(Poster 92) Timing & Technique: Principles of Secondary Repair of Perineal Wound Dehiscence

Objectives: Perineal wound breakdown is a rare but important complication following childbirth-related perineal trauma. Though many providers manage wound breakdown via expectant management, the optimal management of perineal wound breakdown remains debated. In this review, we systematically compile a comprehensive overview of existing data on management of perineal wound dehiscence with emphasis on timing, surgical technique and provider expertise, outcomes, and obstetric anal sphincter injuries (OASI) considerations.

Methods: Our literature search was conducted using PubMed, SCOPUS, and EMBase databases. We included relevant articles discussing variables of interest included timing, surgical technique, personnel, outcomes, and OASI considerations.

Results: Thirteen relevant articles were included in our review: 2 RCTs, 1 retrospective cohort, 9 case series, and 1 case report. Reported findings included 551 total study participants. Timing from diagnosis of dehiscence to repair ranged from 5 hours to 4 months postpartum, however, the majority of studies (11/13) reported re-suturing within 2 weeks of delivery. Preoperative antibiotics were discussed in 2 studies, 1 in the setting of infection. Intraoperative antibiotics were most commonly cephalosporins and cited in 10 studies. Postoperative antibiotics (7/13) had a reported range of 2 to 7 days. Polyglactin was the most common suture type (13/13), followed by chromic. Repairs were largely completed in the OR by an OB/GYN; urogynecology consultants were involved in 2 studies. Follow up ranged from 2 weeks to 6 years; only 1 study did not report on follow up. Complete healing occurred in 57.1-92.9% of patients, reportedly between 2 weeks and 3 months postoperatively. Dyspareunia was the most commonly reported complication and occurred in 5.6-27.8% of patients who underwent early repair, although it was more prevalent in patients with only short-interval follow up. Minor complications included superficial separation (14.3%) and surgical site infection (9.5%) treated with antibiotics. Four studies focused on breakdown of OASI repairs, which were more likely to be present with dehiscence or infection. Repair in these settings often required a specialist given the complex anatomy in this area. Fecal urgency, flatal incontinence, and/or fecal incontinence ranged from 13.6-37.0%, with higher prevalence when reported earlier in the postoperative period.

Conclusions: Evidence supports early resuturing within 2 weeks of perineal wound breakdown, demonstrating good short-term outcomes. Optimal management includes intraoperative cephalosporin administration, polyglactin sutures, and specialist consultation, especially if breakdown of OASI repair is suspected. Future studies should examine long-term outcomes, such as rates of persistent anal incontinence, and overall patient satisfaction regarding the timing and techniques of perineal laceration repair revision.

Table 1:
Description of comparative studies reporting on timing and technique utilized at time of repair of perineal laceration breakdown
* Studies that only included outcomes of patients with dehiscence of OASIS repairs
-- Data not reported in study