Repair of Vaginal or Vulvar Lacerations
These lacerations may result from childbirth, sexual assault,or accidents.
Because this area is quite vascular, primary closure is preferred in an acute setting. In cases involving delayed treatment (>24 hours after the injury), it may be preferable because of tissue inflammation and infection to allow secondary healing followed, if necessary, by a later repair.
Lacerations of the bladder can be diagnosed with retrograde injection of dye through a Foley catheter. Repair should be in multiple layers, using absorbable sutures, without tension. A very acceptable alternative is simple drainage with a Foley or suprapubic catheter. Many cases of small lacerations will close spontaneously over time with this type of urinary diversion and those that don’t may be closed electively weeks to months later.
Lacerations of the rectum may be closed primarily with multiple layers of absorbable suture. The need for fecal diversion should be determined by the mechanism and magnitude of the injury. If treatment has been delayed or there is evidence of significant inflammation of the edges of the laceration, surgical closure should be delayed weeks or months until the inflammation has subsided. If the anal sphincter has been torn, it will retract back into the surrounding tissue, creating a 1-2 cm “crater.” Identify this crater with your finger, then grasp the retracted muscle with an instrument and bring it back to the midline. Suture the edges of the sphincter together, making sure to include the fibrous capsule of the muscle. This will allow proper healing and promote subsequent fecal continence. Failure to close the sphincter is not disastrous, but will usually result in fecal incontinence to some degree and a later corrective procedure.
Other soft tissue lacerations are usually easily repaired with absorbable sutures such as 2-0 Vicryl or 0-Chromic. When the laceration involves the anterior vaginal wall, avoid deep placement of sutures since the bladder and urethra are usually within a few millimeters of the vaginal mucosa. Placing a Foley catheter in the bladder prior to suturing will help to outline the important anterior structures to be avoided. If the laceration involves the posterior vaginal wall, remember that the rectum can be within a few millimeters of the vaginal mucosa. Lacerations involving the lateral vaginal walls – these lacerations are high in the vagina, they are both more difficult (because of exposure and lighting problems) and more dangerous. The ureter courses next to the cervix in the parametrial tissues but becomes accessible to accidental vaginal suturing if the sutures are placed deep and high in the vagina.
The bowel, bladder and ureters are very close to the uterus, cervix, tubes and ovaries. Damage to adjacent structures is not uncommon!