Relationship between Perineal Body Length and Degree of Perineal Tears in Primigravidas Undergoing Vaginal Delivery with Episiotomy

Background. Perineal tears are one of the most common complications of vaginal delivery. Severe perineal tears can cause various morbidities. There are many factors that affect the occurrence of perineal tears. One of the major factors related to the occurrence of perineal tears is the length of the perineal body. However, until now, no research in Indonesia has concluded that the length of perineal body can predict the perineal tears. Objective. To find the relationship between perineal body length and perineal tears, so it can provide a reference on the use of perineal body length to predict severe perineal tears in vaginal delivery with episiotomy. Methods. This nested case-control study was conducted at RSUD Tangerang and RSUD Karawang in Indonesia from February to September 2017. A total of 126 primigravida patients participated in the study consecutively. The length of the perineal body was then measured and followed until the start of the second stage of labor. Afterwards, the perineal length and degree of perineal tears were assessed using unpaired T-test for bivariate analysis, multivariate analysis, and scoring test to predict the occurrence of third- and fourth-degree of perineal tears with power calculation (β) 80% and Zβ 0.842. Results. There was a significant difference in mean length of the perineal body between the group with first- and second-degree perineal tears and the group with third- and fourth-degree perineal tears ( p < 0.001 ). From the multivariate analysis, adjusted OR was 5.26 (95% CI 1.52–18.17). Score test was performed to predict the occurrence of third- and fourth-grade perineal tears. Perineal body length and head circumference could be used as predicting factors of perineal tears. Perineum length ≤ 3.0 cm and head circumference ≥ 33.5 cm posed a risk of perineal tears of third and fourth degrees (70.52%). Conclusion. The length of the perineal body has a good ability to predict the occurrence of perineal tears.

The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review

The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae.

MORPHOMETRIC PARAMETERS AND FEATURES OF THE TOPOGRAPHY OF HUMAN PERINEAL BODY

In modern specialized literature, there is practically no information about the shape, size and topography of one of the most important formations of the perineum - of the perineal body. Knowledge of the anatomical aspects of the structure and location of the perineal center would allow in the future to reduce the postoperative complications associated with unintentional damage. The question of the morphology of the perineal body and associated muscles in clinical practice in obstetric traumatism remains relevant. The aim of the study was to study the morphometric parameters and features of the topography of the human perineal body. The objects of the study were 50 autopsy cases of people aged 60-87 years, 25 of each sex, who died from causes not related to the pathology of the pelvic organs. In each case, the perineal body, location of its center and associated muscles were identified. Methods of classical anatomical preparation, description and statistical analysis were used in the work. As a result of the work, five forms of the perineal body were identified: cruciform, «hourglass», triangular, round, polygonal. There were also cases where it was not possible to determine the shape of the intersection of the fibers. For men, the most common triangular shape, for women - the shape of an «hourglass». In most cases in which the shape of the intersection of the fibers was determined, there were clearly identifiable tendon fibers, that is, the tendinal center of the perineal body was present. The average area of ​​the tendinal center of the perineal body in women was 0.99±0.47 cm², and in men 0.94±0.32 cm². The ratio of cases of displacement of the tendinal center towards the right or left ischial tuberosities is almost equal to 10 cases towards the right ischial tuberosity and 11 cases towards the left. When evaluating the pubo-coccygeal asymmetry, in most cases with a triangular shape, there is a sharp displacement towards the apex of the coccyx. Also, the authors found that the average area of ​​the tendinal center of the perineal body is larger in women than in men. Thus, the human perineal body has a variety of forms, according to the authors, associated not only with the embryological features of the development of the muscles of the perineum, but also with the lifestyle, a history of diseases and surgical interventions in the area of ​​the tendinal center of the perineal body.

Development of a posterior sagittal anorectal surgical teaching model

Background An Anorectal Malformation (ARM) is a rare congenital malformation, which requires proper correction to ensure the best long-term prognosis. These procedures are relatively infrequent and complex, in which a structured approach is important. Therefore, training on an affordable model could be beneficial. Methods A low-cost ARM model was developed. The base was reusable and the perineal body disposable. Both expert pediatric surgeons (Experts) and residents/fellows (Target group) were recruited for this study. After testing the model, they completed a questionnaire regarding the realism and didactic value of the model, using a 5-point Likert scale. Results Forty-four participants were recruited (Target group n = 20, Experts n = 24). The model has high mean scores of 3.8–4.4 for the total group and even higher on several aspects by the Target group. The experts regarded the haptics and manipulation of the fistula less realistic than the Target group (3.7 versus 4.3, p = 0.021 and 4.2 versus 4.6, p = 0.047). It was considered to be a very good training tool (mean 4.3), without significant differences between the groups. Conclusions These results show general consensus that this model is a potent training tool for the component steps of the repair of an ARM with recto-perineal fistula by sagittal approach.

Surgical repair of an obstetric cloaca with review of the literature

A complete perineal wound breakdown of a fourth degree laceration leading to a cloaca is a rare but devastating complication of vaginal childbirth. A 32-year-old primiparous woman presented with an obstetric cloaca 4 months following delivery. She underwent preoperative evaluation and, following extensive counselling, elected to proceed with operative repair. The procedure is presented in 15 well-defined steps with photos. The repair was performed in standard fashion with three supplementary steps. These included: (1) division of the rectovaginal tissue into three distinct layers; (2) attachment of these layers individually to the reconstructed perineal body and sphincter and (3) incorporation of the levator muscles into the repair. The wound healed well within 6 weeks of repair. Now 3½ years postoperatively, the patient has no faecal incontinence or sexual dysfunction and only minimal defecatory dysfunction. The discussion describes our surgical approach in the context of a review of the literature.