Saving Lives, One Rectum at a Time

Mostly, it's good to be back at work. I enjoy what I do, and sometimes, I even feel competant doing it! I still get really tired at times, but that could easily just be the sleep problems from the prednisone.

One of the things that I like about my job is that people know that I'm willing and able to help, especially with clinical problems.

One of the byproducts of that is the attendings page me for stuff. Like, "I'm starting a c-hyst here, known accreta, are you free to give me a hand?". Or things like, "My lady with myasthenia gravis is too fatigued to continue pushing. I don't do forceps. Can you come help her out?"; there's also the ever popular, "My patient is in labor, 8cm dilated, baby's breech. She's refusing a c-section. Can you come help me out?". I think that people page me because they know I'll come. Surely the attending doing the c-hyst doesn't need me, not really; the myasthenia gravis lady is probably deliverable with a vacuum , and in a multipara who's 8cm dilated and breech, as long as you don't let the baby fall on the floor, you're unlikely to cause problems. I'm only a year out of residency (ok, 11 months), and I'm not arrogant enough to think that I'm so good that they really need me. These people have all been docs for longer than I have.

At the same time, it does feel good to be wanted. My first two days back at work were quiet. Almost too quiet. Nobody paged me at all. Then it started again on Wednesday. On Wednesday, I got paged to teach a resident how to repair a fourth degree laceration.

In obstetric terms, a fourth degree laceration extends from the vagina, across the perineum and into the anus/rectum (depending on size). It's a significant injury. I will say that (especially now, with the UC), I'd rather have a c-section than a 4th degree laceration. Because we do fewer operative vaginal deliveries, they're fairly rare. They're also relatively unpredictable.

Teaching residents at times like these is dificult. You usually can't stop and explain the anatomy, because the patient is bleeding from their very large laceration. It's also critical that the repair be done correctly, to minimize the risk of fistulization, non-healing, and anal incontinence.

So, I go to L&D, which is a 15 minute walk from my lab. I talk to the resident briefly about what happened, and we go in and assess the laceration together. She examins the patient, and the laceration (which had been described as a "minimal fourth") extends 3cm into the rectum. Given the amount of blood loss, we don't have time to go over the whole repair beforehand. And this is a 2nd year resident, who hasn't done or seen 4th degree repairs yet.

But I remembered that she needs to do this, and I don't. Some residents graduate from residency without repairing a 4th degree. If those residents go out to practice in the boonies where there aren't other gynecologists to call for consults, it's a problem.

So, I had her start. I directed her, with pointing and whispering, to carefully place a 4-0 vicryl submucosal suture line all along the rectal mucosa, out to the anal verge. She had a hard time imagining what I was trying to get her to do at first, and although I threw 2 of those sutures, she did get it.

The next step is to reapproximate the fibers of the internal anal sphincter (IAS). This is done with more 4-0 vicryl, and placed very gently and delicately in the space between the rectum and anus and the external anal sphincter (EAS). The IAS consists of fibers of smooth muscle, and is much less defined than the EAS. Repair doesn't necesarily improve IAS function (although it is probably better than no repair), but the real goal of bringing those fibers together is to avoid fistulization. So, on each side, the resident (after a very brief demonstration) brought the correct tissue together.

Next? The EAS. This is not a terribly difficult repair. It can be done in an overlapping or end-to-end fashion, but the goal is to unite the ends of the sphincter capsule. Muscle itself doesn't heal when torn. It will, however, scar together when reunited, which will restore function. The goal of the sphincter repair is to allow the sphincter (which is circular before the injury) to heal in a circle that will have adequate muscle strength to maintain continence. I find that although I feel like the continence results for an overlapping repair are better, at the time of delivery, it can be difficult to accomplish. The sphincter actually retracts deep into the tissue of the perineum, and because of swelling and other problems, I find that an end-to-end repair is more practical. Having said that, I usually will attempt an overlapping repair (the preferred repair of the colorectal surgeons), which is accomplished with a series of vertical mattress sutures of 2-0 vicryl. In this patient, we attempted an overlapping repair, but converted to end-to-end when the tissue was too swollen and injured to allow enough manipulation.

At this point, the laceration resembles any "normal" second degree laceration, and is repaired in the usual fasion, with a crown stitch that reunites the torn bulbocavernosus muscles. Some sources will suggest that the surgeon identify the fascia of the rectovaginal septum and reunite it to the perineal body at this point. I was taught to try, but the rectovaginal septum is often very attenuated after childbirth. And, practically, I don't know that I've ever seen anybody really accomplish that maneuver immediately postpartum. If you can do it at the time of a posterior repair, though, it's pretty slick.

The resident did a fantastic job with minimal direction. The postoperative rectal exam felt almost normal. You could feel the suture line, you could not feel any stitches, and there was even some tone in the sphincter. All good things. I think she'll be just fine.

And to be honest, I feel very pleased with my use of the teaching opportunity. I didn't freak out and "show" the resident how to do it. I taught her how to do it, even though I was leaning over the patient's knee, rapidly acquiring a backache as the resident sat comfortably on a stool to do the repair (that's the way it's supposed to be. When you operate, you have to operate in a comfortable position, otherwise your discomfort becomes a distraction. Besides, comfortable is smoothe, and smoothe is fast, and fast is good).

So, all in all, I think that my week's been a success. Even if that repair were the only thing I'd done all week, I still would think it's been a success.

(Picture stolen from www.aafp.org Gotta love those family docs!)