Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

C H A P T E R 98 • Bilateral Salpingo-Oophorectomy 1091

3. CLOSING

The abdominal wall is closed in layers. The anterior rectus fascia is closed in a continuous mass closure.

STEP 4: POSTOPERATIVE CARE

Bladder drainage is maintained until the first postoperative day.

Diet is advanced as tolerated.

Early ambulation is encouraged.

STEP 5: PEARLS AND PITFALLS

Salpingo-oophorectomy in a menstruating woman will effect a surgical menopause, which may cause severe hot flashes and other sequelae of premature menopause.

Mechanical bowel preparation is advised in patients undergoing surgery for an ovarian mass.

SELECTED REFERENCE

1. Rock JA, Jones HW (eds): TeLinde’s Operative Gynecology, 10th ed. Philadelphia, Lippincott Williams & Wilkins, 2008.

C H A P T E R 99

REPAIR OF RECTOVAGINAL FISTULAE

Margie A. Kahn

STEP 1: SURGICAL ANATOMY

Although rectovaginal fistulae may spontaneously arise from Crohn’s disease or malignancy, most cases result from failed obstetric repairs and complications of posterior vaginal prolapse repair operations.

Successful repair requires a wide enough dissection to obtain a tension-free layered closure of viable, well-vascularized tissue, using a pedicled Martius bulbocavernosus graft if necessary.

Although successful early secondary repair has been described, repair after postpartum dehiscence is traditionally delayed for 3 months to allow maximal reinnervation and vascularization of the wound.

Numerous failed repairs may require a diverting colostomy before and 3 months following reoperation to ensure adequate healing.

Fistulae superior to the levator muscles may require an abdominal approach to achieve adequate mobilization of tissue. In the pre-antibiotic era, the rectal advancement and vaginal flap operations had the advantage of avoiding a suture line in the rectum. However, the use of these operations may make overlapping the retracted muscle of the anal sphincter more difficult.

Preoperatively, all patients receive a bowel preparation and prophylactic antibiotics.

Infiltration of the operative field with 20 U of vasopressin in 100 mL of normal saline or a local anesthetic with epinephrine reduces blood loss and helps hydrodissect scarred tissue planes.

1092

C H A P T E R 99 • Repair of Rectovaginal Fistulae 1093

STEP 2: PREOPERATIVE CONSIDERATIONS

Most postpartum fistulae are accompanied by two quadrant anal sphincter defects identifiable by perineal dimples at the 3 o’clock and 9 o’clock positions.

In the worst cases, the vaginal mucosa directly abuts the rectal mucosa. If gross inspection and palpation are equivocal, endoanal ultrasonography and anorectal manometry may be used to identify the anatomic and functional significance of the defects. In the following figure, the normal sphincter is on the right.

Extensive dissection to achieve anal overlapping sphincteroplasty can interfere with the neurovascular bundles at the 4 o’clock and 8 o’clock positions (Figure 99-1).

Clitoris

Dorsal nerve of clitoris

Ischiocavernosus muscle

Bulbocavernosus or Bulbospongiosus

muscle Deep perineal nerve

Superficial perineal

nerve

Transverse perineal muscle

Pudendal nerve

MC

Anal sphincter muscle

Inferior anal nerve

FIGURE 99–1

1 0 9 4 S E C T I O N X I V • G Y N E C O L O G Y

STEP 3: OPERATIVE STEPS

1.INCISION

The Lone Star Retractor and stays are applied, and the proposed surgical field is injected with vasopressin.

The perineal incision line is marked at the junction of the vagina and perineum (Figure 99-2). (If there is deficient perineum, a modified cruciate incision will allow a Z-plasty.)

The initial incision is made with needle-tip electrocautery set on a pure cutting current

(Figure 99-3).