Perineal Laceration Repair Research Articles

Objective structured assessment of medical students’ technical skills in second-degree perineal laceration repair with sponge model-based training

PurposeIn this cohort study, we used a sponge simulator to train students in second-degree perineal laceration repair. We examined whether the training course improved the students’ skills, as measured with an objective structured assessment of technical skills (OSATS) and by a senior physician. We also examined the correlation between these ratings to assess the validity of OSATS application in this context.MethodsBetween April and July 2022, 40 medical students took part in gynecological/obstetrics training that included a lecture about perineal trauma and the viewing of a video that demonstrated second-degree perineal laceration repair using a sponge model. They then underwent initial evaluation by a senior physician and OSATS application, yielding two independent scores. After training with the sponge model, a second evaluation was performed. The OSATS assessed practical skills (8 items) and suture results (2 items). The senior physician assigned ratings on a five-point ordinal scale ranging from 1 (excellent) to 5 (poor).ResultsTraining with the sponge simulator significantly increased students’ OSATS (practical skills, p < 0.001; suture results, p < 0.05) and senior physician (p < 0.001) ratings. The OSATS and senior physician ratings correlated strongly (Spearman’s r: first assessment, – 0.72; second assessment, – 0.74; p < 0.01).ConclusionThe sponge-based training improves students’ skills for the repair of a second-degree perineal laceration. The OSATS for the sponge model might be a valid option to examine medical students in an obstetrical course.

How It Works 3: Perineal Trauma – The Importance of Assessment and Repair

The perineum can undergo trauma after a vaginal birth. Poor or no repair of perineal lacerations can result in negative short and long-term outcomes for the birther. As midwives, it is imperative that we have the knowledge and skills to properly assess and perform perineal repairs within our scope as well as correctly identify more advanced tears in order to consult a specialist. A review of the relevant anatomy and suturing process is discussed so midwives can feel more confident in this common procedure and essential skill.

Structured Workshop for Repair of High-Grade Perineal Lacerations Among Obstetrics and Gynecology Residents, The Need for Repetition and Retraining.

The objective of this study was to evaluate the effectiveness of structured workshops in improving the knowledge and skills of obstetrics and gynecology residents for repairing high-grade perineal lacerations. This quasi-experimental multicenter study evaluated the baseline knowledge of obstetrics and gynecology residents using an online patient-management problem (PMP) tool. After the initial evaluation, a workshop was conducted using sponge models to teach the practical technique for repairing high-grade perineal lacerations, including external and internal anal sphincter repair. The residents' knowledge was reassessed by PMP exams at 3 and 6months after the workshop, and the scores were compared to the baseline statistics. Eighty residents participated in the study, including 26, 22, and 32 at the first, second, and third-year levels of residency, respectively. The total PMP scores significantly improved after three months of the workshop, with an increasing total score from 15.5 (baseline) to 31.3 (p = 0.027) (range of total score from - 63 to + 52). The senior residents performed better before and after three months of the intervention. However, in the six-month follow-up, the total PMP score of all residents decreased to 12.3 with no significant difference with pre-education scores at all levels. Similar significant results were also reported for each PMP question at all levels of residency. The study found that obstetrics and gynecology residents had substandard knowledge in repairing perineal lacerations. Although the training workshop significantly increased residents' knowledge, its effectiveness diminished over time, indicating a need for continuous or periodic training. The online version contains supplementary material available at 10.1007/s13224-023-01792-6.

Non-Obstetric Traumatic Vulvar Hematomas in Premenarchal and Postmenarchal Girls

Traumatic non-obstetrical hematomas of the vulva are rare, and most reports only involve adult patients. There are no data on presentation, management, and outcomes from either conservative or surgical management in pediatric and adolescent patients. The objective of this project was to compare the etiology, treatment, and outcomes of traumatic vulvar hematomas occurring in premenarchal and postmenarchal young women. A retrospective chart review was performed on females aged 0-24 years seen at a tertiary care academic center using ICD 9 and 10 codes for traumatic vulvar hematoma from 2006-2019. Data describing their clinical presentation and course were collected. IRB approval was obtained. Twenty patients, aged 3-23 years (median age of 13.5 years) were identified. All 8 premenarchal patients presented with a straddle injury, whereas only 50% of postmenarchal patients were found to have a straddle injury. Other etiologies among postmenarchal patients included consensual sexual intercourse and recent vulvar surgery. Hematoma diameter ranged from 1-3 cm in premenarchal patients and 0.4-7 cm in postmenarchal patients. Associated perineal lacerations were reported in 50% of the premenarchal girls and 8% of postmenarchal young women. Of the 8 premenarchal patients, 5 were managed conservatively, and 3 were taken to the operating room for repair of perineal lacerations; 1 patient also underwent evacuation of a 3-cm hematoma. Of the 12 postmenarchal patients, 5 had surgical intervention, 2 for pain secondary to large 7-cm hematomas and 3 for suspected vulvar abscesses, which were identified as hematomas after drainage. One patient in each group required a Foley catheter for comfort. Two postmenarchal patients required a second surgery for further wound management. One premenarchal patient with surgical treatment required a follow-up exam under anesthesia. Four patients were admitted for pain and postoperative observation, 1 of whom was premenarchal. Eleven patients were seen for follow-up, and 10 were doing well. One postmenarchal patient in the conservative management group returned to the Emergency Department with continued pain 10 days later. In this study that examined traumatic vulvar hematomas in premenarchal and postmenarchal young women, the only mechanism of injury in premenarchal girls was straddle injury, and surgical intervention was usually needed only for repair of perineal lacerations, not a primary hematoma. In the postmenarchal patients, surgical intervention was undertaken for larger hematomas and suspected vulvar abscesses. Our study suggests that most hematomas up to 3 cm in premenarchal patients and up to 6 cm in postmenarchal patients can be managed conservatively.

Effect of early skin-to-skin contact after vaginal delivery on pain during perineal wound suturing: A randomized controlled trial.

To evaluate whether early skin-to-skin contact at the end of the second stage of labor could relieve perineal wound suture pain. From March 2020 to November 2020, a total of 241 parturients with full-term single fetuses delivered through the vagina and who underwent episiotomy suture (n=120) or perineal laceration repair (n=121) in our hospital were included in the study. Parturients were categorized according to whether they received episiotomy suture or perineal laceration repair. They were randomized into an early skin contact group and a traditional neonatal care group. The primary outcome was pain, which was quantified by the Numerical Rating Scale, Visual Analog Scale, Verbal Rating Scale, Faces Pain Scale-Revised. The secondary outcomes were healing of the perineal wound, the maternal cooperation rate and operation time. The confounding factors of severe pain were analyzed. Early skin-to-skin contact alleviated the pain of perineal laceration repair and episiotomy suture, shortened the operation time of episiotomy suture and improved the cooperation rate of parturients receiving suture. It had no effect on perineal wound healing, operation time, or the cooperation rate of perineal laceration repair. In addition to the operation and early skin contact, the occurrence of high-grade pain was also associated with prepregnancy body mass index, group B streptococcus (GBS) positive, and academic degree. Early skin-to-skin contact at the end of the second stage of labor can alleviate pain and improve the delivery experience of vaginal delivery.

Assessing the effect of e-learning on perineal repair knowledge and skill acquisition: a pre/post-intervention study

Objectives Competency in perineal laceration repair is a core component of family medicine training. Recently, new surgical skills teaching formats that have emerged include surgical simulation and electronic learning. While this approach has been studied within surgical sub-specialties, research among family medicine trainees is sparse. The purpose of our study was to evaluate the feasibility and impact of an open-access online learning program on acquisition of knowledge and skills of second-degree perineal laceration repair. Methods We employed a pre/post-intervention study protocol using an online educational module. Participants included PGY1 Family Medicine residents at Michael Garron Hospital. Knowledge and skill were assessed at baseline and one week after e-module release. The primary outcomes measured were knowledge and technical skill, as analyzed by Wilcoxon signed-rank test. Results Eleven participants were included in the knowledge recall andten participants in the performance assessment. For knowledge recall, six participants improved, one declined and four obtained the same score (p=0.031). For performance, nine improved and one obtained the same score (evaluator 1 p=0.004, evaluator 2 p=0.004). Intra-class correlation coefficient between evaluators was 0.940. Conclusions Overall, we observed a statistically significant improvement in knowledge and technical performance after exposure to the online module, indicating that this could represent a promising learning delivery format for non-surgical trainees, who may not benefit from abundant bedside exposure to perineal repair. Next steps include increasing sample size and assessing skill and knowledge at greater than one week.

787: The effect of neuraxial morphine (Duramorph) on postpartum pain after a severe perineal laceration

Postpartum pain has negative consequences on maternal-infant bonding, future narcotic abuse, and development of chronic pain. With the rise of the opioid epidemic, it is important to find novel approaches in managing this pain. This pilot study investigates the use of neuraxial morphine (Duramorph) in postpartum pain control after a severe perineal laceration. A single-blind randomized controlled trial (NCT03926559) was conducted on parturients admitted to the obstetric service at Augusta University Medical Center. Patients were enrolled if they had an epidural and if they had a second, third, or fourth degree perineal laceration that was identified immediately postpartum. Participants were randomized to receive either 2mg of Duramorph or sham injection of no drug within 30 minutes after their perineal laceration repair, prior to the removal of their epidural. Primary outcomes were perineal pain at 24 and 48 hours postpartum as measured on a 11-point Numerical Rating Scale (NRS-11). Secondary outcomes were amount of additional oral narcotics used in morphine milliequivalents (MME) over 24 and 48 hours postpartum, and maternal satisfaction as measured on a Likert (1-10) scale. Between 04/2019 to 08/2019, 154 patients were consented, of which 78 patients had a severe perineal tear and were eligible for the study. 58, 13, and 7 patients had second, third, and fourth degree perineal tears respectively. Baseline demographic characteristics between the groups were comparable. As seen in Table 1, there was a statistically significant reduction in pain scores at 24 hours in women who received Duramorph compared to sham for all perineal tears. There was also a statistically significant decrease in narcotic use at 24 hours, as well as an increase in maternal satisfaction for all perineal tear groups in the Duramorph group compared to sham (Table 2). The use of Duramorph in the immediate postpartum setting may alleviate pain in the first 24 hours and may also decrease the number of oral narcotics consumed during the early postpartum period.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

ACOG Simulation Working Group: A Needs Assessment of Simulation Training in OB/GYN Residencies and Recommendations for Future Research

To evaluate current availability and needs of simulation training among obstetrics/gynecology (OB/GYN) residency programs. Cross-sectional survey. Accreditation Council for Graduate Medical Education accredited OB/GYN residency programs in the United States. Residency program directors, gynecology simulation faculty, obstetrics simulation faculty, and fourth-year residents. Of 673 invited participants, 251 (37.3%) completed the survey. Among the survey responses, OB procedures were more broadly represented compared to the GYN procedures for simulation teaching: 8 (50%) of 16 OB procedures versus 4 (18.2%) of 22 GYN procedures had simulation teaching. Among the simulated procedures, a majority of residents and faculty reported that simulation teaching was available for operative vaginal delivery, postpartum hemorrhage, shoulder dystocia, perineal laceration repair, conventional laparoscopic procedures, and robotic surgery. There were significant differences between residents and faculty perceptions regarding the availability and needs of simulated procedures with a minority of residents having knowledge of Council on Resident Education in Obstetrics and Gynecology (47.2%) and American College of Obstetrics and Gynecology (27.8%) simulation tools compared to the majority of faculty (84.7% and 72.1%, respectively). More than 80% of trainees and faculty reported they felt the average graduating resident could perform vaginal, laparoscopic, and abdominal hysterectomies independently. Simulation is now widely available for both gynecologic and obstetric procedures, but there remains tremendous heterogeneity between programs and the perceptions of residents, program directors, and faculty. The variations in simulation training and readiness for performing different procedures following residency support the need for objective, validated assessments of actual performance to better guide resident learning and faculty teaching efforts.

2292 How to Build a High Fidelity Model for Teaching Perineal Laceration Repair

Video Objective Train the trainer: Hands on creation in less than 10 minutes an anatomically accurate simulation model for repair of third and fourth degree obstetric lacerations Setting 1. Create in less than 10 minutes an anatomically accurate high fidelity simulation model using beef tongue and beef intestine and craft supplies in order to teach the repair of third and fourth degree obstetric lacerations to obstetrics and gynecology residents. 2. Understand the anatomy of the perineum and anal sphincter as illustrated by this simulation model. 3. In the setting of insufficient training in ob/gyn residencies regarding 3rd and 4th degree obstetric laceration repairs and assuring competence in this area by the time residents graduate, simulation models have become increasingly relevant. This video aims to provide residency program directors and educators with a detailed step-by-step hands-on creation in less than 10 minutes of an anatomically correct high fidelity simulation model using beef tongue and beef intestine along with easily obtained craft supplies which can be used for teaching OB/GYN residents third and fourth degree obstetric laceration repairs Interventions n/a Conclusion The video provides an easily made (within 10 minutes) anatomically accurate high fidelity model utilizing beef tongue and beef intestine along with easily obtained craft supplies that can be used to teach the correct techniques for third and fourth degree repairs for obstetric lacerations.

Randomized Trial of 3 Techniques of Perineal Skin Closure During Second-Degree Perineal Laceration Repair.

Perineal lacerations during childbirth are common, and suturing the perineal skin during repair has been associated with increased postpartum pain. This study sought to test the hypothesis that no difference in postpartum perineal pain exists between 3 methods of skin closure for second-degree repair: suture, no suture, and surgical glue. A single-blind randomized controlled trial of women after vaginal birth who had a second-degree perineal laceration was conducted at a tertiary care teaching hospital from August 2014 to April 2017. Women were randomized to perineal skin closure with suture, no suture, or surgical glue using a 1:1:1 allocation. Pain was assessed using the short-form McGill Pain Questionnaire, a 100-mm visual analog scale (VAS), and Present Pain Index (PPI) at one day, 2 weeks, 6 weeks, and 3 months postpartum. Wound healing was assessed at 6 weeks using the Redness, Edema, Ecchymosis, Drainage, Approximation (REEDA) scale. Pain scores were compared across groups using a chi-square test, Mann-Whitney U test, or analysis of variance where appropriate. A total of 35 women were randomized: 14 received suture, 11 had no suture, and 10 received surgical glue for perineal skin repair. Demographic characteristics were similar between groups. At 2 weeks postpartum, women with suture had higher median pain scores on the short-form McGill Pain Questionnaire (15.0 suture vs 2.0 glue vs 2.0 no suture, P = .03) and VAS (50.0 suture vs 3.0 glue vs 7.0 no suture, P = .02). Significant differences in pain were not seen on the PPI. At 3 months, women in the suture group had higher median pain scores on the short-form McGill Pain Questionnaire compared with surgical glue (1.0 vs 0, P = .04). Wound healing was similar across groups (REEDA score: 0 suture vs 1.0 no suture, vs 0 surgical glue, P = .24). Compared with no suture and surgical glue, suturing the perineal skin was associated with the highest postpartum pain scores.

A Novel Approach to Simulation-Based Perineal Repair in Undergraduate Medical Education.

There is no formalized hands-on teaching of suturing skills for clerkship students during their dedicated obstetrics and gynaecology (OB/GYN) teaching sessions at the University of Toronto. Nevertheless, the students are exposed to suturing during gynaecologic surgery, Caesarean sections, and perineal repairs. As a result, a formal pilot workshop on knot-tying and perineal laceration repair was developed for incorporation into the third-year clerkship curriculum with the goals of increasing students' knowledge and technical skills. Participants consisted of students enrolled in their OB/GYN clerkship rotation at St. Michael's Hospital at the University of Toronto from December 2016 to August 2017. Prior to the workshop, students' (n = 82) baseline knowledge of perineal lacerations was assessed with a pre-test quiz and their knot-tying speeds (two hand-ties and two instrument ties) were recorded. Students were then taught perineal anatomy, laceration types and repair techniques, suturing, and knot-tying. Under direct supervision, students practiced the technical skills for 45 minutes. Knowledge and knot-tying speeds were then reassessed following the educational session. There was a statistically significant improvement in both knowledge (51% to 71%; P < 0.05) and technical skills (258.8 seconds to 197.4 seconds; P < 0.05) after the workshop. Importantly, 94% of students "agreed" or "strongly agreed" that this method of learning was more enjoyable than traditional methods. This pilot project demonstrates that a formal hands-on workshop improves medical knowledge, technical skills, and student satisfaction. This has the potential for students to have increased opportunities at the bedside, with higher patient acceptance and safety.

Early secondary repair of labial tears, 1st and 2nd degree perineal lacerations and mediolateral episiotomies in a midwifery-led clinic. A retrospective evaluation of cases based on photo documentation

ObjectivesTo examine whether early secondary repair of labial tears, 1st and 2nd degree perineal lacerations and episiotomies provided an anatomically acceptable result. Study designA retrospective analysis of 126 women undergoing an early secondary repair of birth lacerations not involving the sphincter complex within 21 days postpartum. Patients were included from 1 January 2014 to 11 August 2017 at Aarhus University Hospital, Denmark. Photo documentation of the wound was available just before the early secondary repair and at the follow-up visit after the repair. Photos were evaluated by two trained Urogynaecological Consultants. Main outcome measuresWhether the anatomic result of the early secondary repair was acceptable based on photo documentation. ResultsEarly secondary repair was performed by a specialised team of midwives in 94.4% and by doctors in 5.6% of the cases. In all, 72.2% were 2nd degree perineal lacerations. The most common indications for early secondary repair were wound dehiscence (55.3%) and suboptimal primary repair (34.1%). At the follow-up clinical examination seven days after the early secondary repair, the result was considered anatomically acceptable in 67.5% of the cases, not optimal in 22.2% and not possible to evaluate in 10.3% of the cases. In 7.9% of the cases, wound infection was suspected after the early secondary repair. ConclusionsBased on photo documentation, early secondary repair of birth lacerations not involving the sphincter complex provides an anatomically acceptable result in the majority of cases without risk of serious complications.

The efficacy and safety of modified anterior vaginal wall repair for anterior vaginal prolapse and cystocele in elderly women

Objective To investigate the efficacy and safety of modified anterior vaginal wall repair in the treatment of anterior vaginal prolapse and cystocele in elderly women. Methods We retrospectively analyzed the clinical value of modified anterior vaginal wall repair in 58 elderly women with stage Ⅱ-Ⅳ anterior vaginal prolapse and cystocele, which were evaluated by pelvic organ prolapse quantitation (POP-Q) system.The modified anterior vaginal wall repair was based on the paravaginal repair as an add-on to a reverse bridge repair and cross stitching of bilateral sutures stemmed from vaginal repair.According to the condition of each patient, other pelvic floor repair, perineal laceration repair, and paraurethral fascia reinforcement might be performed at the same time.The curative effectiveness was subjectively and objectively evaluated in the postoperative follow-up. Results A total of 58 operations were successfully finished.The follow-up time was 6-24 months with an average of (14±8) months.The subjective cure rate was 100% and the rate of objective cure defined as the top of the vagina above the level of ischial spine was 100% at 3-months follow-up (n=58). The subjective and objective cure rate was 100% and 96.6% (56/58) at 6 months follow-up (n=58), 100% and 94.1% (32/34) at 12 months follow-up (n=34), 91.7% (11/12) and 91.7% (11/12) at 24 months follow-up (n=12), respectively. Conclusions The modified anterior vaginal wall repair is safe and effective for anterior vaginal prolapse and cystocele in elderly women. Key words: Pelvic organ prolapse; Vagina; Cystocele

“I Have a Tear Down There?”: Implementing a Three‐dimensional Anatomical Education Tool Into Post‐partum Perineal Laceration Care

Perineal lacerations are a common outcome of vaginal childbirth, with 53–79% of women obtaining some degree of an obstetrical laceration during vaginal delivery. Upon hospital discharge, a woman is expected to demonstrate a certain level of confidence to care for her newborn and herself, however, studies indicate many women feel underprepared in handling common health issues faced after discharge. Despite the high occurrence rate, there is a paucity of educational tools that can be utilized in Obstetrics/Gynecology (OBGYN) clinics to educate women on repair and care of perineal lacerations. In addition, there are several factors that add to the complexity of patient education: 1) the anatomy of the female perineum associated with lacerations is complex; 2) new moms focus education efforts on caring for the new baby, not on female reproductive anatomy; and, 3) the constraints of modern OBGYN wards allow for only a brief time dedicated to patient education. Advent of mobile technology presents an opportunity for effective delivery of accurate and accessible information to patients. Thus, a mobile educational tool on pelvic anatomy may provide an efficient method of patient education. Accordingly, the first aim of this project was to create a three‐dimensional (3D) anatomy tool accessible from a mobile device for health care providers to use when discussing obstetric perineal lacerations with the patient in clinic. The second aim was to assess whether the tool is valuable for health care providers to use in patient encounter and education, and whether it increases patient confidence in knowledge and self‐care. An interactive 3D model of the female reproductive organs and perineal structures was created. 3D models were obtained Touch of Life Technologies (Aurora, CO) and were modified to display only the relevant anatomy. The models were hosted in a server accessible from a mobile device with labels highlighting the relevant anatomy. Health providers were oriented on how to use the tool at faculty meetings, then were invited to complete a survey to assess the tool's usability, aesthetics, relevance, and potential barriers of use in clinic. Healthcare providers then utilized the tool on postpartum recovery floors and follow‐up appointments in OBGYN offices during discussions of post‐partum care instructions to patients with obstetrical lacerations. Patients then completed a survey assessing their anatomy knowledge, confidence in self‐care of the laceration, and fear/anxiety surrounding the laceration. Early results indicate the efficacy of this mobile tool to deliver patient education, as well as assisting providers in sharing their anatomical knowledge with their patients. All health care provider and patient education surveys will be completed by March 2018 and available to report at this conference. This tool has potential use in other OBGYN contexts, including urogynecology, general surgery, and family planning.Support or Funding InformationThis abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

A Model Practice Template for Hydrotherapy in Labor and Birth.

A Model Practice Template for Hydrotherapy in Labor and Birth.

Breakdown of Perineal Laceration Repair After Vaginal Delivery: A Case-Control Study.

The aim of the study was to estimate risk factors associated with breakdown of perineal laceration repair after vaginal delivery. This is a case-control study of women who sustained a breakdown of perineal laceration repair after vaginal delivery between 2002 and 2015. Cases were patients who sustained a perineal wound breakdown after vaginal delivery and repair of a second-, third-, or fourth-degree laceration. Controls, matched 1:1, were patients who either sustained a second-, third-, or fourth-degree perineal laceration and repair without evidence of breakdown and who delivered on the same day and institution as the case. A total of 104,301 deliveries were assessed for breakdown of perineal laceration. One hundred forty-four met the inclusion criteria. These were matched with 144 controls. Logistic regression analysis demonstrated that smoking is associated with increased risk for breakdown of perineal laceration (adjusted odds ratio [adj. OR], 6.4; 95% confidence interval [CI], 1.2-38.5), whereas a previous vaginal delivery is protective (adj. OR, 0.14; 95% CI, 0.05-0.3). In addition, third- or fourth-degree laceration (adj. OR, 4.0; 95% CI, 1.1-15.7), presence of episiotomy at time of delivery (adj. OR, 11.1; 95% CI, 2.9-48.8), operative delivery (adj. OR, 3.4; 95% CI, 1.2-10.3), midwife performing the laceration repair (adj. OR, 4.7; 95% CI, 1.5-15.8), and use of chromic suture (adj. OR, 3.9; 95% CI, 1.6-9.8) were independent risk factors for breakdown of perineal laceration. Smoking, nulliparity, episiotomy, operative delivery, third- or fourth-degree laceration, repair by a midwife, and use of chromic suture are independent risk factors for breakdown of perineal laceration repair after vaginal delivery.

End-to-End Compared With Overlap Repair of Third-Degree Perineal Lacerations

End-to-End Compared With Overlap Repair of Third-Degree Perineal Lacerations

Severe Perineal Lacerations in Obstetric Practice: The Effect of Institutional Practice Guidelines on Repair Failures in a Single Centre.

Background. There is a high incidence of failure after repair of severe perineal lacerations (SPLs). A tertiary referral hospital in the Caribbean introduced guidelines in an attempt to improve outcomes. We performed an audit of SPL repairs at this centre in an attempt to determine the effect on repair failure. Methods. All patients with SPL repairs between November 1, 2007, and December 30, 2012, were identified. The primary aim was to determine the incidence of failed repairs (wound dehiscence, anal sphincter disruption, rectovaginal fistula, and/or faecal incontinence). The Cleveland Clinic Incontinence Score (CCIS) was used to assess continence at discharge and 24 weeks after repair. Data were analyzed with SPSS version 12. Results. There were 8108 vaginal deliveries, 23 third-degree injuries, and 3 fourth-degree injuries. Three patients experienced a repair failure. Notably, 69% of surgeons chose an inappropriate suture for sphincter repair. Conclusions. Experienced operators are performing repairs, but there is a high prevalence of inappropriate suture choice for repairs. A targeted educational campaign may be necessary to remind clinicians of the best practice in repair techniques.

Occurrence and surgical repair of third degree perineal lacerations in adult female camels (Camelus dromedarius) by one-stage (Goetz) technique

Retrospective analysis of third degree perineal lacerations in 7 female camels (6-17 yrs of age) that were surgically corrected by one stage repair (Goetz technique) is presented. Majority (3/7) of the camels was primiparous and all parturitions had a history of calving assistance. Six (6/7) camels recovered by first intention of healing. Dehiscence of perineal structure occurred in only one camel due to infection and healed by second intention. Subsequent matings resulted in pregnancy in four camels and one camel died due to unrelated causes. We conclude that perineal lacerations can occur in primiparous camels with difficult assisted deliveries and that one stage repair of perineal lacerations in camels improves the perineal conformation and such camels may easily regain normal fertility.

Complete anal sphincter complex disruption from intercourse: A case report and literature review

INTRODUCTIONAnal sphincter injuries are uncommon injuries outside of obstetric practice – but they may cause disastrous complications. PRESENTATION OF CASEWe present a case of complete anal sphincter disruption from anal intercourse in a 25 year old woman. Clinical management is presented and technical details of the repair are discussed. She had an uneventful post-operative course and good continence after 154 days of follow up. DISCUSSIONThis is one of a handful of reported cases of anal sphincter disruption secondary to anal intercourse. The established risk factors in this case included receptive anal intercourse coupled with alcohol use. We review the pertinent surgical principles that should be observed when repairing these injuries, including anatomically correct repair and appropriate suture choice. There is little evidence to support simultaneous faecal diversion for primary repair of acute perineal lacerations. CONCLUSIONAcute post-coital sphincter injuries should be treated operatively on an emergent basis, without diversion because they are low energy injuries with minimal tissue loss and excellent blood supply. Although repair of each injury should be individualized, the majority of these injuries do not require concomitant protective colostomy creation.