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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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The dissection continues until the probe is identified (Fig. 14-34).
FIGURE 14-34 The probe remains in place to guide the dissection into the
rectovaginal plan.
It is crucial that the mobilization continues at least 3-4 cm cephalad from
where the fistula is encountered. The probe is removed during the
mobilization when it is no longer needed to guide the operator for
identification (Fig. 14-35).
FIGURE 14-35 The mobilization continues at least 3-4 cm cephalad from where the
probe had been in the tract.
The rectal side is cored out and closed in layers with 2-0 and 3-0
polyglactin sutures. Typically, in both a side to side and forward to back
(Fig. 14-36).
FIGURE 14-36 The rectal side is cored out and closed in layers.
We leave the needle on the forward to back suture that is located at the
most medical and cephalad extent to use to anchor the flap.
We also close the internal opening from the anal side with figure-of-eight
sutures (Fig. 14-37).
FIGURE 14-37 Closure of the anal side.
The external opening at the vagina or labia is cored out (Fig. 14-38).
FIGURE 14-38 The external opening on the vaginal side is cored out.
On the transverse incision side, figure-of-eight sutures are placed to close
this aspect of the vaginal opening. We sometimes leave the needle on
these to assist in anchoring the flap. The two openings in this internal
wound (the perineal wound) should be far apart if you have done sufficient
mobilization.
We place an antibiotic-soaked gauze and turn my attention to the labia.
We choose the side to mobilize the labia based on whether the fistula
tracts veers to one side or the other. For instance, if the external opening is
at the base of the left labia, we would choose the right side.
An incision is made over the labia and deepened (Fig. 14-39).
FIGURE 14-39 Antibiotic-soaked gauze in wound. Incision made over labia.
Once fat is encountered, we mobilized the skin off the fat laterally and
medically (Figs. 14-40 and 14-41) and look for the change in character of
the fat that represents the bulbocavernosus muscle pedicle.
FIGURE 14-40 Once fat is encountered, the skin is mobilized laterally.
FIGURE 14-41
We dissect widely and under the area and place a Penrose drain (Fig. 14-
42). Care is taken to avoid trauma to the fatty flap on the side toward the
perineal body as the blood supply will come from that area. The desired
tissue has minimal attachments and can be easily mobilized with scissors
cephalad.
FIGURE 14-42 A Penrose is placed around the bulbocavernosus.
When the pubic bone is reached, the tissue is divided between ties, leaving
the tail long as a handle on the flap side (Fig. 14-43). Mobility is
ascertained, and sometimes very careful distal dissection is required being
mindful of the area of the blood supply.
FIGURE 14-43 The bulbocavernosus is detached at the pubic bone.
Next the tunnel is made to the transverse perineal wound. Using a blunt
instrument (Fig. 14-44), it is constructed. It must be enlarged to easily
accommodate two fingers (Fig. 14-45).
FIGURE 14-44 An instrument can be used to make the tunnel.
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