Transvaginal Repair of Fistulae
- 1.2k Downloads
There are three sections in the chapter on fistulae: vesicovaginal and urethrovaginal fistula, rectovaginal fistula, and repair of perineal fistula.
KeywordsFistula Vesicovaginal fistula Urethrovaginal fistula Peritoneal flap Rotational pudendal artery-based inner thigh flap Martius flap Rectovaginal fistula Rectoperineal fistula
Rotational pudendal artery-based inner thigh flap. A lateral 5 o’clock deep episiotomy is performed to include the labia, the levator, and the lateral vaginal wall to expose the left pararectal space. The fistula is repaired after proper exposure and creation of wide vaginal wall flaps. An inverted U incision is made lateral to the labia, and a wide base flap is dissected free from the adductor fascia. The labial and underlying fatty tissues are dissected medially from the vaginal wall and laterally from the pubic bone and adductor fascia. Delayed absorbable sutures are preplaced on the margins of the vaginal incisions. The labial flap is rotated laterally and the inner thigh flap is rotated medially toward the vaginal canal. The preplaced sutures are applied to the rotational flap, and the anastomosis of the flap to the vaginal margins is completed. The area of the fistula is covered with a well-vascularized tissue-thick flap of skin. The rotated lateral labia flap is approximated to the lateral margins of the inner thigh (MP4 238040 kb)
Repair of vesicovaginal fistula using a peritoneal flap. The fistulous tract is dilated and a small Foley catheter is inserted in the fistula to provide retraction and facilitate the dissection. A circular incision is made around the fistulous tract leaving a small margin of the fistula. An anterior vaginal flap is created. Lateral dissection of the vaginal wall 3 cm from the fistula is done. A posterior vaginal wall flap is created to expose the prerectal space. A peritoneal flap is mobilized and dissected free for later use in reconstruction. The fistulous tract is not excised and is closed in layers. The first layer includes the tract and the whole bladder wall. The second layer includes the perivesical fascia and the retracted bladder musculatures. The peritoneal flap is advanced distally to cover the area of the reconstruction. The distal vaginal flap is excised and the posterior vaginal wall advanced distally to cover with new vaginal tissue the area of the fistula (MP4 237662 kb)
Repair of urethra-vaginal fistula using a Martius flap. The patient had multiple surgeries to repair the fistula. A small Foley catheter is inserted into the fistula. Inferior and superior vaginal wall flaps are created to expose the fistula with an attenuated urethral wall and retracted deficient periurethral fascia. The periurethral fascia is mobilized and dissected proximal to the fistula. The fistulous tract is closed in a vertical fashion with multiple layers. The periurethral fascia is advanced distally to cover the area of the reconstruction. A Martius flap is created, rotated, and transferred under the labia to cover the area of the reconstruction. The vaginal wall is advanced distally to cover with new vaginal wall the flap and the reconstructed area (MP4 33925 kb)
Repair of rectovaginal fistula using a Martius flap. After copious irrigation of the rectum with antibiotic solution, the vaginal is prepared and a Foley catheter inserted into the fistula. A circular incision is made around the fistulous tract. An inverted U incision is done posterior to the fistula, and a wide base flap is created 4–5 cm proximal to the fistula. The prerectal fascia is dissected as a separate layer as well as the lateral vaginal wall adjacent to the fistula. Distal to the fistula, another vaginal flap is created to expose the distal posterior rectal wall. The fistula is closed in layers. The first layer includes the whole rectal wall and the fistulous tract. The second layer includes the perirectal fascia and covers completely the first layer of closure. The prerectal fascia is advanced to cover the repair. A Martius flap is created, rotated, and transferred to cover the area of the fistula repair. The posterior vaginal wall is advanced distally after excision of the distal wall, overlapping with new vaginal wall repair (MP4 66222 kb)