(1) layered method
The operation steps are as follows:
1, vulva has vaginal disinfection;
2. Scrub vulva and vagina with soapy water and gauze. Rinse with clear water, and then rinse vulva and vagina with bromogeramine 1: 1000. Place gauze rolls in the rectum to avoid the overflow of intestinal secretions. Before cutting the vaginal wall, 75% alcohol can be used for disinfection.
3. Expose the operating field: spread a disinfection sheet and sew the labia minora on both sides of the labia majora and the disinfection sheet respectively.
4. Incision: Clamp the end of the ruptured rectovaginal wall with tissue forceps. The incision is at the junction of vaginal mucosa and rectal mucosa, reaching one side of the depression on both sides of the anus, that is, the fold side where the anal sphincter shrinks into the broken end. Trim off the remaining scar tissue.
5. Separate the vaginal wall from the rectal wall: pull the vaginal wall with tissue forceps and bend the blunt scissors into the interface between vagina and rectum. Blunt head forward, edge away from top edge. Blunt head in the midline, separating the vaginal wall from the rectal wall. Wrap your fingers with gauze and peel them upward, as far as possible to both sides, with a wide rectum. Then suture the rectal wall to reduce the tension and prevent the suture from cracking and affecting the healing.
6. Repair the anterior wall of rectum: The first layer was sutured intermittently with chrome 00 gut line, and did not pass through mucosa. The first needle is the most important and should be sewn above the wound. The second needle is at the top, and it is sewn intermittently, with two needle gauge about 1/2 cm. The second layer is reinforced by continuous thick stitches and buried above the first needle of the first layer. It is best to sew the third layer, including some muscle fibers and connective tissue, turn the second layer in and push the rectum backward.
7, looking for anal sphincter broken end
The broken end of the constricted anal sphincter can be found in the concave part of the anal skin fold. Firstly, the curved vascular clamp is inserted into the subcutaneous tissue to separate the gap; Then insert the tissue forceps into this gap, and strive to pull out the broken end of the sphincter at one time to avoid repeated pulling, resulting in little muscle fiber damage. Find the broken ends on both sides and pull them to the center line. Put a finger in the anus to see if the anal finger is tightened. Sphincter is sutured with 2-3 stitches of middle silk thread, and the sphincter can be sutured later, because the external opening becomes smaller after sphincter suture, which affects the suture of levator ani.
8. Symmetrically stitch levator ani.
In the future, perineal body should be established according to the repair of posterior vaginal wall.
(2) mucosal flap method
There is no need to sew the rectal wall, so there is less chance of infection. It has its advantages: for example, the scar of rectal defect is wide, and the layered method is used, which has great suture tension and affects wound healing. It is suitable for diseases with short rectal wall fissure. For example, if the fissure is long and the mucosal flap covering the fissure needs to be long, then the blood circulation at the distal end is not enough. The steps are as follows:
Make an inverted V-shaped incision in the posterior wall of vagina, such as the lower ends of both sides of a semicircular incision, put the left index finger into the vagina outside the anal skin folds and depressions, use the big finger to pull the vaginal mucosa outward in the vagina with tissue forceps, cover the finger with gauze, and peel off the vaginal (vaginal) wall downward until the cracked end. In order to avoid the mucosal flap being too thin or perforated, we must be careful with this step. If the middle part of the mucosa is perforated, the previous work will be abandoned and the layered method can only be used again.
Repair of third degree perineal laceration-mucosal flap method
Find and sew the anus, and sew the sphincter to levator ani. The following steps are the same as the layering method.