This is a 38-year-old female who delivered at 41 weeks gestation. She underwent a vacuum-assisted vaginal birth after cesarean of a 9-pound, 6-ounce infant over a right medial lateral episiotomy. One week post-delivery, she presented with dehiscence of her episiotomy repair. This area was cleaned and wet-to-dry dressings applied. Two and a half weeks after her delivery, the patient was brought to the operating room for closure of the wound, and I was consulted interoperatively when the wound edges could not be directly re-approximated. Here you see the patient's right medial lateral episiotomy wound site, which is opened and has been treated with wet-to-dry dressings. Attempt at closure was unsuccessful, and I was consulted about closing the wound. We undermined the edges completely surrounding the wound itself, and then laid a piece of 7-by-10 surgicist into the wound to begin repair. Again, the skin edges have been undermined, and the graft is now being sewn into the wound bed, utilizing 2-0 and 3-0 interrupted vicral sutures. The suture is brought through the graft and out, and then in through the wound edge. The free tail is here being secured to a French eye needle for passage of the free tail through the graft and out through the perineal skin in a horizontal mattress suture fashion. The suture is tied, and redundancy of the graft is then trimmed. Interrupted sutures are continued to be placed, here using a bare Mayo 6 needle on the free end of the suture to bring the tail through the graft and out through the perineal skin. It is important to undermine the surrounding tissue edges so that the graft may lie flat underneath the skin edge. We have found it preferable to secure the superior graft site, and then to work down, trimming the redundant graft as you go, so you can tailor it to approximate to the wound edges. Again, the tail is brought through the graft and wound edge with a bare Mayo 6 needle. I prefer to secure the surgesis graft to the base of the wound so that it is in direct approximation to the wound base, which allows better healing in my experience. The graft is tailored to fit the site, and is irrigated to keep it moist throughout the repair. Here, more interrupted sutures are placed, securing the graft to the base of the wound to kill the dead space that is present there. The redundancy of the graft is excised, and the base of the graft is then secured to the wound edge. It is important to keep the graft flat, to trim the redundancy, and place it underneath the undermined skin edge. This is the final result in the operating room. This is an interoperative photo at the beginning of the repair. It shows the large defect after we have mobilized the surrounding skin edges. The next photo depicts the wound with a surgesis graft covering it. Numerous vicral sutures have been placed to secure the graft under the surrounding perineal skin. In addition, several interrupted sutures are placed to secure the graft to the base of the wound bed to promote healing. This next photo is taken six weeks after repair when the patient returned for a post-operative visit. You see the wound bed healing in quite nicely, and the overall size of the defect is decreasing remarkably. The last photo was taken 10 weeks post-operatively with nearly complete healing of the right medial lateral episiotomy wound. The patient had returned to sexual function without complaint and had no problems with discomfort or hypersensitivity in the region of the wound.

vacuum-assisted vaginal birth

previous cesarean section

dehiscence

episiotomy repair

graft repair