会阴裂伤缝合新进展ppt演示课件

会阴裂伤缝合新进展,会阴解剖,肛门外括约肌与内括约肌的解剖关系,会阴裂伤分度,度裂伤：会阴部皮肤及阴道入口粘膜撕裂（图A）度裂伤：裂伤达会阴体筋膜及肌层（图B）度裂伤：肛门括约肌受损；再细分为3级：3a: 肛门外括约肌撕裂少于50%; 3b: 超过50% 肛门外括约肌撕裂; 3c: 肛门内括约肌同时断裂（图C）度裂伤：直肠粘膜损伤，阴道、肛门、直肠完全贯通（图D）,度及度会阴裂伤分级解剖情况,3a: 肛门外括约肌撕裂少于50%; 3b: 超过50% 肛门外括约肌撕裂; 3c: 肛门内括约肌同时断裂；4：直肠粘膜损伤,会阴裂伤的影响,OASIS（Obstetric Anal Sphincter Injuries）包括度和度裂伤，较度和度裂伤，造成多种近期和远期疾病会阴疼痛尿潴留伤口裂开直肠阴道瘘排便问题性交困难,传统OASIS缝合,1.用3-0或4-0号可吸收线由上至下，作间断缝合直肠裂口。,2.用“8”字或“U”型端端吻合缝合肛门括约肌断端2针。,3. 缝合阴道粘膜,4.间断/连续缝合会阴体，间断/连续褥式缝合会阴皮肤,Sulthan AH 等发现，端端吻合缝合肛门外括约肌，约50%患者术后出现大便失禁，82%患者术后直肠内超声显示肛门外括约肌功能不全Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994; 308: 887-891.Engel AF, Kamm MA, Sultan AH, Bartram CI, Nicholls RJ. Anterior anal sphincter repair in patients with obstetric trauma. Br JSurg 1994; 81: 1231-1234.肛肠科医生进行大便失禁手术治疗时，多采用重叠法缝合肛门外括约肌，并认为端端吻合法缝合肛门外括约肌很容易引起手术失败。Blaisdell PC. Repair of the incontinent sphincter ani. Surg Gynecol Obstet 1940; 70 692-697.,Sultan AH 首先提出在会阴裂伤首次缝合时采用重叠法缝合肛门外括约肌。1995-1996年进行32例OASIS修补时采用重叠法缝合肛门外括约肌，并在术后140天进行临床评估、直肠功能评估、直肠内超声及肛管测压。8%患者出现大便失禁，15%患者经超声检查发现肛门外括约肌功能障碍，44%患者存在肛门内括约肌功能障碍，未出现排便障碍和手术并发症。较既往报道的端端吻合法修补后的结局更满意。Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetric anal sphincter tear using the overlap technique. British Journal of Obstetrics and Gynaecology 1999;106:31823.,Sultan AH实验中的缝合方法,重叠法缝合肛门外括约肌：在其中一侧断端距离边缘1.5cm处进针（ 处），再在肌肉另一断端距离边缘0.5cm从上方进针，呈“U”型重叠缝合两断端2-3针，然后在 处再间断缝合2-3针固定游离的肌肉边缘。,肛门外括约肌两种缝合法图示,传统端端缝合（end-to-end）,重叠缝合（overlap）,随后的临床试验,Sulthan AH 进一步进行了随机临床试验（Randomized Controlled Trial，RCT），64名3b级以上会阴裂伤的孕妇随机分配至两组，分别采用端端吻合及重叠法缝合肛门外括约肌，并随访12个月。,Repair Techniques for Obstetric Anal Sphincter Injuries A Randomized Controlled Trial. Ruwan J. Fernando, MRCOG, Abdul H. Sultan, FRCOG, Christine Kettle, Simon Radley, FRCS, Peter Jones, and P. M. S. OBrien, Obstet Gynecol 2006;107:12618,结论：初次缝合肛门外括约肌使用重叠法，大便失禁、大便急迫和会阴疼痛的发生率显著下降。在端端吻合法组中，一旦上述症状出现，症状似乎持续存在或恶化，而在重叠法组中症状逐渐改善。（I级证据）,结论：就术后12个月的大便失禁情况来说，重叠修补法并不优于端端吻合法。Rygh AB, Krner H. The overlap technique versus end-to-end approximation technique for primary repair of obstetric anal sphincter rupture: a randomized controlled study. Acta Obstet Gynecol Scand. 2010 Oct;89(10):1256-62.,另一项RCT，包含101名3b级以上会阴裂伤的患者，随机分配至端端吻合组及重叠缝合组，术后随访12个月，两组患者结局相似。,相反的结果,而Farrel et al 2012年发表的RCT研究中，174名OASIS孕妇随机分配至端端吻合组（86名）及重叠缝合组（88名），并随访3年，得到的结果与之前的研究相反。,端端吻合组与重叠缝合组术后3年内肛门排气失禁情况的比较,Scott A. Farrell et al. Overlapping Compared With End-to-End Repair of Complete Third-Degree or Fourth-Degree Obstetric Tears Three-Year Follow-up of a Randomized Controlled Trial. Obstet Gynecol 2012;120:8038,端端吻合组与重叠缝合组术后3年内大便失禁情况的比较,结论：随访1年后，使用端端吻合法修补度或度会阴裂伤，肛门失禁的发生率显著低于使用重叠法修补。两种缝合方法远期效果类似。,Mata-Analysis,回顾6个随机临床试验的结果（包括以上3个），Fernando RJ等进行了Mata分析。,Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric anal sphincter injury (Review). The Cochrane Library 2013, Issue 12.,Authors Conclusions目前数据显示，与端端吻合法修补OASIS（度和度会阴裂伤）比较，重叠法修补后发生大便急迫、肛门失禁及在术后12个月症状恶化的风险更低。而在术后36个月随访肛门排气失禁和大便失禁情况，两种方法无明显差别。,RCOG Guideline,英国皇家妇产科学会发布了2015年更新的会阴度和度裂伤管理的指引。,RCOG,1.关于直肠的修补The torn anorectal mucosa should be repaired with sutures using either the continuous or interrupted technique. Whichever technique is used, figure of eight sutures should be avoided during repair of the anal mucosa as they can cause ischaemia.（D）肛门直肠粘膜应该采取连续或间断缝合技术修补，但无论采取哪种方式缝合，都应尽量避免“8”字缝合法，因为它会造成组织缺血。,2.关于肛门内括约肌（IAS）Where the torn internal anal sphincter (IAS) can be identified, it is advisable to repair this separately with interrupted or mattress sutures without any attempt to overlap the IAS.（C）如果能确定肛门内括约肌，建议单独间断或褥式缝合肛门内括约肌，不要尝试使用重叠法,RCOG,3.关于肛门外括约肌（EAS）For repair of a full thickness external anal sphincter (EAS) tear, either an overlapping or an end-to-end (approximation) method can be used with equivalent outcomes.(A)如果肛门外括约肌完全断裂，可选用重叠法或端端吻合法缝合，目前证据提示两种方法结局相当For partial thickness (all 3a and some 3b) tears, an end-to-end technique should be used.(D)如果部分肛门外括约肌断裂（3a和部分3b级裂伤），应当使用端端吻合法缝合,RCOG,4.关于缝合材料3-0 polyglactin should be used to repair the anorectal mucosa as it may cause less irritation and discomfort than polydioxanone (PDS) sutures. (D)肛门直肠粘膜应使用3-0薇乔线，因其与普迪思（PDS）相比，较少出现刺激及不适感When repair of the EAS and/or IAS muscle is being performed, either monofilament sutures such as 3-0 PDS or modern braided sutures such as 2-0 polyglactin can be used with equivalent outcomes.(B)缝合肛门内外括约肌可使用3-0普迪丝（PDS）或2-0薇乔,5. 关于术后抗生素应用The use of broad-spectrum antibiotics is recommended following repair of OASIS to reduce the risk of postoperative infections and wound dehiscence.（B）术后建议使用广谱抗生素减少感染和伤口粘连的风险。,6. 关于软化大便药物的应用The use of postoperative laxatives is recommended to reduce the risk of wound dehiscence.（C）Use of stool softeners such as lactulose is recommended for about 10 days after the repair.术后建议使用缓泻剂降低伤口粘连的风险。术后建议使用大便软化剂如乳果糖约10天。Bulking agents should not be given routinely with laxatives.（B）大便膨胀剂（如纤维素类药物）不应与缓泻剂同时使用。,7.对于将来分娩方式的选择The role of prophylactic episiotomy in subsequent pregnancies is not known and therefore an episiotomy should only be performed if clinically indicated.再次妊娠时行预防性会阴切开术的效果并不明确，因此应该仅在有指征的情况下行会阴切