Perineal wound breakdown

Patients with perineal wound breakdown typically present within several days to 2 weeks post partum. Fever, wound swelling, discharge, and pain are often the inciting complaints that cause patients to present to their physician. Evidence of wound separation, purulent discharge, edema, and erythema is often present. Endometritis, operative vaginal delivery, episiotomy, and shoulder dystocia are significant risk factors associated with perineal morbidity.

The successful surgical correction of rectovaginal injuries depends on healthy tissues at the site of injury and good surgical technique, as well as the avoidance of postoperative infection. Under adverse circumstances, even the simplest of operative repairs can fail. Several simple techniques should be employed prior to the surgical approximation of a perineal wound dehiscence, as the majority of these lacerations heal well by secondary intention. First, a thorough irrigation of the wound with normal saline should be performed. Next, devitalized and necrotic tissue should be thoroughly debrided under local anesthesia. If the patient has a cellulitis of the perineum, cultures should be collected, followed by intravenous oxacillin 1–2 g every 4–6 hours or cefazolin (Ancef) 1 g every 6–8 hours during hospitalization. If there is suspicion of MRSA, then vancomycin 1 g IV every 12 hours should be used until cultures and sensitivities are available. Upon resolution of cellulitis, intravenous therapy can be changed to oral dosing based on culture results for a 10-day total course of therapy. In addition, twice-daily irrigation of the wound with normal saline should be performed in order to augment secondary healing.

If a wound does not approximate by secondary intention, consideration should be given to closure in the operating room. If the wound is the result of a recent trauma or the breakdown of a surgical repair, the operation must be delayed until the injured tissues are free of edema and induration or other evidence of residual infection. Traditionally, this has been thought to be at least 4 weeks and often longer. Multiple studies have questioned the necessity of this waiting period and have shown excellent results with much shorter waiting periods. Arona et al. used initial debridement of the wound, outpatient wound care, and surgical repair when the wounds were free of infection and demonstrated healthy granulation tissue. A total of 23 secondary repairs were performed from day 4 to day 10 (average 7 days) and all were successful with no need for subsequent reoperation [1].

Preoperative preparation of patients with either perineal tears or rectovaginal fistulae is an important part of the total management of these injuries. Preparation should first begin with mechanical evacuation of the bowel by instituting a variety of measures, beginning with a clear liquid diet 3 days prior to surgery. Furthermore, on the day before surgery the patient should ingest 4 L of Golytely (each liter containing 105 g of polyethylene glycol plus electrolytes) over 4 hours and one 10 oz (25 g) bottle of magnesium citrate (at a concentration of 1.745 g/oz) at 23:00 hours. Fleets enemas should be administered until clear at bedtime. Reglan 10 mg IV or given orally should be given prior to the ingestion of Golytely, and then every 6 hours as needed for nausea.

In addition, the patient should receive an antibiotic bowel preparation and a regimen of antibiotic prophylaxis to cover the intraoperative and postoperative periods. Although the perfect method of antibiotic bowel preparation has yet to be devised, one antibiotic bowel preparation consists of metronidazole (Flagyl) 1 g IV at 12:00 and 23:00 hours with neomycin 1 g taken orally at 12:00, 18:00, and 23:00 hours the day prior to surgery. The antibiotic prophylaxis that is instituted should give broad aerobic and anerobic coverage such as provided by cefoxitin (Mefoxin) 2 g IV on call to surgery and then 2 g IV every 6 hours twice, then 1 g every 6 hours for 3–5 days. Other antibiotic regimens give similar results. The use of antibiotics is extremely important because of the considerable risk of postoperative infection, leading to operative failure.

Under anesthesia, a rectal examination should be performed. If any stool or fecal liquids are encountered, they should be removed and the patient should be treated with povidone enemas until clear before beginning the repair procedure.

Complete perineal tear

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