This patient is a 52-year-old female who suffered a fourth degree obstetrical laceration during the birth of her child over 30 years ago in Southwest Asia. A village midwife assisted her delivery and the injury was allowed to heal by secondary intent. At initial presentation, she was mostly fecally continent, however, had fecal urgency and soiled herself at least once a week. Intercourse was painful and she often experienced unintended anal entry. Personal hygiene was difficult and embarrassing. After suffering for over 30 years, she requested surgical correction to this both physiologically stressing and humiliating acquired deformity. Surgical exam and low lithotomy revealed a cloaca-like deformity. The external anal sphincter retracted to a posterior hemicircumferential position, also classically known as the dovetail sign, with no superior tone as indicated by the arrows. Rectal mucosa protruded anteriorly. A thin scar band septum was all that separated the vagina and rectum. There was no perineum and the rectovaginal septum was detached. A 3D transanal ultrasound was performed and showed a thin, attenuated internal sphincter as shown here. Additionally, the external anal sphincter was noted to have a defect from 9 o'clock to 3 o'clock as shown by the pointer here. The patient received a rectal betadine and saline prep in the operating room. No other preoperative bowel preparation was given. The surgery was performed in low lithotomy position. Rather than using a commercially available self-retaining retractor, we prefer to use sterilized rubber bands attached to hemostats as shown here. This allows for more flexibility with the retractors as well as significantly lower cost. As shown here, a cruciate incision was made approximately 8 cm by 8 cm, intersecting on the remnant scar tissue between the rectum and vagina. The vaginal mucosa was then incised in the midline and the incision extended cephalid 4 cm to allow identification of the rectovaginal septum, which was then sharply dissected off of the overlaying vaginal tissue. The dissection was then performed laterally to identify and free the ends of the internal and external sphincters. The external anal sphincter was re-approximated in overlapping fashion with 2-0 PDS sutures in a mattress fashion. Additional interrupted 2-0 vicral sutures were placed above and below the external sphincter to provide a tension-free repair and to re-approximate the internal sphincter. The rectovaginal septum was then placated in the midline in a single layer in running fashion with 2-0 vicral. Site-specific repairs were additionally performed to reattach the rectovaginal septum laterally, paying special attention not to incorporate the levator ani muscles into the repair. The repair was evaluated to ensure adequate vaginal diameter and to ensure no vaginal banding was present. The rectovaginal septum was then attached to the new peroneal body using interrupted 2-0 vicral stitches. The superficial and deep transverse peronei muscles were next reattached to the peroneal body using interrupted vicral stitches. Next the epithelium over the peroneum was closed by approximating the cruciate skin incisions past the midline to create a tension-free closure using multiple 3-0 vicral interrupted sutures. A penrose drain was placed at the distal portion of the epithelial closure to allow for drainage overnight. A 5cm peroneal body was noted at the end of the case. Good resting rectal tone was noted circumferentially on digital exam. A premarin-soaked curlex was placed into the vagina overnight. Pain control was achieved using a combination of liposomal, bupivacaine and oral pain medications. The patient was discharged home the next morning with a Foley catheter for 48 hours after failing an active voiding trial. She subsequently passed her voiding trial on post-op day 3. No further antibiotics were given and a low-residue diet was recommended. At 6 months, the patient is faecally continent.

52-year-old female patient

fourth-degree obstetrical laceration

surgical correction

fecal urgency

painful intercourse