we look at this next picture, you can see the surgical removal of the fistula, the perineotomy with the transected sphincter, and again, let's pretend that we have that patient that didn't have an intact sphincter, and then, you know, you've gone through the superficial transverse perineal muscles and really, really have developed that rectovaginal space. I think a good rule of thumb is at least a couple of centimeters around the entire circumference if you can. Here, they're showing a far-to-near stitch to repair the anal mucosa. I would argue you can do what we talked about before, which is either running or interrupted. I think it's been shown that there's no data looking at whether or not the knots need to be inside the lumen. I know the classic training is that the knots should be tied in the lumen to prevent, you know, it being a wick for bacteria. Again, I think that's really not as important anymore. And again, this is showing those same kind of far-to-near sutures, cutting the excess stitch, and then, you know, mobilizing. So, here is where if you were going to do something like a Martius flap, and we're going to, I'm going to show you a video of that in a little bit. This is where once your mucosa has been closed that you would drop that flap and then try to kind of go out laterally, not necessarily looking at, you know, the levators or doing a levator placation, but finding some endopelvic fascia to be able to kind of have a interposition between your rectal suture line and ultimately your vaginal suture line. This, again, is showing the approximation of the levator ani muscles. I would argue you don't want to really get the levators. You want to get some sort of intervening tissue and then bring back together the superficial transverse peroneal muscles and then ultimately close the vagina over it. With the vagina running, synthetic absorbable suture would be our choice, like leoglycryl. Some people like monocryl. Here is a example of that in real kind of surgical time, if you will. You can see this patient has essentially a cloaca as well. You don't have to do this kind of inverted U. I think what this allows you to do is gain access laterally to that external anal sphincter. So I do like doing things this way. We then move and mobilize that vaginal mucosa cephalad and ultimately the allyses get put on the external anal sphincter and you try to mobilize as much as you can. Usually one side declares itself as the external anal sphincter, as being the side that is more easily dissected out and is going to be the overlapping part of it. Here's an example of the internal sphincter being sewn and then the external coming together in an end-to-end fashion. If you look at wheelists, they talk about this 90-degree angle. I think that really, again, speaks to what we don't want to happen. That is from a levator placation, which in someone who you're doing a copal claism, great idea, but not so sure you want to have that 90-degree shelf, if you will, in someone who has just completed having a baby and is going to be sexually active. So here's just a graphic depiction of that vest over pants. This is something that I find very difficult to teach to residents unless you actually have them sitting next to you and you can show them, doing the near to far, far to near, and ensuring that you get a good overlapping repair. So to Martius flap or not to Martius flap? In my experience, this is just, again, a graphic description of what I'm going to show you a video of in a little bit. Martius flap at the time of repair, really, I think of Oasis and rectovascular fistula is not necessary. This is more, I think, someone who has a rectovascular fistula in the setting of radiation, someone who's been fixed transvaginally, transperineally before and has recurred. While I was trained in the era of like, this is a very morbid procedure where you're going to have drains coming out of the labial fat pad. I have never, in the times that I've done these repairs, left a drain in. I think as long as you obtain excellent hemostasis, even with the hemostatic agents that we have now that you can add to your surgical hemostasis, I haven't ever put in a drain into the labia. Doing a Martius flap, essentially for a rectovascular fistula, you're going to amputate the blood supply to the labial fat pad superiorly and then ultimately preserve the inferior blood supply to then be able to flap it through and over your repair. And again, the goal of this is to provide vascularity and not only that, but also to the repair, but also to be able to separate your two suture lines, one being the rectal suture line and the other being the vaginal suture line. This next picture is just sort of not coming up very well, but I'm going to show you guys a meeting from the annual colorectal surgery meeting. I think one of us in Uruguay needs to make a good Martius flap video so we can show it next time. But essentially, you know, this is showing how you make an incision over the labial fat pad using meticulous. I always use a Bovi meticulous dissection. You're going to mobilize the fat pad off of the bone, kind of lateral to medial. In the video, they don't kind of, they don't clamp across the blood supply. I think that that's important to kind of undermine it right at the superior aspect of the fat pad and suture ligate. You can, you know, you got a good blood supply there. And so you'll see in the colorectal video, they're clearly not concerned about, they have excellent hemostasis despite that. I wonder, you know, why, but I think tying it off as this picture was trying to show there's a suture at the top of that fat pad, which you can then use to help guide your fat pad into your repair. I then close the labial skin incision with interruptives. I think drainage is important. You know, doing a, you know, the deep tissue, a couple of interruptives into the deep subcu, I think makes sense. And then closing the skin with some interruptives to allow any seromas to drain. I suppose if I put a drain in, you could close differently. But I wouldn't recommend closing with a subcuticular or anything like that. I think less is more in these scenarios. And when we watch the video of us doing the actual repair, you can see that even with the perineal skin, we generally do just interruptives to allow for drainage between the rectum and the vagina. So now I want to, in a second, just show you part of this video where they mobilize the fat pad and how they kind of bring it in. So I think we could cut to that. The incision was then made in the labia majora to expose the labial fat pad and bulbo cavernosus muscle. The bulbo cavernosus was identified and mobilized laterally. Can you tell me what's going on in the video? One has to remember that the blood supply to the flap. Like are they incising the labia? In inferior location from the posterior labial vessels. Okay. And then just let me know once they grab that fat pad and swing it into the vagina. Along the pubic bone. Okay. The rectovaginal fistula was re-identified with a lacrimal probe. At this point, the fistula was curetted at both openings and the vaginal side closed with a figure of a 2-0 vicral suture. The vaginal flap was trimmed down to healthy vaginal tissue proximal to the fistula opening. A window was then created using a right angle clamp from the base of the labial incision to the rectovaginal septum. The defect was widened to prevent damage to the blood supply and to prevent kinking of the blood supply. The flap was gently delivered through the defect into the rectovaginal septum, avoiding twisting and maintaining proper orientation. It was then trimmed down to accommodate the rectovaginal septum space. The flap was then attached into the rectovaginal septum with internal forced air through the rectovaginal septum. The flap was then re-approximated to the labial incision using an interrupted 2-0 vicral suture to hold it in place. A lacrimal probe, which is not showed in the video, was used to confirm closure of the space. The vaginal flap was then re-approximated to the introitus using interrupted 2-0 vicral sutures, making sure to avoid any tension. Hopefully you guys got a sense of the general steps of the procedure. And then I think to kind of close things out tonight, we're going to watch a video that we put together out of our division looking at the repair of Oasis with a concurrent rectovaginal fistula. And then I'd be happy to take questions. So let's play the video. The patient is a 29-year-old G1P1 who underwent spontaneous vaginal delivery complicated by a fourth-degree perineal laceration. The primary repair was performed in the delivery room with appropriate antibiotic prophylaxis. However, her postpartum course was complicated by a perineal wound breakdown. The exam at three weeks postpartum was significant for a large external anal sphincter defect, an attenuated perineal body, and a 2-millimeter rectovaginal fistula. Located approximately one centimeter above the anal sphincter complex. In the operating room, we first begin by identifying the rectovaginal fistula with a lacrimal probe. Using sharp dissection, we proceed to incise the cloaca towards the fistula's tract. The tract is then excised. Next, we identify the ends of the retracted external anal sphincter muscles and grasp them with Alice clamps. These are dissected out using a combination of bogey cautery and blunt dissection. Medial traction is applied while dissection is performed in a circumferential manner around the cylindrically shaped sphincter muscle. The right half of the external anal sphincter muscle has been mobilized. We now perform the same dissection on the patient left. The right and left halves of the external anal sphincter muscle can now overlap without excessive tension. The rectal mucosa is re-approximated using a fine absorbable suture such as monocryl. The internal anal sphincter is then re-approximated using 3-O-PDS suture in a mattress fashion. We now re-approximate the external anal sphincter muscle in an overlapping fashion using 2-O-PDS suture. We now re-approximate the external anal sphincter muscle in an overlapping fashion using 2-O-PDS suture. The perineal repair is performed by bringing together the bulbocavernosis muscles. We then re-approximate the vaginal mucosa in a running fashion. The transverse perineal muscles are brought back together. And finally, the skin of the perineum is re-approximated. At the end of the procedure, the patient's perineum is approximately 4 centimeters in length. And the external anal sphincter has excellent bulk. So that's it from our perspective. I want to thank everybody for tuning in tonight and I'm happy to take any questions. What kind of perineal care you were mentioning at all before and if you can address the specific of your aggressive perineal care routine? Sure, it's a great question. So I think the short answer is yes, that we should expect successful short-term and long-term outcomes after sphincter repairs. You know, with all of our sphincter repairs, they are generally done, you know, as an outpatient. We don't limit women with what they can and can't do. You know, we do send them home with a full seven days of augmentum flagellum. And I can tell you honestly, while it's, you know, I showed you guys some of our short-term outcomes that, you know, we haven't published yet. I can tell you anecdotally that with the proper kind of management, i.e., I see these patients essentially twice a week until they're totally healed to ensure that they don't have a breakdown, that they're doing everything they should be doing, that yes, they can go home same day even and return to their normal activity with good pain control. The perineal care that we recommend is twice daily, even three times daily, sits back for 10 to, you know, 15 minutes. I generally put women in their own bathtub. I think it's a lot easier to sit in a bathtub and more comfortable than it is to, like, hang your perineum over a sitz bath, but whatever is more feasible for the patient to do. The whole, like, hold a handheld shower, I said to the patient, you know, it feels like it's five minutes that you're doing it, but you're actually probably doing it for, like, two minutes. So the whole handheld shower thing doesn't work. I think immersion and then good drying, even a hairdryer on a cool setting to dry that area afterward makes a big difference. I mentioned that, you know, try not to give them diarrhea. I think that can inflame the area that can cause skin breakdown that can cause skin irritation. Closing that perineal skin with interruptives rather than a subcuticular. I think that has made a big difference in my own practice. You know, the women that I would see with breakdown, you know, or separation of the skin and pain were the ones that I put too much suture in. I remember as a fellow defender telling me, don't even close the skin, it's going to open up. And, you know, I still close it a little bit, but I leave big gaps so that there can be some drainage. And I really think the key to this is just aggressive, aggressive follow up. You know, things can change on a dime, you know, whether it's the, like, one or two cases a year I see of C. diff, you know, because we've got them on these antibiotics. Regimens getting that, you know, taking care of sooner rather than later, but figuring out that the patient's like, you know, I didn't realize I had to take twice daily since bath or, you know, just troubleshooting things in a timely and early fashion is what makes it feasible for them to go home the same day and do really well. With respect to the, who should be doing these sphincter repairs. I mean, I'm not sure I'm the right one to speak to this because clearly I'm biased, but I absolutely think it should be in our armamentarium and we are the experts when it comes to this. I have seen so many debacles when it comes to colorectal surgeons trying to fix complex fistulas or fistulas in the setting of, you know, Oasis, that, you know, in my opinion, we're the ones that should be doing it. I've given expert witness testimony against colorectal surgeons that have not done the job appropriately. I think the go-to trick for a lot of these surgeons is rectal advancement flap and then put together the sphincteroplasty, you know, somehow. I think rectal advancement flaps certainly have a place. I'm not sure they have a place in someone who has a big hole there because of, you know, a birth injury. A birth injury. So, while I can't, I'd have to look at what has been published in the colorectal, recently in the colorectal surgery literature, I would argue that we as urogynecologists have published the most on these repairs, early repairs, late repairs, overlapping, end-to-end fistula, Martius, no Martius, you know, I think we have a much more robust background and are much more better equipped to do this. Well, thank you. And a couple more. So, one is in regards of 3A degree injuries, do you recommend repairs in OR for all kind of third degrees or 3A might be still okay to be repaired in delivery room? Yeah, I think that the short answer is whatever allows you the best exposure. The times, you know, that I've been called in to help someone with an oasis, few and far between. We have enough of them, sadly, at Northwestern that, you know, the generalists are very good at repairing them, but the times that I've been called in to help are the times where the patient has not been in an optimal position, still in the L&D bed, not in the OR and really all you need is good exposure. So, all I've done is move them to the OR, put them up in, you know, good stirrups and the generalist is like, oh, that's easy enough, you know, I don't really need you. So, I would argue that if you feel like you can get good exposure, good lighting, good anesthesia in the delivery room, but especially for something like a 3A, absolutely you could do it, but I don't think you would be wrong ever to take the patient back to the operating room. While it can be a pain in the butt, you know, I think you would, you will get your best exposure there and you're not going to miss anything, hopefully, in the operating room. You know, I've seen patients who they've had their 3A repaired or their 3B repaired and a buttonhole fistula, you know, two centimeters above the external anal sincter was missed and because the patient probably didn't have adequate exposure. So, while I think it's fine to do it where you are most comfortable, I think you can't go wrong by taking those patients back to the OR. That question is technical in terms of, in regards to your video, you showed midline incision, is there any role for inverted U incision when you're trying to spare that midline? Yeah, so the video did show a midline and I almost always do an inverted U, that just happened to be like my best video, that showed things more clearly as far as the procedure is concerned and also had that concurrent fistula repair, but I do like the inverted U absolutely because I think it just gives you easier access to the sphincter. The other thing that it can do, especially in someone who's got like a cloaca, is that inverted U, when you ultimately close the skin vertically, if you will, from that horizontal incision, it can give you a much better perineal body and much more bulk and also more space between the vagina and the rectum, which I think is really helpful and a midline, you don't get as much that way. And can you speak to your protocols and your people clinic in terms of how many times, how often do you see patients and do you do ultrasounds or just physical exam, what is your basic routine for? So essentially, we put together more of a research-based protocol where everybody that comes in with an OASIS, we see within a week of delivery. They then return a week later for an endovaginal ultrasound to look at the levators and also the sphincters. That is not based on anything, you know, that's just what everybody gets mostly under the different study protocols that we have going on. That being said, if someone is symptomatic, you know, we have seen symptomatic patients who a week later come back with a sphincter that feels intact on exam and is broken and those are the patients that we take to the operating room to fix their sphincter. But generally, it's a one week, two week and then at the two week, we have our physical therapist kind of lay eyes on the patient, teach them some home exercises to get them kind of started in the process. And then we tell the patients two weeks from now, go see whichever physical therapist is most convenient on our list and we send every single patient to pelvic floor physical therapy that they start usually around four weeks postpartum. In terms of technical safety counts and repair, how do you address skin? So when you finish up, do you interrupt or do you run the features? Yeah, I used to, you know, really clean everything up and have this like perfect skin repair. I absolutely do not do that anymore because like the funder told me 10 years ago, it's going to break down. So I really like just interrupting the perineal skin to give that exit of any seroma, blood, whatever. So the short answer is I almost always interrupt the perineal skin. And I don't want about the matches. Sorry, it's a very popular topic. You're getting a lot of questions. And what I don't want is Martial Flabs technique. So when you do that, do you use just subcutaneous tissue or you really try to include muscle and the flap and develop in that and about the tissue barrier too for IAS repair? Do you try to preserve the total perineal body integrity? What is how you're addressing this? Yeah, so I have to say I don't routinely include muscle. I really use the subcutaneous fat pad, the labial fat pad. I think it's less morbid, less bloody. And I do it not only to preserve the total perineal body integrity and build up the perineal body like you guys saw in that, you know, chronic kind of almost cloaca, but also to provide vascularity just like you would drop an omental flap from above on a vescovaginal fistula repair. And, you know, I think it serves two purposes, and that's to give it some extra blood supply. And also, again, to separate the two suture lines and to preserve the perineal body integrity. Absolutely. Well, thank you. What was excellent talk. And on behalf of the Office of Education Committee, I'd like to thank you, Dr. and everyone else for joining us today. Our next webinar is titled Vaginal Repair of Low Urinary Tract Fistula. And we will be presented by Dr. Grace Chan on October 16th. So I hope to see you back in a month.

pediatric anal sphincter injuries

rectovaginal special repair

approach for repair

suture type

antibiotic therapy

aggressive perineal care

rectovaginal fistula removal

internal anal sphincter repair

Martius flap