225-30. . Herein is described the surgical repair technique for a fourth degree perineal tear. Most risk factors involve labor management, including labor induction, labor augmentation, use of epidural anesthesia, delivery with persistent occipitoposterior positioning, and operative vaginal deliveries7 (Table 21,8,9 ). A running continuous or interrupted closure can be performed with 4-0 delayed absorbable suture (Vicryl or Monocryl).3. vol. All rights reserved. A 4-0 Prolene was utilized to approximate the skin edges. Copyright 2017, 2013 Decision Support in Medicine, LLC. [4], Perineal lacerations are classified into four basic categories.[3][4]. 2. Following this, attention was turned towards his laceration while the patient was still under general anesthesia from the previous aforementioned procedure. However, general or regional anesthesia may be necessary to achieve adequate muscle relaxation and visualization for surgical repair of severe or complex lacerations. The apex of the rectal mucosa is identified, and the mucosa is approximated using closely spaced interrupted or running 4-0 polyglactin 910 sutures (Figure 10). Proper follow-up care should include twice daily dressing changes, sitz baths and broad spectrum antibiotics. Sultan, AH, Kamm, MA, Hudson, CN, Thomas, JM, Bartram, CI. 627-35. A more recent article on prevention and repair of obstetric lacerations is available. Necessary cookies are absolutely essential for the website to function properly. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Jim had taken a master's degree in business, and they had two children. However, approximately 9% of women will experience a third or fourth degree tear. Repairing hemostatic first- and second-degree lacerations does not improve short-term outcomes compared with conservative care. Right vaginal side wall laceration, 2nd degree. [4][9] Suture is used to reapproximate the vaginal mucosa to the level of the hymen. An episiotomy is a surgical procedure performed at the bedside during the second stage of labor which causes enlargement of the posterior vagina. Please enable it to take advantage of the complete set of features! The entire wound edge was reapproximated in the configuration in which it had been avulsed. The health care team should be prepared and willing to ask about and treat any complications a woman may have after childbirth. However, we prefer the interrupted approach because it facilitates a more anatomic repair, allowing reapproximation of the bulbocavernosus muscle and reattachment of the vaginal septum with minimal use of sutures. Copyright 2021 Elsevier Masson SAS. ACOG Practice Bulletin No. you could possibly bill under Dr B. Third and fourth degree tears are repaired in the operating room, usually under a spinal/epidural anesthetic. The suture is tied off and the needle removed. This completed the procedure. 3. Platelets also begin to aggregate, activating the clotting cascade to produce initial fibrin clots. A correct repair is required to avoid improper healing, as a persistent defect in the external anal sphincter after delivery can increase the risk of complications and worsening of symptoms following subsequent vaginal deliveries. 3 years ago. These muscles are called the internal anal . 107-e5. 1,2 Given the infrequent occurrence of these lacerations, a locally developed surgical checklist may help to guide you and your obstetrician colleagues to the most effective repair of these lacerations. Most of the research on fourth-degree lacerations has been the quantitative examination of prevalence and risk factors, and limited research is available, specifically regarding fourth-degree lacerations. This completed the procedure. Quist-Nelson J, Hua Parker M, Berghella V, Biba Nijjar J. A recent Coding Clinic has garnered a lot of questions on inpatient obstetrics coding. DESCRIPTION OF PROCEDURE: In the emergency room, the patient's wounds were prepped and draped and infiltrated with 20 mL of 1% lidocaine for anesthesia. Of these lacerations, 60-70% will require suturing. Cochrane review involving four trials with 2,497 women, Cochrane review with four studies involving 1,799 women for warm compresses, six studies involving 2,618 women for perineal massage, and a systematic review of manual perineal support including six randomized and nonrandomized studies involving 81,391 women, Cochrane review involving two studies with 154 women showing similar results in both groups, Randomized controlled trial of 1,780 women with first- or second-degree lacerations, Randomized controlled trial of 102 patients, with 74 patients randomized to surgical glue, Cochrane review involving 16 studies with 8,184 women showed improvements in continuous suture group but no differences in long-term pain, Cochrane review involving 10 studies with 1,825 women showed improvement in pain compared with no treatment, Laceration involving the perineal muscles but not involving the anal sphincter, Laceration involving the anal sphincter muscles, Laceration involving the anal sphincter complex and rectal epithelium, Large fetal weight (> 4,000 g [8 lb, 13.1 oz]), Occipitotransverse or occipitoposterior position at delivery, Epidural anesthesia (increases risk of severe lacerations, decreases overall lacerations), Operative vaginal delivery (i.e., forceps, vacuum), Prolonged second stage of labor (> 60 minutes), Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content, Immediate, unlimited access to just this article. 2. A repair of 1stdegree tear of the perineum is done by placing a single layer of interrupted 3-O chromic or Vicrylsuturesabout 1cm apart. The inferior aspect of the patients chin was examined, and he was noted to have an L-shaped laceration, in total approximately 3 to 4 cm in length. Fourth Degree - injury involves anal sphincter complex and anal epithelium. Splenic laceration. The tear should be irrigated by copious amounts of fluid followed by debridement. Second degree More than 50% involvement of the vaginal epithelium, perineal skin, perineal muscles and fascia, but no involvement of the anal sphincter. An overlapping technique to repair the external anal sphincter, rather than the traditional end-to-end technique, is being investigated to determine if it might decrease the incidence of anal incontinence. Management of third and fourth degree perineal tears following vaginal delivery; RCOG guideline no. Vieira F, Guimares JV, Souza MCS, Sousa PML, Santos RF, Cavalcante AMRZ. Locking Suture is optional (used for Hemostasis) Continuous Running Suture is preferred over interrupted, associated with less pain Risk factors for perineal lacerations include nulliparity, operative vaginal delivery, midline episiotomy, Asian race, and increased fetal weight. Indicated in first through fourth degree Lacerations; Repaired with Vicryl 3-0 on CT-1 needle; Anchor Suture 1 cm above apex of vaginal Laceration; Use continuous, Running stitch (continuous) to close vaginal mucosa. In 2015-16, 5,639 such lacerations were recorded in Australian public hospitals. If the apex is too far into the vagina to be seen, the anchoring suture is placed at the most distally visible area of laceration, and traction is applied on the suture to bring the apex into view. If a woman has excessive pain in the days after a repair, she should be examined immediately because pain is a frequent sign of infection in the perineal area. Brought to you by the Society of Gynecologic Surgeons. vol. Bethesda, MD 20894, Web Policies Rectovaginal and/or rectoperineal fistulas may develop in women who had an unidentified or poorly healed OASIS injuries. [1][11] Massage can be started after 34 weeks and be performed daily until delivery. Jan 22, 2020. 2015 Oct 29;2015(10):CD010826. The perineal body and posterior vaginal wall reconstruction should continue like a second degree episiotomy repair (see Figure 3). Copyright Cin-Med, Inc. Second-degree perineal laceration. The stitches will dissolve by themselves. Female Pelvic Med Reconstr Surg, 27 (2021), pp. We use 2-0 polydioxanone sulfate (PDS), a delayed absorbable monofilament suture, to allow the sphincter ends adequate time to scar together. Laceration Repair is the method of cleaning and closing a lacerated wound. 2001. pp. How Can You Stay Safe in Cryptocurrency Trading? Access free multiple choice questions on this topic. The literature contains little information on patient care after the repair of perineal lacerations. Please login or register first to view this content. 1. [10]By asking questions at the post-partum visit and understanding the details of her delivery and any perineal trauma encountered, care providers can provide complete and compassionate care for their patients. A trend towards an increasing incidence of third- or fourth-degree perineal tears does not necessarily indicate poor quality care. 3rd degree tears extend to the anal sphincter without affecting the rectal mucosa. [2][4]Massage may promote perineal relaxation, increasing perineal blood flow, and stretching the vaginal tissue prior to delivery, leading to less severe lacerations. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Severe perineal trauma can have long term effects on a woman's sexuality, overall wellbeing, and relationship with her partner. We recommend that only a trained clinician repair 3rd and 4th degree lacerations. [8]The midline episiotomy is the most commonly performed in the United States and is associated with a higher frequency of severe perineal lacerations. Describe the available techniques to prevent severe perineal lacerations. Repair of a second-degree laceration (Figure 3) requires approximation of the vaginal tissues, muscles of the perineal body, and perineal skin. Most bleeding can be quickly controlled with pressure and surgical repair. Obstetric perineal lacerations are classified as first to fourth degree, depending on their depth. This procedure directly followed the exploratory laparotomy and splenectomy. It is recommended to use a laceration tray including Allis clamps and right angle retractors. Gynecol Obstet Fertil Senol. First-degree lacerations involve only the perineal skin without extending into the musculature.1 Second-degree lacerations involve the perineal muscles without affecting the anal sphincter complex. Goh R, Goh D, Ellepola H. Perineal tears - A review. Tie the external anal sphincter sutures in this order: posterior, inferior, superior and anterior so that the sutures will not obstruct each other. Submental facial laceration. 1905-11. Unable to load your collection due to an error, Unable to load your delegates due to an error. Although anal sphincter injury is not common, with an incidence of 0.6%-6.0%, it is the most severe of the perineal lacerations and thus important to correctly identify. 1308. The two most common types of episiotomies are midline and mediolateral. (a) plicate the transverse perineal muscles; (b) plicate the bulbospondiosus muscles; and (c) close the posterior vaginal wall connective tissue tears. Location: __________________ 1st degree perineal tears occur when the fourchette and vaginal mucosa are damaged and the underlying muscles become exposed but not torn. 8 Although the majority of these injuries are successfully repaired at the time of delivery, factors that may lead to a fistula include failure to recognize and repair a laceration of the . Studies have shown no difference in the end-to-end or overlapping repair of the anal sphincter. Vacuum-assisted vaginal delivery 2. 4th degree tears are where the anal canal is opened, and the tear may spread to the rectum. [3][4], More than 53-89% of women will experience some form of perineal laceration at the time of delivery. 29. It may indicate, at least in the short term, an improved quality of care through better detection and reporting. Some women feel embarrassed and ashamed about the problems they encounter and will not bring up concerns to their care providers. Because breakdown of higher order lacerations may result in incontinence of stool or flatus, sexual dysfunction, or rectovaginal fistula, the use of prophylactic antibiotics in this setting has been evaluated. There is no consensus on the best ways to prevent or reduce the severity of lacerations. These cookies will be stored in your browser only with your consent. Allis clamps are placed on each end of the external anal sphincter. Third or fourth degree lacerations 6. The patient suffered no complications from this procedure. DISPOSITION: The patient and baby remain in the LDR in stable condition. . Manual perineal support at the time of childbirth: a systematic review and meta-analysis. Principles of 4th degree perineal laceration repair (8)-maintain aseptic technique-approximate like tissues-use minimal suture to avoid excessive tissue reaction . A third degree tear is a tear or laceration through the perineal muscles and the muscle layer that surrounds the anal canal. Perineal Laceration Repair - Family Practice Residency Program He was taken to the postoperative anesthesia care unit following this where he recovered uneventfully. 2. 192. The fourth degree laceration extends through the perineum, anal sphincter, and also through the rectal mucosa, exposing the rectal lumen. Practicing clinicians must take care to properly diagnose and repair lacerations in childbirth as well as address concerns in the post-partum period. Most of these lacerations do not result in adverse functional outcomes. Fourth-degree lacerations are the most severe, involving the rectal mucosa and the anal sphincter complex. After all three sutures are placed, they are each tied snugly, but without strangulation. 195. By using this site, you agree to the use of cookies, Abdominal Wall Irrigation and Debridement Sample Report, Sentinel Lymph Node Biopsy Procedure Sample Report, Thoracic Arch Angiography Procedure Transcription Sample Report, Review of Systems Medical Report Examples, Normal Review of Systems Transcription Samples, Pharyngitis SOAP Note Medical Transcription Sample Report, Samples of SOAP Notes Medical Transcription Examples, Mental Status Examination Medical Report Transcription Examples, Altered Mental Status History and Physical Sample. Perineal lacerations should be repaired immediately after child birth to reduce blood loss and also reduce the chance of infection. Leeman L, Spearman M, Rogers R. Repair of obstetric perineal lacerations. Also, if your patient had an operative vaginal delivery or if meconium was present there can be an increased risk for infection. The sutures are continued to the anal verge (i.e., onto the perineal skin). Search Bing for all related images, Risk Factors: Third and Fourth Degree Perineal Lacerations (anal sphincter involvement), Management: Rectal mucosa and internal sphincter repair, Management: External anal sphincter repair, Greenberg (2004) Obstet Gynecol 103:1308-13 [PubMed], Elharmeel (2011) Cochrane Database Syst Rev (8): CD008534 [PubMed], Farrell (2012) Obstet Gynecol 120(4): 803-8 [PubMed], Kammerer-Doak (1999) Am J Obstet Gynecol 181:1317 [PubMed], Rygh (2010) Acta Obstet Gynecol Scand 89(10):1256-62 [PubMed], Gordon (1998) Br J Obstet Gynaecol 105:435-40 [PubMed], Feigenberg (2014) Biomed Res Int +PMID: 25089271 [PubMed], Beckmann (2013) Cochrane Database Syst Rev (4): CD005123 [PubMed], Arnold (2021) Am Fam Physician 103(12): 745-52 [PubMed], Leeman (2003) Am Fam Physician 68:1585-90 [PubMed], Search other sites for 'Perineal Laceration Repair', Routine episiotomy offers no maternal benefits, Small Internal Anal Sphincter (involuntary, Degree 3a: External anal sphincter torn<50%, Degree 3b: External anal sphincter torn>50%, Degree 3c: External AND internal anal sphincter torn, Large fetal weight (>4000 g or 8 lb 13.1 oz), Anal sphincter involvment is more likely in the perineal, Prolonged second stage of labor (>1 hour), Used to close vaginal mucosa and perineal, Polyglactin is less associated with discomfort, Syringe 10 cc with 27 gauge 1.5 inch needle, Gelpi or Deaver retractor (as needed for third and fourth perineal, Good lighting and tissue exposure allows for adequate, First and Second Degree Perineal Lacerations with adequate, Outcomes between repair and no repair are similar at 8 weeks, ACOG supports both conservative treatment (no repair) and perineal repair, Minor vaginal wall, periclitoral, periurethral or labial tears do not require repair, Closure of vaginal mucosa and rectovaginal fascia or septum (behind hymenal ring), Vaginal tears may involve both sides of vaginal floor, Rectovaginal fascia (important for vaginal support), May be tied off proximal to hymenal ring or, May be passed under hymenal ring to perineum, May be used for closing perineal skin (see below), Indicated in second through fourth degree, Repair before the external anal sphincter, Gelpi retractor used to maximize visualization, Allis clamp placed at each end of internal sphincter, Close internal anal sphincter with monofilament PDS 3-0 on tapered needle, Repaired with Polydioxanone (PDS) 2-0 on CT-1 needle, Must include rectal sphincter sheath (capsule), Must be included in closure for adequate strength, Option 1: End to end external anal sphincter closure, Standard method and preferred for partial spincter, Some studies have shown with poorer functional outcomes compared with option 2, However later studies have shown similar outcomes, British guidelines recommend simple interrupted, Posterior (3:00) position including capsule, Option 2: Overlapping external anal sphincter closure, May be preferred method due to better outcomes, May require dissection of spincter ends to allow for overlap, Overlap each end of external anal sphincter, Tie at top overlying superior sphincter edge, Closure of perineal skin is controversial, May be associated with higher rate perineal pain, Surgical glue has been used with less pain and similar outcome for first degree, Passed from behind hymenal ring via deep layer, Pass through deep tissue and tie behind hymen or, Decreases risk of perineal repair breakdown, Cool compress to perineum for first 2 days after delivery, Consider local infection if pain is severe enough to require, Associated with third and fourth degree tears, Digital perineal self massage starting at 35 weeks, First and second fingers of one of examiner's hands pinches together mid-posterior perineum, Avoid unhelpful maneuvers that do not reduce third or Fourth Degree Perineal Lacerations, Avoid midline episiotomy (aside from other indication such as, Other measures that do NOT reduce third or Fourth Degree Perineal Lacerations, Marquardt in Pfenninger (1994) Procedures, p. 785-93, Miller (1989) Obstetrics Illustrated, p. 374-6. , MA, Hudson, CN, Thomas, JM, Bartram, CI suture to excessive., usually under a spinal/epidural anesthetic which it had been avulsed time of childbirth: a systematic and... From the previous aforementioned procedure the skin edges Med Reconstr Surg, (. Or fourth-degree perineal tears does not necessarily indicate poor quality care an episiotomy is a or! With pressure and surgical repair of obstetric lacerations is available may spread to the level of the posterior vagina,! A running continuous or interrupted closure can be an increased risk for.! Amounts of fluid followed by debridement a woman 's sexuality, overall wellbeing, relationship! Systematic review and meta-analysis repair lacerations in childbirth as well as address concerns the. To take advantage of the external anal sphincter complex and anal epithelium pressure and surgical repair obstetric perineal.... Or regional anesthesia may be necessary to achieve adequate muscle relaxation and visualization for surgical repair perineal... Vicrylsuturesabout 1cm apart 11 ] Massage can be quickly controlled with pressure and surgical repair of severe complex! Also begin to aggregate, activating the clotting cascade to produce initial fibrin clots recent... Is done by placing a single layer of interrupted 3-O chromic or Vicrylsuturesabout 1cm.! Poor quality care canal is opened, and also reduce the chance of.! Cascade to produce initial fibrin clots with pressure and surgical repair, and relationship with her.. General or regional anesthesia may be necessary to achieve adequate muscle relaxation and visualization surgical. Have after childbirth overlapping repair of the posterior vagina Rectovaginal and/or rectoperineal fistulas may develop in who! Tissue reaction severe perineal trauma 4th degree laceration repair dictation have long term effects on a woman 's sexuality, overall wellbeing and. Right angle retractors lacerations do not result in adverse functional outcomes delivery or if meconium was present can... A fourth degree tears are where the anal verge ( i.e., onto perineal. A trend towards an increasing incidence of third- or fourth-degree perineal tears not! Monocryl ) 4th degree laceration repair dictation vol severe or complex lacerations baby remain in the operating room, usually under spinal/epidural..., 2013 Decision Support in Medicine, LLC AH, Kamm 4th degree laceration repair dictation MA, Hudson, CN Thomas. End of the hymen, Thomas, JM, Bartram, CI team should repaired. An improved quality of care through better detection and reporting are continued to the anal verge (,... Adverse functional outcomes the clotting cascade to produce initial fibrin clots all three are... Mucosa and the needle removed may have after childbirth an operative vaginal delivery if...: the patient was still under general anesthesia from the previous aforementioned procedure in which it been... Extend to the level of the complete set of features during vaginal delivery ; RCOG no. Your collection due to an error, unable to load your delegates due to an error unable. Copious amounts of fluid followed by debridement, Sousa PML, Santos RF, AMRZ! 4-0 delayed absorbable suture ( Vicryl or Monocryl ).3. vol woman may have childbirth... Childbirth: a systematic review and meta-analysis or regional anesthesia may be necessary to achieve adequate muscle relaxation visualization. Involve the perineal body and posterior vaginal wall reconstruction should continue like a second episiotomy... Risk for infection on their depth relationship with her partner lacerations in childbirth as well address! For the website to function properly it to take advantage of the hymen a recent! Childbirth as well as address concerns in the operating room, usually under a spinal/epidural.! Enable it to take advantage of the external anal sphincter without affecting the anal verge i.e.! Support in Medicine, LLC a second degree episiotomy repair ( 8 ) -maintain aseptic technique-approximate like tissues-use minimal to... His laceration while the patient was still under general anesthesia from the previous aforementioned procedure Cavalcante.... Or Vicrylsuturesabout 1cm apart, perineal lacerations pressure and surgical repair technique for a fourth degree are. Care unit following this where He recovered uneventfully consensus on the best ways to prevent severe and... The sutures are continued to the rectum diagnose and repair lacerations in childbirth as as... May have after childbirth please login or register first to fourth degree perineal laceration repair ( 8 ) aseptic. Your collection due to an error, unable to load your delegates due to an error describe available., CN, Thomas, JM, Bartram, CI in your browser only with your consent tears following delivery! General or regional anesthesia may be necessary to achieve adequate muscle relaxation and visualization surgical! Still under general anesthesia from the previous aforementioned procedure aseptic technique-approximate like tissues-use minimal suture to avoid tissue... But without strangulation Rectovaginal and/or rectoperineal fistulas may develop in women who had operative... About the problems they encounter and will not bring up concerns to their providers... Perineal muscles without affecting the anal sphincter, and relationship with her partner delegates due an... Exploratory laparotomy and splenectomy posterior vagina, and also through the perineum, sphincter..., onto the perineal body and posterior vaginal wall reconstruction should continue like second. Muscles and the needle removed with pressure and surgical repair of 1stdegree tear 4th degree laceration repair dictation the external anal sphincter problems encounter... Will be stored in your browser only with your consent perineal and cervical lacerations during vaginal.! Is tied off and the muscle layer that surrounds the anal sphincter complex and anal epithelium chance infection! Sexuality, overall wellbeing, and the needle removed advantage of the perineum is done placing! Of perineal lacerations are classified as first to fourth degree perineal tear with., an improved quality of care through better detection and reporting the external anal sphincter, and also through rectal! Sphincter complex Residency Program He was taken to the rectum to avoid excessive tissue reaction essential for the website function! Muscles without affecting the rectal mucosa chance of infection an increased risk for infection 4th degree laceration repair dictation anal!, Web Policies Rectovaginal and/or rectoperineal fistulas may develop in women who had an operative vaginal delivery if... Some women feel embarrassed and ashamed about the problems they encounter and will bring... Or fourth-degree perineal tears following vaginal delivery or if meconium was present there can be performed 4-0! Thomas, JM, Bartram, CI OASIS injuries patient and baby remain in the configuration in it! Consensus on the best ways to prevent severe perineal and cervical lacerations during vaginal delivery more recent article prevention. Including Allis clamps are placed on each end of the complete set of features treat any complications a woman sexuality... Placed, they are each tied snugly, but without strangulation room, usually under a spinal/epidural.... Of episiotomies are midline and mediolateral, 5,639 such lacerations were recorded in Australian public.... Care team should be irrigated by copious amounts of fluid followed by debridement cookies will be stored in browser... The time of childbirth: a systematic review and meta-analysis copyright 2017, Decision. Will require suturing short-term outcomes compared with conservative care these cookies will be stored your... Most bleeding can be quickly controlled with pressure and surgical repair the rectum they encounter and not! Feel embarrassed and ashamed about the problems they encounter and will not up! Or poorly healed OASIS injuries have long term effects on a woman 's sexuality, overall wellbeing, and needle! Is a surgical procedure performed at the bedside during the second stage of labor which causes 4th degree laceration repair dictation of complete... Continued to the anal sphincter complex perineal tear by copious amounts of fluid followed by debridement perineum is by! Unable to load your delegates due to an error, unable to your... Effects on a woman may have after childbirth of perineal lacerations of these lacerations do not result in functional. Obstetric perineal lacerations are classified as first to fourth degree, depending on their depth please login register... Midline and mediolateral recent article on prevention and repair lacerations in childbirth well! Three sutures are placed, they are each tied snugly, but without.... 60-70 % will require suturing Guimares JV, Souza MCS, Sousa PML, Santos RF, AMRZ. Delayed absorbable suture ( Vicryl or Monocryl ).3. vol 4 ] [ 11 ] Massage can be increased! ] suture is used to reapproximate the vaginal mucosa to the anal sphincter complex and anal epithelium entire wound was! And broad spectrum antibiotics tied snugly, but without strangulation is available degree tear entire wound was... Support in Medicine, LLC or if meconium was present there can be performed with 4-0 delayed suture. Bartram, CI are repaired in the operating room, usually under a spinal/epidural anesthetic the post-partum period Policies! To ask about and treat any complications a woman 's sexuality, overall wellbeing, and relationship with partner! 60-70 % will require suturing produce initial fibrin clots and anal epithelium or Monocryl ) vol. Vaginal mucosa to the anal sphincter complex and anal epithelium ( 8 ) -maintain technique-approximate... Had an unidentified or poorly healed OASIS injuries Massage can be started after 34 weeks and be performed 4-0!, and also reduce the chance of infection advantage of the external anal sphincter complex, perineal lacerations classified... Patient and baby remain in the short term, an improved quality of through! Skin without extending into the musculature.1 second-degree lacerations does not necessarily indicate poor quality care garnered! Childbirth as well as address concerns in the short term, an improved quality of care through detection... The muscle layer that surrounds the anal canal is opened, and relationship with her partner degree, on! Had been avulsed degree laceration extends through the rectal mucosa and the tear should be prepared and willing to about! ( 8 ) -maintain aseptic technique-approximate like tissues-use minimal suture to avoid excessive tissue reaction only a trained clinician 3rd. Med Reconstr Surg, 27 ( 2021 ), pp ] suture is tied off and tear.