E: The skin is closed.
Some surgeons recommend the overlapping repair regardless of whether it is performed immediately postpartum, delayed postpartum, or several years after obstetric injury. Performance of the overlapping technique is difficult immediately postpartum and requires adequate anesthesia, exposure, and equipment. Many surgeons believe that this can only be accomplished in the operating room. This repair lacks the theoretical advantage of using scar tissue to improve suture holding; however, it maximizes surface area for scarification of the sphincter ends. For a delayed postpartum repair, it is recommended to wait 3 to 6 months to permit complete resolution of inﬂammation and reinnervation.
Four randomized control trials compared end-to-end approximation to overlapping sphincteroplasty after acute obstetrical injury (109–112). Fitzpatrick et al. randomized 112 primiparous women undergoing immediate repair of a third-or fourth-degree sphincter tear (109). The authors did not detect any significant differences in objective or subjective outcomes between either of the two repairs at 3 months follow-up. Approximately one-half of the women had minor alteration in fecal continence, whereas 7 (6%) had daily soiling. Despite good symptomatic results, 74 (66%) had full-thickness EAS defects on endoanal ultrasonography. Williams et al. randomized 112 women to overlapping or end-to-end repair with either polyglactin (Vicryl) or polydioxanone (PDS) (110). They, too, found no difference in outcomes between the different methods of repair or type of suture used. Fernando et al. randomized 64 women and discovered a lower rate of fecal incontinence symptoms and fecal urgency after overlapping repair compared to end-to-end repair (111). Farrell et al. randomized 149 women to one of the two techniques and was the only study to discover higher rates of fecal incontinence of ﬂatus in the overlapping group compared to the end-to-end group (61% vs. 39%; OR 2.44) (112). There was a trend toward overall higher rates of fecal incontinence; however, these were not statistically different (15% vs. 8%) (112). A Cochrane review that included the first three randomized controlled trials concluded that the overlapping repair technique resulted in less fecal incontinence and fecal urgency, but the data were insufficient to recommend one repair over the other (113). Another randomized controlled
Figure 28.4 (continued)
Figure 28.4 (continued) trial involved a delayed repair in 23 patients more than 1 year following delivery (114). The scar was preserved for each repair, and a puborectalis plication was performed. At a median follow-up of 18 months, there were no detectable differences in continence scores; however, the study was clearly underpowered. Consequently, the authors believe there is no definitive evidence to support an overlapping technique at the time of acute obstetrical injury and repair but prefer an overlapping technique as a delayed repair.
Efficacy Despite the many large series reporting the outcomes of overlapping sphincteroplasty, almost all are retrospective in nature and lack validated measures of symptom severity and qualityof-life considerations. Several overlapping sphincteroplasty series with a total of 891 patients were evaluated from 1984 to 2001. Although the length of follow-up was variable, the results showed excellent and good outcomes in approximately two-thirds of patients (median 67%, range 52%–83%) (115). None of these studies had long-term outcomes.
More recent studies suggest poor long-term outcomes for the overlapping sphincteroplasty.