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Review
. 2021 Jul;32(7):1761-1769.
doi: 10.1007/s00192-020-04502-2. Epub 2020 Sep 15.

Isolated rectal buttonhole tears in obstetrics: case series and review of the literature

Joanna C Roper  1 , Ranee Thakar  1   2 , Abdul H Sultan  3   4
Affiliations
Review

Isolated rectal buttonhole tears in obstetrics: case series and review of the literature

Joanna C Roper et al. Int Urogynecol J. 2021 Jul.

Abstract

Introduction and hypothesis: The management of isolated rectal buttonhole tears is not standardised and can be challenging in an acute obstetric setting. Our aim was to review the published literature and describe management and repair techniques in a case series.

Methods: A literature search was carried out. All results were screened and reviewed. Rectal buttonhole tears following vaginal delivery between April 2012 and January 2020 in our institution were identified. Repair technique and post-operative management were recorded.

Results: There were nine published case reports (four instrumental deliveries, two vaginal breech and three normal vaginal deliveries). Four case reports described a two-layer closure and five described a three-layer closure. Two cases were repaired in collaboration with colorectal surgeons. All nine cases made an uneventful recovery. We identified three patients with buttonhole tears all of whom had instrumental deliveries. A colorectal surgeon repaired the tear in two layers in one case, and an obstetrician performed the repair in the other two cases, one in three layers and the other in two layers. One patient had a de-functioning stoma at a later date due to a second breakdown of the recto-vaginal fistula repair.

Conclusion: Buttonhole tears are rare but techniques of repair vary. Most cases reviewed had an uneventful recovery after repair. We provide standardised steps for repair and management of isolated rectal buttonhole tears along with a video demonstrating the repair technique in an animal tissue (pig) model.

Keywords: Isolated rectal buttonhole tear; Obstetric anal sphincter injury; Rectal examination; Rectovaginal fistula; Third and fourth degree tears.

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Conflict of interest statement

None.

Figures

Fig. 1
Fig. 1
Isolated rectal buttonhole tear (arrow)
Fig. 2
Fig. 2
Isolated rectal buttonhole tear in pig specimen (arrow)
Fig. 3
Fig. 3
Layers for repair in pig specimen (RM = rectal mucosa, RV = rectovaginal fascia, VS = vaginal skin)
See this image and copyright information in PMC

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