Management of Rectovaginal Fistula - up.ac.za 2015/sat/s3... · Differentiate • Rectovaginal...
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Transcript of Management of Rectovaginal Fistula - up.ac.za 2015/sat/s3... · Differentiate • Rectovaginal...
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Management of
Rectovaginal Fistula
BH Pienaar
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Differentiate
• Rectovaginal fistula– Above the dentate line– More common– Important to distinguish from
• Ano vaginal fistula– Treatment is different– Uncommon– Sphincter involvement– Medical management if secondary to Crohn’s
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ClassificationRectovaginal Fistula
• Location– Low/Perineal
• Approach perineal
– High (middle/upper third rectum)• Transabdominal approach
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ClassificationRectovaginal Fistula
• Aetiology– Obstetric trauma– Radiation injury– Iatrogenic trauma (PPH)– Neoplastic– Inflammatory bowel disease (Crohn’s)
• Size– Small < .5 cm– Medium .5-2.5 cm – Large . 2.5 cm
• Combination of the above.– To decide the approach
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Pathophysiology
– Obstetric trauma• Pressure • Infection of episiotomy• Failure to correct perineal defects
– Stapled resection • PPH
– Crohn’s disease• Perirectal abscess
– Diverticulitis • Pelvic/Perirectal abscess
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Pathophysiology
Radiation therapy in pelvic malignancyMost difficult
Other risk factorsPrevious pelvic surgeryDiabetesSmoking
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Symptoms
Faeces and flatus through vagina
Vaginitis/Cystitis
Asymptomatic (Faecal consistency)
“Incontinence”
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Examination
Standard routine examinationSizeLocation
Sphincter functionVaginal tampon/Rectal methylene blueBarium enema (diluted)CT scan Endorectal/Vaginal sonographyBiopsy
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Anatomy
Rectovaginal septum
Anal sphincter complex
Perineal body
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Preparation
Complete mechanical bowel preparation
Neomycin advocated by some
Systemic antibiotic use
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Local repair
Trans anal advancement flap repairPatient proned/operating anoscope
Flap contains mucosa and submucosaMucosal fistulous opening excisedApproximation of muscle wall of rectumFlap sutured interrupted
Vaginal wall left openSphincter status
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Local repair
Trans vaginal advancement flap repairPatient lithotomy
Flap contains posterior vaginal wallMucosal fistulous opening excisedApproximation of levator aniFlap sutured interrupted
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Transabdominal
Essential for high complicated fistulaRadiationIBDDiverticular disease
Affected bowel must be resectedOmentum as interposition buttressing structure
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Other
Gracilis interposition75% success rate (no Crohn’s)33% success rate (with Crohn’s)
Martius graft (1928: pedicled bulbocavernosus fat pad)
Colostomy with/without proctectomy
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New possibilities
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Transvaginal advancement flap
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Levator ani approximation
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RECTAL ADVANCEMENT FLAP
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Purpose of the Exercise
Notto have the
original defect and the
repair suture line overlapped
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Thank you