15.4.

2014

Rectovaginal Fistula Repair

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Vagina and Urethra

A nterior Repair and Kelly Plication Site Specific Posterior Repair Sacrospinous Ligament Suspension of the Vagina Vaginal Repair of Enterocele Vaginal Evisceration Excision of Transverse Vaginal Septum Correction of DoubleBarreled Vagina Incision and Drainage of Pelvic A bscess via the Vaginal Route Sacral Colpoplexy Le Fort Operation Vesicovaginal Fistula Repair Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula McIndoe Vaginoplasty for Neovagina Rectovaginal Fistula Repair Reconstruction of the Urethra Marsupialization of a Suburethral Diverticulum by the Spence Operation Suburethral Diverticulum via the Double-Breasted Closure Technique Urethrovaginal Fistula Repair via the DoubleBreasted Closure Technique Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence Transection of GoebellStoeckel Fascia Strap Rectovaginal Fistula Repair via MussetPoitout-Noble Perineotomy Sigmoid Neovagina Watkins Interposition Operation

Rectovaginal Fistula Repair

Rectovaginal fistulae must be divided into two groups. The first group consists of those that occur secondary to obstetric or gynecologic surgery for benign disease. The second group consists of those that are associated with radiation therapy for pelvic malignancy. Rarely is a diverting colostomy needed for fistulae from benign disease. A transverse colostomy is always needed, however, for pelvic cancer patients who have rectovaginal fistulae secondary to irradiation. An outside blood supply, such as a muscular flap, is not required for the repair of small rectovaginal fistulae secondary to obstetric or gynecologic surgery, unless there is excessive scarring or repeated attempts at closure have been unsuccessful. Patients with rectovaginal fistulae associated with pelvic irradiation, however, require a vascular flap to improve blood supply to the irradiated tissues. The bulbocavernosus muscle is the most convenient source of blood supply, but other sources include the omentum, gracilis muscle, and myocutaneous flaps. The cardinal principles of repair of rectovaginal fistulae are (1) delay of repair until all inflammation has cleared at the fistulae site, even if a preoperative perineotomy is required; (2) excision of all fibrotic and scar tissue surrounding the fistulous tract; (3) complete mobility of the rectum and colon to eliminate any tension on the rectal mucosa after excision of the scarred tissue; (4) use of delicate surgical technique to preserve as much vascularity as possible; (5) broad surface-to-surface closure; (6) improved vascularity using an outside blood supply; and (7) diverting colostomy, in cases of irradiation, until 3-4 months after the fistula has been confirmed closed by repeated examination. Physiologic Changes. The rectovaginal fistula is closed, and normal defecation per anus is resumed. The bulbocavernosus flap used to cover the rectovaginal fistula suture line improves vascularity and gives an additional layer to the closure, thus improving the chances of permanent fistula repair. Points of Caution . The margins of the rectal mucosa must lie adjacent to each other without tension. Tension on the rectal mucosa suture line will invariable result in separation of the wound. Hemostasis is a vital factor. The hemorrhoidal plexus of veins can be difficult to control, but meticulous technique in clamping, tying, and/or electrocoagulating each of these vessels is imperative to fistula closure. Dilatation of the anus at operation produces temporary rectal paralysis of the sphincter muscle and, thereby, temporary rectal incontinence, preventing the buildup of flatus and stool in the terminal rectum and avoiding tension on the suture line. Technique

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Rectovaginal Fistula Repair

Occasionally, a fistula high inside a narrow vagina is difficult to expose. Therefore, a mediolateral episiotomy should be performed without hesitation to allow maximum exposure to the operating site. The mediolateral episiotomy should be extended up the vaginal mucosa to the margin of the fistula. If adequate exposure cannot be obtained completely from the vaginal approach, the abdominal route should be considered, particularly in those cases where the fistula is high in a deep vagina.

Extreme care should be taken that the bowel mucosa is adequately mobilized and that devitalized, scarred, or avascular portions of the mucosa have been excised. If the intestinal mucosa cannot be mobilized and it is apparent that the closure of the intestinal mucosa will be under tension, the surgeon should perform a laparotomy and totally mobilize the rectosigmoid colon from above. Many fistula repairs fail because this in not done. After adequate mobilization of the intestinal mucosa, the edges of the intestinal mucosa are closed in an inverting fashion with interrupted 3-0 Dexon suture with a Lembert stitch.

The perirectal fascia and even some levator ani muscle may be drawn into a second layer of closure using 0 Dexon.

If an outside blood supply is desirable, the margin of the excised fistula tract is connected with the incision of the episiotomy. The bulbocavernosus muscle is palpated under the labia majora, and a longitudinal incision is made down the labia majora through the fat pad until the bulbocavernosus muscle is located.

The bulbocavernosus muscle is dissected out and transected above its insertion into the perineal body, http://www.atlasofpelvicsurgery.com/2VaginalandUrethra/14RectovaginalFistulaRepair/chap2sec14.html

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Rectovaginal Fistula Repair transected above its insertion into the perineal body, leaving its blood supply from the branches of the The bulbocavernosus muscle is sutured over the pudendal artery intact. A tunnel approximately 3 cm perirectal fascia with interrupted 3-0 Dexon wide is created from inside the vaginal canal with a sutures. Kelly clamp, and the bulbocavernosus muscle is drawn through this tunnel underneath the labia
minora and hymenal ring.

The edges of the vaginal mucosa are then approximated with interrupted 2-0 Dexon sutures. The wound over the labia minora may be sutured by subcuticular 3-0 Dexon or interrupted 4-0 nylon sutures. Occasionally, there will be troublesome bleeding from the bed of the bulbocavernosus muscle. If this cannot be brought under adequate control by delicate clamping and suturing, it is often possible to pack this area with Avitene collagen hemostat. In this event, a small 1/4-inch closed suction drain can be brought out from the inferior edge of the labial incision. To have the entire wound completely dry and avoid hemostatic agents or drains is preferred, however. Care must be taken to ensure that the stool is completely soft and that there is no buildup of flatus above the sphincter. The latter can be accomplished by two techniques. One is to dilate the sphincter to 45 cm manually, thus temporarily paralyzing the rectal sphincter and leaving the patient fecally incontinent for approximately 1 week. The other is to incise the rectal sphincter at the 7 or 9 o'clock position in one plane only. Multiple radial incisions in the rectal sphincter may produce permanent fecal incontinence. It is highly recommended that the patient use a stool softener for 3-6 months following fistula repair.

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