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  24. Fernando RJ, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal sphincter injury. Cochrane Database of Systematic Reviews 2006, Issue 3. [DOI: 10.1002/14651858.CD002866.pub2]Figures legends Figure 1. Discovery of the vaginal outlet anatomy and histologyA. The yellow arrow represents the hymeneal membrane and its tags. Upon dissecting the hymen membrane, the hymeneal ring is white and indicated by the orange arrow. The low segment of the hymeneal ring fuses with the hymeneal plate, creating the crease and protuberance (the blue arrow).B. The excised fragment of the vaginal outlet without posterior perineal muscles. The yellow arrow refers to the hymeneal membrane; the orange denotes the hymeneal ring; the blue arrow points out the hymeneal plate.C. The histology (Hematoxylin & Eosin stained, and 40x magnification) of the vaginal outlet structure consists of the three histological layers: superficial (the green arrow), middle (the orange arrow deep layer (the blue arrow) of the excised strip of the vaginal outlet obtained during parturition. The vaginal outlet consists of the three histological layers: superficial (the green arrow), middle (the orange arrow, and deep layer (the blue arrow). The first histological layer (the hymeneal membrane) is the superficial layer (the green arrow), consisting of multilayer flat squamous cells of the epithelium, loose fibrous connective tissue, collagen fibers, numerous network of capillary blood vessels, and multiple nerve endings. The second or the middle layer (the hymeneal ring) is well-organized, compressed fibers of the collagen fibers, a network of blood vessels of a larger caliber than in the superficial layer, heavily distributed nerve endings more than in the superficial layer (the orange arrow). Finally, the third layer (the hymeneal plate) is less organized and compact collagen fibers than the hymeneal ring (the blue arrow). In this layer, the smooth vaginal muscles fuse with the hymeneal plate, and it is the only connection of the vaginal wall with the vaginal outlet. A significantly smaller number of nerve endings is present in this stratum when compared to the hymeneal ring—none of the microscopic specimens from the V-shape excision shows perineal skeletal muscle.
Figure 2. The implementation of Ostrzenski’s vaginal outlectomy at the time of fetal head crowning.A. The side of local anesthetic injection before the vaginal outlet excision,B. The fragment V-shape excision that includes tissue of the transitional vulvar skin, hymeneal membrane, hymeneal ring, and hymeneal plate,C. The minimal amount of bleeding is associated with a vaginal outlectomy.
Figure 3. Crowning of the fetal head through the vaginal outlet (“belt-like”) is depicted. The vaginal outlet anatomy consists of a hymeneal membrane (stretched to the point that is almost invisible); the next layer is the hymeneal ring, and under it is the upper crease that separates the next layer of the hymeneal plate, seen as the protuberant configuration. The lower part of the hymeneal plate and the inner surface of the labium minus create a well-visible lower crease.
Figure 4. Post outlectorrhaphy, the suture line (the black arrow) is almost invisible, and the vagina orifice is not gapping.
Figure. 5. Comparison of vaginal outlectomy bleeding with vaginal outlectomy extension and midline episiotomy bleedingA. Amount of bleeding associated with vaginal outlectomy,B. Vaginal outlectomy extension to the posterior perineum, bleeding is heavier than from an uncomplicated vaginal outlectomy,C. Midline episiotomy (the black arrow) divides the skin, posterior-distal vaginal wall, the perineal body, posterior perineal fascia, and five surgically separated muscles (1- the bulbospongiosus muscle, 2- the urethrovaginal sphincter muscle, 3- the superficial transverse perineal muscle, 4- superficial external anal sphincter muscle, 5- the perineal body muscle located under the posterior-distal vaginal wall. The white on blue numbers represent the separated posterior perineum musculatures. The white on green no. 5 depicts the perineal body, and no. 6 describes the levator ani defect.