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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 13-5 A and B. Excision and saucerization of involved tissues.
Debride tissue with a curette (Fig. 13-6) and control hemostasis with
electrocautery.
FIGURE 13-6 Curette the tracts once they are open.
Wide excision of all apocrine-based tissue.
Excise the pathologic tissue down to the subcutaneous tissue or fat with
electrocautery (Fig. 13-7).
FIGURE 13-7 Excision of the disease.
Radical excision may result in large defects that may require flap coverage
or skin grafting (see later).
Negative-pressure dressing may assist in more rapid healing of wound
defects.
This can be used in conjunction with grafting, which can be done at a
later date after the formation of granulation tissue.
May be used for patients with mild, localized disease as this technique will
not have a long-term effect on symptoms.
If unable to graft, multiple topical dressings have been used (eg, Vaseline
gauze, xeroform).
Excision and grafting
Radical excision is the only method that may result in a cure, but
recurrence can still occur.
Negative-pressing dressing (ie, wound Vac) should be placed and kept in
place until granulation tissues have covered the entire wound.
In the perianal region, you need to avoid excising an excessive amount of
anoderm to avoid anal stenosis from excessive scarring.
Pearl: Hidradenitis is only in hair-bearing areas and should not be
adjacent to the anus.
Split-thickness skin grafts should be harvested.
Anterolateral thigh is ideal source for skin graft harvest.
Thickness of skin graft should be around 0.01 in (setting on the
dermatome).
Mark the area of harvest and lubricate the skin with mineral oil to allow
for dermatome to glide smoothly on the skin.
Apply the dermatome to the skin with even, firm, direct pressure.
Harvest the amount of skin needed to cover the granulation tissue.
Immediately after harvesting the graft, place Telfa gauze soaked in
dilute epinephrine for hemostasis.
Meshing
Meshing creates slits in the skin to allow drainage of hematoma and/or
seroma.
Also expands surface area of the graft, allowing for a larger area to be
covered.
Meshing should be done at a 1:1 or 2:1 ratio.
When placing skin through the mesher, spray with saline so skin does
not stick within the mesher.
Application of skin graft
Ensure wound bed is ready with healthy granulation tissue (Fig. 138A).
FIGURE 13-8 A and B. A patient with Hurley stage III disease who underwent
radical excision and closure with split-thickness skin grafting. (Courtesy Bradley
Davis, MD.)
Align edges of skin graft within 1 mm of normal skin without
overlap (if graft overlaps normal skin, the overlapping skin will
necrose and slough)
Graft should be placed dermis side down (dermis is shiny and wet
appearing; Fig. 13-8B).
Options to secure graft
3-0 chromic suture, simple interrupted spaced about 1 cm apart
around the periphery of the graft to normal skin junction
Surgical staples
Fibrin sealant
Topical skin adhesive
Entire surface of the graft must be adherent to the wound bed.
Any portion of the graft that is not adherent to the wound bed
will become necrotic and not heal.
Ensure the entire graft is in contact with wound by securing the
graft to the wound bed where the graft may be tented.
Options for dressings
Harvest site
Wrap donor site in plastic wrap/Tegaderm/Ioban (3M)
Typically, this is most comfortable for patients.
Xeroform cut to size of donor site and slather with bacitracin,
covered with Telfa and wrapped in Kerlix gauze—remove Telfa and
Kerlix after 24 hours
AQUACEL (ConvaTec, Bridgewater, NJ)
Graft
Wound Vac is the best method to ensure that the graft will remain in
place and not dislodge.
Layer of ADAPTIC (KCI/Acelity) directly on graft
Black or silver sponge
Plastic adhesive
Set Vac to −125 mm Hg
Leave in place for 4-5 days; remove on postoperative day 5 to
assess healing
After takedown, can assess how much of the graft has taken and
then apply xeroform dressing
As the area becomes epithelialized, can transition from xeroform
to moisturizing lotion
Excision and flaps
Types of flaps: pedicled gracilis myocutaneous flaps, anterior obturator
artery perforator flaps, and superior gluteus maximus musculocutaneous
flaps
Flaps are usually performed in conjunction with plastic surgery
colleagues.
Excision should be done as described earlier—all apocrine bearing
diseased tissue should be excised down to healthy subcutaneous adipose
tissue.
Flaps rely on robust blood supply from perforators of the superior gluteal
artery, inferior gluteal artery, and deep femoral arteries.
When to divert?
Need to first assess baseline bowel function and continence
Frequency of bowel movements
Quality of stool
Sensation to defecate
Urge to defecate
Baseline continence
Assess sphincter function
Physical examination
Typically, there is no need for further diagnostic studies beyond careful
digital rectal examination, but can obtain anorectal manometry for
objective documentation of sphincter function.
Need to assess extent of dissection
Approximate the location of the excision in relation to the anal verge
and if the skin graft/flap suture lines will encroach upon the anal verge
Will the selective use of bulking and constipating agents be sufficient to
minimize dressing changes?
Can use fiber supplementation twice daily
Can add loperamide up to 16 mg per day
Postoperative Care
Patient may need to be on prolonged antibiotic therapy (ie, doxycycline),
leading to surgery and beyond.
This will help quell the active suppurative response.
Patient may need strict bed rest with bathroom privileges only to avoid
dislodgement of the graft.
Patient may need Foley catheter.
Donor site pain is usually worse than graft site.
When the Vac is deployed onto a skin graft, don’t apply suction one time
only.
To help with sealing the Vac
Stoma paste
DuoDERM (ConvaTec)
Liquid adhesive
If the Vac fails in immediate postoperative period
Remove Vac dressing and apply Xeroform gauze slathered in bacitracin
with a fluff dressing to mold the graft to the wound bed.
Fecal diversion may be required in select patients such as those with
underlying continence issues or those with wound management
problems.
Suggested Readings
Asgeirsson T, Nunoo R, Luchtefeld MA. Hidradenitis suppurativa and pruritus ani. Clin Colon Rectal
Surg. 2011;24(1):71-80. doi:10.1055/s-0031-1272826.
Church JM, Fazio VW, Lavery IC, Oakley JR, Milsom JW. The differential diagnosis and comorbidity
of hidradenitis suppurativa and perianal Crohn’s disease. Int J Colorectal Dis. 1993;8(3):117-
119.
Chapter 14
Rectovaginal Fistula
TRACY HULL
Perioperative Considerations
One of the most important aspects when repairing an anorectovaginal
fistula is evaluating the patient before considering the operative approach
and procedure.
The tissue must be soft, supple, and free of any sepsis.
An examination under anesthesia with seton placement (usually for a
month) and unroofing of any cavity is essential.
We completely open a fistula tract to the level of the anal muscle to allow
it to heal from the bottom up and have the shortest tract as possible. We
then wait until the area has completely healed before proceeding.
When the tissue is not soft, consideration of a stoma should be entertained.
We have found hyperbaric oxygen to be extremely helpful when tissue is
fibrotic from previous failed attempts at repair. It is also useful in
radiation-induced fistulas.
Typically, 20 treatments (one daily for 5 days per week) before and
then waiting 2-3 weeks after the last treatment before doing surgery is
our preferred choice.
Then immediately after the repair, 20 more treatments are given.
Additionally, women who are menopausal may have improved supply of
their tissue with vaginal hormone cream for a month prior.
For patients with Crohn disease, the appearance of the anal canal and
rectum is extremely important.
The internal opening of a Crohn-related fistula will typically be at the
base of an ulcer.
Placing a seton and aggressively treating with biologics many times
will then leave the woman with a dry ulcer and repair then can be
considered.
If the anal canal never becomes inflammation free, no repair will be
successful.
The status of the anal sphincter anteriorly is also an important preoperative
consideration.
Even when the perineal body is thick, the muscle may not be intact.
We have a low threshold for obtaining an anal ultrasound to look at the
muscle as it may greatly influence our choice of repair (Fig. 14-1).
FIGURE 14-1 Anal ultrasound in a woman with an intact perineal body, but
anterior defect in the IAS and EAS. EAS, external anal sphincter; IAS, internal anal
sphincter.
We cannot stress enough the importance of being patient and ensuring the
tissue is soft, supple, and sepsis free before embarking on any repair.
For all repairs, unless the patient has a stoma, a full bowel preparation is
given. A Foley catheter is inserted, and intravenous (IV) antibiotics are
given. The area is prepped with betadine (or baby shampoo if iodine
allergic). During the procedure, the perineal wound is periodically
irrigated with antibiotic irrigation (we currently use bacitracin).
Our algorithm for repair is shown in Figure 14-2.
FIGURE 14-2 Algorithm for repair. RVF, rectovaginal fistula.
Sterile Instruments/Equipment
Anal retractors, fiberoptic lighted: small, medium, and large
Hill-Ferguson retractors: often used for perianal cases positioned in
lithotomy
Fansler retractors: small, used selectively for perianal cases such as
those positioned in prone (ie, Kraske) or those with large redundant
mucosa
Pratt bivalve anal retractor
Right-angle retractors
Set of Lockhart-Mummery fistula probes
Set of curettes
00-silk ties
Silicon, radio-opaque yellow (mini) vessel loop, 1.3 mm wide and 0.9 mm
thick, or a blue (maxi) vessel loop, 2.5 mm wide, 1 mm thick
Monopolar electrocautery
We routinely use 40 cut/60 coagulation settings, pure or blend.
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