Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_190_библиотеки_им_акад_М_И_Перельмана
.pdf
Section 14.4. Laparoscopic Repair of Cystourethrocele,
https://t.me/med1917
Vesicovaginal Fistula, and Vaginal Vault Prolapse
Bulent Berker, Babac Shahmohamady, Naghmeh Saberi, and Camran Nezhat
Pelvic organ prolapse may occur when pelvic support structures
are subjected toincreased intra-abdominal pressure. Commonly,
there is an intrinsic defect of the pelvic floor. There are several
theories regarding the etiology of pelvic organ prolapse; none
fully explains the origin and natural history of the process. Proposed causes includedenervation ofthe pelvic floormusculature,
direct injury to the pelvic floor musculature, abnormal synthesis
or degradation of collagen, and defects in endopelvic fascia.[1]
Although support for the pelvic viscera, the vagina, and neighboring structures involves a complex interplay among muscles,
fascia, nerve supply, and appropriate anatomic orientation, the
endopelvic fascia and pelvic floor muscles provide most of the
support function in the female pelvis.[2]
Loss of support of the pelvic organs may involve any or all
of the three following areas: anterior, posterior, and apical compartments. Defects in the anterior vaginal compartment result in
cystourethrocele formation and sometimes stress urinary incontinence. Posterior compartment defects result in rectocele and
enterocele.Apicaldefectsresultinuterovaginalprolapseandvaginal vault prolapse.[3] Usually, pelvic floor defects occur in several places, requiring multiple procedures in the same patient.
The existence of numerous surgical techniques for treating genitourinary prolapse and incontinence demonstrates that no single
method is completely satisfactory.
The anatomy,pathophysiology, andtreatment of pelvic organ
prolapse have significantly evolved over the last decade, with
increasing understanding of anatomy and development of minimally invasive surgical procedures.[2] The introduction of videolaparoscopy by Nezhat has revolutionized modern-day gynecologic and general surgery.[4–6] Although operative laparoscopy
has been used for decades, only recently has it gained widespread
popularity for major operative procedures. The increasing application of operative laparoscopy is theresult of advances inlaparoscopic techniques and equipment.[6,7] Laparoscopic reconstructive pelvic surgery requires a thorough knowledge of pelvic floor
anatomyand its supportive components before repair of defective
anatomy is attempted.
REPAIR OF CYSTOURETHROCELE
Prolonged, bothersome vaginal protrusions and pelvic pressure
that worsens with ambulation and daily activity are common
symptoms in women who have vaginal prolapse. Other symptoms include difficulty walking, voiding, or defecating; urinary
incontinence; recurrent mucosal irritation; ulceration; and coital
difficulty. Improvement of the quality of life is achievable in cer-
tain patients with behavioral modification and nonsurgical vaginal devices.
The arcus tendinous fascia pelvis is a band of dense regular
connectivetissuestretchedbetweenthepubic bone and the ischial
spine. Thepubocervical fascia forms a trapezoidal layer spanning
the area between the two arcus tendineae.[1] Paravaginal repair
is required when cystourethrocele results from a separation of
the pubocervical fascia from its lateral attachment to the pelvic
side wall. If this defect is accompanied by GUSI, the paravaginal
repair almost always will correct the problem.[8]
Dissection during anterior colporrhaphy splits the vaginal
muscularis, and vaginal repair involvesplication ofthemuscularis
and adventitia in the midline and can pull the lateral attachments farther from the pelvic side wall. Paravaginal repair
restores the lateral attachments to the pelvic side wall at the
linea alba. Reported failure rates range from 0% to 20% for
anterior colporrhaphy and from 3% to 14% for paravaginal
repair.[9]
In determining the correct surgical approach, preoperative
clinical assessment of the patient is very important. Successful
surgical correction of the cystocele depends on the type of defect
found in the pubocervical fascia. On examination of the anterior
vagina, anterolateral support should be confirmed. If oneor both
anterolateral sulci are absentand vaginal rugation is present, then
a detachment of the pubocervical fascia from the fascial white
line – a paravaginal defect – should be suspected.[2] Four different pubocervical fascial defects can cause cystocele. Distinguishing these defects is important, as each type requires a different
operative procedure.
1. The paravaginal defect results from detachment of the pubo-
cervical fascia from its lateral attachment to the fascia of the
obturator internal muscle at the level of the arcus tendineus
fascia of the pelvis.[10–12] This is the most common cause
of cystourethrocele. The repair consists of reestablishing the
lateral pelvic side wall attachments of the pubocervical fascia
and restoring the stability of this “hammock” by correcting
the fundamental anatomic defect.
2. The transverse defect is caused by transverse separation of
the pubocervical fascia from the pericervical ring into which
the cardinal and uterosacral ligaments insert. The base of the
bladder herniates into the anterior vaginal fornix and forms
a cystocele without displacing the urethra or urethrovesical
junction.
3. The midline or central defect results from a break in the cen-
tral portion of the hammock between its lateral, dorsal, or
ventral attachments.
407
408 — Bulent Berker, Babac Shahmohamady, Naghmeh Saberi, and Camran Nezhat
https://t.me/med1917
4. With the distal defect, the distal urethra becomes avulsed or
separated from its attachment to the urogenital diaphragm
as it passes under the pubic symphysis.
Technique
Many operations have been described to correct loss of pelvic
support. The abnormalities are identified, and the operation is
planned with the intention of correcting each defect to achieve
the optimal outcome.[13] The patient should be able to tolerate
general anesthesia, increased intra-abdominal pressure, and the
Trendelenburg position.
The principles of the transabdominal approach used at
laparotomy are employed during laparoscopy. This technique has evolved as an alternative in reconstructive pelvic
operations.[14,15] Laparoscopy involvesa smaller incision,eliminates the need for abdominal packing, causes less manipulation
of the viscera,affordsa better view ofthepelvis, and allows precise
Figure 14.4.2. Laparoscopic surgical approach to repair of paravaginal
defect.
hemostasis.
The patient is given intravenous antibiotics prophylactically.
After induction of general endotracheal anesthesia and placement, a 10- to 11-mm umbilical trocar is inserted. Three lower
abdominal 5-mm ancillary trocars also are placed; two are lateral
to the epigastric vessels at the level of the iliac crest, and one is
in the midline 5 cm above the pubic symphysis. The patient is
put in the Trendelenburg position and tilted to the left to shift
the bowel away from the operating field. After evaluation of the
peritoneal cavity and completion of other indicated procedures,
the pelvic reconstruction can proceed. The retropubic space is
entered and dissected. The pubic symphysis, obturator foramen,
and obturator neurovascularbundle are identified. Theparavaginal defect (the lateral vaginal sulci) can be seen detached from
the arcus tendineus fascia (Figures 14.4.1, 14.4.2).
The bladder is mobilized medially,andthepubocervicalfascia
is exposed. The ischial spine can be located digitally by placing
the operator’s fingers inside the vagina while viewing through
the laparoscope. During mobilization of the bladder, the lateral
superior sulcus of the vagina is lifted by the assistant’s fingers in
the vagina to facilitate dissection.
Separation of the lateral sulcus from the pelvic side wall can
be seen laparoscopically. Permanent sutures (2-0 Prolene) are
used to attach the superior lateral sulcus of the vagina to the
arcus tendineus fascia (white line). The superior lateral sulcus of
the vagina is elevated with the assistant’s fingers in the vagina.
Beneath the prominent paraurethral vascular plexus, the vagina
is sutured to the linea alba of the pelvic side wall.
The paraurethral vascular plexus runs longitudinally along
the axis of the vagina and is electrodesiccated before the placement of sutures. Otherwise, bleeding may occur if the plexus is
penetrated by theneedle.Such bleeding invariably stops whenthe
suspension sutures are tied. To avoid bleeding, the first paravaginal suspension stitch should be placed close to the ischial spine.
Figure-of-eight sutures are used for the suspension stitches to
obtain good hemostasis and suspension. After placement of the
first stitch, additional sutures are placed through the vaginal sulcus with its overlying fascia and the arcus tendineus fascia ventrally toward the pubic symphysis. The last stitch should be as
close as possible to the pubic ramus.
Before this first sutureisplaced,the gynecologist shouldidentify the ischial spine by vaginal palpation and by viewing through
the laparoscope to avoid injuring the pudendal vessels and nerve.
The initialstitchisplacedthroughthelineaalbaapproximately1.0
to 1.5 cm ventral to the ischial spine.[16] Frequent vaginal examinations are done while suturing to assist the proper placement
of the stitches, assess the adequacy of suspension, and establish
anterior support. The procedure is completed by bladder neck
suspension.
Figure 14.4.1. A representation of paravaginal defect.
VESICOVAGINAL FISTULA REPAIR
The primary etiology of vesicovaginal fistula in developed countries is surgical trauma associated with gynecologic procedures.
Most fistulas occur after hysterectomy for benign conditions
because these procedures are far more common than surgery
Laparoscopic Repair of Cystourethrocele, Vesicovaginal Fistula, and Vaginal Vault Prolapse — 409
https://t.me/med1917
for cancer. However, the risk of fistula formation is higher after
radical surgery because of the scope of surgery, the presence
of tumor, and, in some cases, radiation-induced changes. In
contrast, urogenital fistulas in developing countries are usually
associated with childbirth. Despite the best efforts of the surgeon, injuries to the urinary tract may still occur as part of
the healing process in pelvic surgery. Tissue necrosis follows tissue ischemia, attributable to external pressure (crush or clamp
injury), kinking of urinary tract tissue (proximity to a ligated
pedicle), or marked inflammation with tissue fibrosis. Direct
injury to the urinary tract by laceration or puncture usually
results in immediate urine leakage, whereas delayed injury from
retroperitoneal fibrosis, tissue pressure, or partial obstruction
may not result in fistula formation and urine leakage for days or
weeks.
Postoperative patients with a vesicovaginal fistula usually are
easily diagnosed with urine leaking through the vagina. Classically, fistulas occur between the seventh and the 12th day after
obstetric or gynecologic surgery. The diagnosis can be confirmed
by filling the bladder with a dilute solution of methylene blue.
The vaginal vault is then directly inspected to visualize the fistula. If no defect is clearly seen, then cystoscopy can be a valuable
diagnostic help. In a patient who is experiencing urinary incontinence, the tampon test, in which a tampon is inserted into the
vagina after filling the bladder with a dilute solution of methylene blue and have the patient ambulate, can help confirm the
diagnosis. In addition to the cystoscopy and the cystourography,
an intravenous pyeloureterogram is recommended to rule out
concomitant ureteral fistulas before proceeding with the surgical
repair.[17]
There is debate in the literature regarding the most appropriate period of time to wait before proceeding to surgery should
the defectnot heal, with the number of surgeons advocating early
intervention (1 to 3 months) approximately equal to the number
advocating later intervention (more than 3 months). The purpose of waiting is to allow recovery from inflammation, infection, and tissue necrosis. Although this might be true for complicated fistula and postpartum fistula, extensive infection and
tissue necrosis are uncommon with gynecologic surgery–related
fistula. Thus, waitingis less relevantfor fistula following hysterectomy.
Vesicovaginal fistulas are treated with different surgical techniques, depending on their cause and location.[18] Small vesicovaginal fistulas that are not responsive to nonsurgical management usually are repaired easily.[19] The edges of the fistula are removed, and the defect is closed. Latzko’s technique [20] is used commonly for fistulas that are surrounded
by severe fibrosis and close to the bladder neck or urethral
meatus. Lee and coworkers [21] recommended an abdominal approach for fistulas in the upper part of a narrow
vagina, multiple fistulas, and those associated with other pelvic
abnormalities or close to the ureter. A combined abdominal
and vaginal approach is used in some instances.[22] Nezhat
et al. [23] first reported the laparoscopic approach in 1994.
Laparoscopic repair of vesicovaginal fistula may offer the patient
less morbidity and a quicker recovery.The laparoscopic approach
significantly reducesthe access trauma of traditional laparotomy,
with additional advantages of magnified vision of pelvic organs
and less traumatic tissue handling.
Technique
The basic principles for repair include adequate exposure, excision of fibrous tissue from the edges of the fistula, approximation
of the edges without tension, the use of suitable suture material,
and efficient postoperative bladder drainage.[21]
A 10-mm infraumbilical incision is made for the insertion
of the operative laparoscope. Three 5-mm trocars are inserted
in the lower abdomen for the suction–irrigator probe, grasping
forceps, and bipolar forceps. A simultaneous cystoscopy is done,
and bothureters are catheterized to aidin their identification and
protection during excision and closure of the fistula. A ureteral
catheter is pulled through the fistula into the vagina to facilitate
identification during excision.
A digital rectovaginal examination is carried out to exclude
rectal involvement. An opening is made in the vagina, avoiding
the bladder and rectum, and an inflated glove in the vagina helps
maintain pneumoperitoneum. The anterior vaginal wall is elevated witha grasping forceps, and the fistula isidentified with the
previously inserted catheter, which also delineates the posterior
bladder wall. The bladder is filled with water, and a cystotomy
is made above the fistula. The water is evacuated as the bladder is distended by the pneumoperitoneum from the cystotomy.
The fistula tract, vesicovaginal space, and ureters are observed
laparoscopically (Figures 14.4.3, 14.4.4, and 14.4.5). The vesicovaginal space is developed laparoscopically with the CO
2
laser
and hydrodissection or any other cutting modality. The bladder
is freed posteriorly from the vaginal wall.The fistula is identified,
held with a grasping forceps, and excised. Adequate bladder dissection and mobilization are essential to eliminate tension upon
suturing.
Initially, the vaginal wall opening of approximately 1.5 cm is
closed with one layer of interrupted polyglactin suture (Figure
14.4.6). Then the vesical defect is repaired in one layer with interrupted 1-0 Endoknot polyglactin sutures (Ethicon), using extracorporeal knotting. Defects in the vagina and bladder are closed
separately. Hemostasis in the vesicovaginal space and fistula area
is essential. A peritoneal flapisobtainedsuperior and lateral to the
bladder dome, close to the round ligament and diverted toward
the bladder base. The flap is used to separate the vesicovaginal
space. It is secured with two interrupted polyglactin sutures.
The dissected peritoneal area heals secondarily. No intraperitoneal drainage is used. After the procedure, a suprapubic or
transurethral catheter is inserted and the ureteral catheters are
removed.
VAGINAL VAULT PROLAPSE
Vaginal vault prolapse is seen whenever the apex of the vagina
descends below the introitus, turning the vagina inside out. It is
uncommon in the United States, affecting between 900 and 1200
women annually.[24] Vaginal vault prolapse occurs as a result of
damage to the supporting structures of the vaginal apex, the cardinal or the uterosacral ligaments. The most common cause of
this condition is hysterectomy with failure to adequately reattach
the cardinal–uterosacral complex to the pubocervical fascia and
rectovaginal fascia at the vaginal cuff. Other predisposing factors include enterocele, damage to the endopelvic fascia or pelvic
floor ligaments during labor and delivery, and postmenopausal
410 — Bulent Berker, Babac Shahmohamady, Naghmeh Saberi, and Camran Nezhat
https://t.me/med1917
Bladder
Fistula
Catheter
Vaginal mucosa
Figure 14.4.3. The fistula tract, vesicovaginal space, and ureters are observed laparoscopically.
Left ureter
Right ureter
Bladder
Vagina
Fistula
Figure 14.4.4. The bladder has been freed posteriorly from the vaginal wall.
Left ureter
Right ureter
Fistula tract
Figure 14.4.5. The bladder fistula is identified and excised with the CO2laser.
Laparoscopic Repair of Cystourethrocele, Vesicovaginal Fistula, and Vaginal Vault Prolapse — 411
https://t.me/med1917
Figure 14.4.6. The vaginal wall repair is complete, and the bladder
opening repair is in progress.
atrophy. Vaginal vault prolapse is usually associated with
cystocele, rectocele, enterocele, or a combination of these
defects.[1,6,25]
The approaches to the treatment of vaginal vault prolapse
include the use of a pessary, vaginal reconstruction, and vaginal
closure. For the obliterative approach, patient selection criteria
should include the patient’s physiologic age, sexual desires, general health status, and symptoms. Total colpocleisis is not an
option for sexually active women.
The goalof vaginal vault suspensionis to correct all anatomic
defects, maintain or restore normal bowel and bladder function,
and restore a functioning vagina.Transvaginal sacrospinousvault
suspension and needle urethropexy may result in a satisfactory
outcome in most operations.[26] The vaginal route may be used
in women whose preference or medical disorders contraindicate
the abdominal approach. However, studies have shown a 33%
rate of recurrent prolapse associated with sacrospinous fixation
and transvaginal needle suspension. The probability of an optimal surgical outcome is twice as great with a transabdominal
operation.
Among the proposed surgical techniques to prevent and
correct this condition is abdominal sacral colpopexy using the
interposition of a synthetic suspensory hammock between the
prolapsed vaginal vault and the anterior surface of the sacrum.
[13,14,26] However, this technique usually requires a midline
abdominal incision, abdominal packing, and extensive bowel
manipulation. It has a potential for infection, wound separation
or dehiscence, and ileus or bowel obstruction. To minimize these
drawbacks, sacral colpopexy can be carried out laparoscopically.
Laparoscopic sacrocolpopexy was first described by Nezhat et al.
in 1994.[27] Thisprocedure is discussed inmoredetailin Chapter
14.3.
CONCLUSION
Laparoscopic pelvic reconstructive surgeries maybe complex and
require advanced laparoscopic skills. However, when performed
by experienced surgeons, the success ratesof these procedures are
comparable to traditional routes of repair.[12,16,23,27,28].
REFERENCES
1. Deval B, Haab F. What’s new in prolapse surgery? Curr Opin Urol.
2003;13(4):315–323.
2. Miklos JR, Moore RD, Kohli N. Laparoscopic surgery for pelvic
support defects. Curr Opin Obstet Gynecol. 2002;14(4):387–395.
3. Birnbaum SJ. Rational therapy for the prolapsed vagina. Am J
Obstet Gynecol. 1973;115(3):411–419.
4. Nezhat C.Videolaparoscopyandvideolaseroscopy:anewmodality
for thetreatment of endometriosis and otherdiseases of reproductive organs. Colposc Gynecol Laser Surg. 1986;2:221–224.
5. Nezhat C, Siegler A, Nezhat F, et al. Appendectomy. In: Operative
Gynecologic Laparoscopy, Principles and Techniques. 2nd ed. New
York: McGraw-Hill;2000:339–353.
6. Tadir Y, Fisch B. Operative laparoscopy: a challenge for general
gynecology. Am J Obstet Gynecol. 1993;169:7–12.
7. Margossian H, Walters MD, FalconeT. Laparoscopic management
of pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol. 1999;
85(1):57–62.
8. Richardson AC. How to correct prolapse paravaginally. Contemp
Obstet Gynecol. 1990;35:100.
9. Weber AM, Walters MD. Anterior vaginal prolapse: review of
anatomy and techniques of surgical repair. Obstet Gynecol. 1997;
89:311.
10. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol. 1976;126:568.
11. Baden WF, Walker TA. Urinary stress incontinence: evolution of
paravaginal repair. Female Patient. 1987;12:89.
12. Liu CY. Laparoscopic cystocele repair: paravaginal suspension. In:
Liu CY, ed. Laparoscopic Hysterectomy and Pelvic FloorReconstruc-
tion. Cambridge, MA: Blackwell; 1996.
13. Arthur HG, Savage D. Uterine prolapse and prolapse of vaginal
vault treated by sacral hysteropexy. J Obstet Gynaecol Br Emp.
1957;64:355.
14. Randall CL, Nichols DH. Surgical treatment of vaginal inversion.
Obstet Gynecol. 1971;38:327.
15. Symmonds RE, Williams TJ, Lee RA, Webb MJ. Posthysterectomy enterocele and vaginal vault prolapse. Am J Obstet Gynecol.
1981;140:852.
16. Nezhat C, Nezhat F, Gordon S, Wilkins E. Laparoscopic versus
abdominal hysterectomy. JReprodMed. 1992;37:247.
17. Angioli R, Penalver M,MuziiL, etal. Guidelines of how tomanage
vesicovaginal fistula. Crit RevOncol Hematol. 2003;48(3):295–304.
18. Drutz HP. Urinary fistulas. Obstet Gynecol Clin North Am.
1989;16:11.
19. Falk HC, Orkin LA. Nonsurgical closure of vesicovaginal fistulas.
Obstet Gynecol. 1957;9:538.
20. Latzko W. Behandlund hochsitzender blasenund mastdarmscheidenfisteln nach uteruseztipation mit hohom schedienverschluss.
Zentralbl Gynakol. 1914;38:904.
21. Lee RA, Symmonds RE, William TJ. Current status of genitourinary fistula. Obstet Gynecol. 1988;72:313.
22. Taylor JS, Hewson AD, Rachow P. Synchronous combined
transvaginal repair of vesicovaginal fistulas. AustNZJSurg.
1980;50:23.
23. Nezhat CH, Nezhat F, Nezhat LC, Rottenberg II. Laparoscopic
repair of a vesicovaginal fistula: a case report. Obstet Gynecol.
1994;83:899.
24. Dunton JD, Mikuta J. Post-hysterectomy vaginal vault prolapse.
Postgrad Obstet Gynecol. 1988;8:1.
412 — Bulent Berker, Babac Shahmohamady, Naghmeh Saberi, and Camran Nezhat
https://t.me/med1917
25. Drutz HP, Alnaif B. Surgical management of pelvic organ prolapse and stress urinary incontinence. Clin Obstet Gynecol. 1998;
41(3):786–793.
26. Sze EH, Miklos JR, Partoll L, et al. Sacrospinous ligament fixation
with transvaginal needle suspension for advanced pelvic organ
prolapse and stress incontinence. Obstet Gynecol. 1997;89:129.
27. Nezhat CH, Nezhat F, Nezhat C. Laparoscopic sacral colpopexy
for vaginal vault prolapse. Obstet Gynecol. 1994;84(5):885–
888.
28. Sotelo R, Mariano MB, Garc´ıa-Segui A, Dubois R, Spaliviero M,
Keklikian W, Novoa J, Yaime H, Finelli A. Laparoscopic repair of
vesicovaginal fistula. JUrol. 2005;173(5):1615–1618.
Section 14.5. Laparoscopic Rectovaginal Fistula Repair
https://t.me/med1917
Ceana Nezhat, Patrick Yeung, and Deidre T. Fisher
The discovery of a rectovaginal fistula is distressing to both the
patient and her surgeon. This socially crippling condition likely
includes the uncontrolled passage of flatus or stool from the
anorectal canal through the fistulous tract into the vagina. Fortunately, fistulas between the anorectal canal and vagina are relatively uncommon, accounting for less than 5% of all anorectal
fistulas.[1]
ANATOMY
Fistulas occurring caudad or adjacent to theexternal anal sphincter are termed anovaginal fistulas and are managed differently
from rectovaginal fistulas. Fistulas occurring more than 3 cm
above the anal canal are true rectovaginal fistulas. There are several classification systems for rectovaginal fistulas.[2–6] Although
some surgeonshave classified fistulasas “high” or “low,” we favor
classification with respect to condition of the perineal body and
rectovaginal septum. The first three types are classified as (i) loss
of perineal body without evidence of a fistulous tract, (ii) loss
of perineal body with a fistulous tract in the lower third of the
vagina, and (iii) an intact perineal body with a fistulous tract in
the lowest third of the vagina. A vaginal approach is commonly
used to repair these three types of rectovaginal fistulas, whereas
types IV and V fistulas, which involve the middle and upper
thirds of the vagina, respectively, require either a transabdominal
or laparoscopic approach.
ETIOLOGY
The etiology of rectovaginal fistulas includes obstetric trauma,
congenital anomalies, endometriosis, carcinoma, irradiation
damage, inflammatory boweldisease,and complications of gynecologic and colorectal surgery.[7] Obstetric injuries are, by far,
the most common etiology and usually arise as a complication of
a repaired fourth-degree perineal tear.[5] Obstetric risk factors
include prolonged labor, difficult forceps delivery, shoulder dystocia, andmidline episiotomy. Reassuringly, only 0.1% of vaginal
deliveries result infistula formation.[5] Rectovaginalfistulas may
result from direct surgical injury to the rectum or vagina or indirectly, as a result of tissue necrosis or postoperative infection.
Fistulas may be secondary to surgical trauma, malignancy, or an
inflammatory process and may occur anywhere along the vaginal wall, including the apex. In fact, the most common cause
of high fistulas is repeated episodes of diverticulitis with abscess
formation. Rectovaginal fistulas are associated with inflamma-
tory bowel disease in 10% of patients.[5] Crohn’s disease may
result in complex fistulas, especially because the lesions may be
transmural.[8,9] These fistulas have little chance of healing in the
presence of severe proctitis; therefore, intensive medical treatment of inflammatory disease is indicated before surgical methods are employed.
DIAGNOSIS
Symptoms include vaginal passage of flatus, foul discharge, diarrhea, orfrank stool. Also, patientsmay complain ofabdominal or
pelvic pain, rectal bleeding, or a mucus-like discharge, depending on the size and complexity of the fistula. Usually, symptoms
occur between 7 and 10 days postoperatively and coincide with
tissue breakdown and/or infection.
The first stepin making thediagnosis is toconsider rectovaginal fistula as a possible diagnosis. Therefore, a detailed clinical
evaluation including a detailed history and physical examination is warranted. This includes a thorough examination of the
vagina; the integrity of the rectum, external and internal anal
sphincters, and puborectalis; and perineum, including the perineal body. Type IV and V fistulas may not readily be apparent
on physical examination or vaginal inspection and may even be
missed by endoscopy.[3] If no fistula is seen but one seems likely
because of history and symptoms, there are a number of maneuvers that can be performed in the office or under anesthesia in
the operating room to help identify the fistula. With the patient
in pelvic tilt or Trendelenburg position, air can be injected via
a Foley catheter or a bulb syringe into the rectum while observing for bubble formation in a saline-filled vagina. We have used
sigmoidoscopy or vaginoscopy, with either the submersion of a
hysteroscope or cystoscope in the saline-filled vagina, to visualize
the bubbles from air simultaneously injected into the rectum to
identify the precise location of the fistula. Similarly, an indigo
carmine dye enema may be given, and a tampon inserted into
the vagina may indicate the presence of a fistula. However, the
most useful studies include direct visualization with proctosigmoidoscopy with gentle passage of a probe through the fistulous tract into the rectal canal. This also allows for assessment
of intestinal mucosa and identification of additional defects or
fistulas. In addition, rectogram and barium enema studies are
helpful to confirm the presence of a type IV or V fistula, whereas
occasionally CT and magnetic resonance imaging (MRI) with
oral contrast may also uncover the underlying etiology. Lastly,
if there is any concern of malignancy, biopsy should be considered.
413
414 — Ceana Nezhat, Patrick Yeung, and Deidre T. Fisher
https://t.me/med1917
SURGICAL MANAGEMENT
General Principles
The repair of the rectovaginal fistula can be surgically managed
using a vaginal, anal, abdominal, or laparoscopic route. In addition to the surgeon’s expertise, one must consider the location,
size, and complexity of the fistula; accessibility; status of anal
sphincter; and the original etiology for the defect. Basic principles usedfor successful repair includeadequate exposure toallow
for complete excision of the fistulous tract and fibrosis to ensure
healthy, well-vascularized tissue for reapproximation.[10–13] In
addition, thefistula site mustbe free ofinfection, induration, and
fecal contamination. In fact, preoperatively, several days of a liquid diet with a full mechanical and chemical bowel preparation
will decrease chances of contamination of the repair site. If the
patient has Crohn’s disease, she may require high-dose systemic
steroids and/or chemotherapeutic agentsto bring herdisease into
remission before repair. If significant fecal contamination, prior
surgery, or persistent abscess is present, a diverting colostomy
or ileostomy may be considered. Lastly, suitable suture material
and a tension-free closure will help minimize chances of a failed
repair.
Technique
Although the usual surgical repair of high rectovaginal fistulas is
traditionally via a laparotomy approach, there have been several
reports of the procedure performed laparoscopically. Schwenk et
al. [14] reported a laparoscopic resection of the sigmoid colon
with the fistulous tract and intracorporeal colorectal anastomosis in 1997. Pelosi et al. [15] performed laparoscopic upper rectovaginal mobilization to facilitate the transvaginal repair of a
recurrent rectovaginal fistula. Total laparoscopic repair is still
rare because of the complexity of the procedure and the need
for keen suturing technique. However, Nezhat et al. [4] reported
two cases of total laparoscopic rectovaginal fistula repair. Most
recently, Kumaran et al. [3] reported a laparoscopic rectovaginal fistula repair following a laparoscopic-assisted vaginal hysterectomy. Our laparoscopic surgical treatment for type IV and
V rectovaginal fistulas is similar to that used for laparoscopic
treatment ofinfiltrative endometriosis involving the rectovaginal
septum.[4,11–13] After general anesthesia, a multiple-puncture
operative laparoscopy technique is used and the patient is placed
in modified dorsolithotomy position with a slight Trendelenburg position. A detailed inspection of the abdomen and pelvis is
performed. At times, extensive adhesiolysis and mobilization of
the bladder from the vagina are necessary, and sometimes bilateral ureterolysis is necessary to restore normal anatomy (Figure
14.5.1).
Rectovaginal examination along with concomitant rigid sig-
moidoscopy by the assistant are then used to identify correct
planes, and the bowel is suctioned of its contents. Dissection to
the pararectal areas down to the level of levator ani muscles may
be necessary for optimal exposure and adequate mobilization.
At this point, various maneuvers may be used to identify the
course of the fistulous tract. For example, indigo carmine dye
may be injected into the peritoneal end of the fistula while the
surgeon observes leakage of dye using the proctosigmoidoscope.
The fistulous opening may be seen as a small dimple or pit and
Figure 14.5.1. Survey of the pelvis revealed adhesions between vaginal
apex and rectosigmoid colon.
occasionally canbe gently probed for confirmation. The simultaneous use of both laparoscopy and proctosigmoidoscopy should
reveal the presence of the fistulous tract. The vaginal wall should
be elevated with grasping forceps (Figures 14.5.2, 14.5.3) and the
rectovaginal space developedwith CO
laser andhydrodissection
2
or sharply until the fistula is apparent.
The fistula isthen excised with CO
laser or scissorsto healthy
2
and vascularized margins (Figure 14.5.4). Adequate rectum dissection and mobilization are essential to eliminate tension upon
suturing. Rectal and vaginal defects are then closed separately
with several interrupted 1.0 polyglactin sutures (Figure 14.5.5).
With the pelvis filled with fluid, air is injected transanally to
allow visualization of the repair site under water. This will help
ensure that the repair is airtight. Apiece of omentum is theninterposed between vaginal and rectal repairs. Meticulous hemostasis in the rectovaginal space is imperative; therefore, a drain is
not usually necessary. If a temporary colostomy is required, the
hollow of the sacrum is entered and the rectosigmoid colon is
mobilized. At this stage, the rectosigmoid colon is transected
approximately 25 cm from the anal verge with a 60-mm
Figure 14.5.2. Fistulous tract canbe seen afterdissection and elevation
of the vagina.
Laparoscopic Rectovaginal Fistula Repair — 415
https://t.me/med1917
Figure 14.5.3. Development of rectovaginal space with CO2laser.
stapling device (Endopath; Endosurgery Inc., Cincinnati, OH)
and the proximal end of the colon is transfixed to the skin
of the 30-mm cannula site, thus performing a diverting colostomy.
POSTOPERATIVE CARE
Attention to the details of postoperative care is vital to prevent
complications after a rectovaginal fistula repair. A low-residue
diet, adequate hydration, abstaining from laxatives, and no rectal instrumentation (including digital examination, enemas, and
suppositories) will prevent both direct mechanical trauma and
hyperstimulation ofthe bowel when infection is present. Inaddition, a 2-week course of broad-spectrum antibiotics providing
coverageof bowel and vaginalflora will preventsubsequentinfection of the repair.[5,10] Sigmoidoscopic evaluation of the repair
site 6 weeks later will ensure successful closure of the fistula.
If a temporary colostomy was performed, before consideration
of colostomy reversal either by minilaparotomy or laparoscopy,
examination under anesthesia is performed. A careful vaginal
examination and rigid proctosigmoidoscopy will ensure a healed
fistula and normal rectal mucosa.
Figure 14.5.4. Fistulous tract is excised with adequate margin with
.
CO
2
Figure 14.5.5. Rectal and vaginal defects are closed separately with
sutures.
CONCLUSION
Although thediscovery of a rectovaginal fistulais often disruptive
both psychosocially and sexually, it can be successfully managed
and depends on the location and etiology of the defect. Operative laparoscopy has revolutionized abdominal surgery and is
a reasonable alternative to laparotomy for increasing numbers
of indications. These advances extend to treatment of rectosigmoid colonandrectovaginalseptumpathology.Advantagesofthe
laparoscopic approach to rectovaginal septum are better visualization in thisdeep and small space,with Trendelenburg position,
magnification, and lighting. With the patient in lithotomy position, one can use the sigmoidoscope simultaneously. This allows
the surgeon to view the rectum from its mucosal as well as peritoneal surface for identification, precise dissection, and resection
of the fistula. Lastly, as with all minimally invasive procedures,
its advantages include less postoperative pain, minimal wound
complications, and a quicker recovery.
REFERENCES
1. Fry RD, Kodner IJ. Rectovaginal fistula. Surg Ann. 1995;27:113–
131.
2. Rosenshein NB, Genadry RR, Woodruff JF. An anatomic classification of rectovaginal septal defects. Am J Obstet Gynecol.
1980;137:439–443.
3. Kumaran SS, Palanivelu C, Kavalakat SJ, Parthasarathi R, Neelayathatchi M. Laparoscopic repair of high rectovaginal fistula: is it
technically feasible? BMC Surg. 2005;5:20.
4. Nezhat CH, Bastidas JA, Pennington E, Nezhat FR, Raga F, Nezhat
CR. Laparoscopic treatment of type IV rectovaginal fistula. Am
Assoc Gynecol Laparosc. 1998;5:297–299.
5. Aronson MP, Lee RA. Fecal incontinence and rectovaginal fistulas. In: Rock J, Jones HW, eds. TeLinde’s Operative Gynecology.
Philadelphia: Lippincott Williams & Wilkins; 2003:1121–1160.
6. Ettayebi E, Behamou M. Anorectal malformation: treatment by
laparoscopy. Pediatr Endosurg Innov Technol. 2001;5:209–213.
7. Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal
fistulas: classification, etiologies, and imaging evaluation. Radi-
ology. 2002;224:9–23.
8. Radcliffe AG, Ritchie JK, Hawley RP. Anovaginal and rectovaginal
fistulas in Crohn’s disease. Dis Colon Rectum. 1988;31:94–97.
416 — Ceana Nezhat, Patrick Yeung, and Deidre T. Fisher
https://t.me/med1917
9. Ludwig KA, Milson JW, Church JM, et al. Preliminary experience
with laparoscopic intestinal surgeryfor Crohn’s disease.AmJSurg.
1996;67:817–821.
10. Stenchever MA, Fenner DE. Anatomic defects of the abdominal wall and pelvic floor. In: Stenchever M, Droegemueller W,
Herbst A, et al., eds. Comprehensive Gynecology. St. Louis: Mosby;
2001:565–606.
11. Nezhat C,Gary SB, NezhatFR, et al. Endometriosis: Advanced Man-
agement and Surgical Techniques. NewYork: Springer-Verlag; 1995.
12. Nezhat C, Nezhat FR, Pennington E. Laparoscopic treatment
of infiltrative rectosigmoid colon and rectovaginal septum
endometriosis by the technique of videolaparoscopy and the CO
laser. Br J Obstet Gynaecol. 1992;99:664–667.
13. Nezhat C, Nezhat FR, Luciano AA, et al., eds. Operative Gyneco-
logic Laparoscopy: Principles and Techniques. 2nd ed. New York:
McGraw-Hill; 2000.
14. Schwenk, Bohm B, Muller J. Laparoscopic resection of high rectovaginal fistula with intracorporeal colorectal anatomosis and
omentoplasty. Surg Endosc. 1997;11:147–149.
15. Pelosi MA, Pelosi MA. Transvaginal repair of recurrent rectovaginal fistula with laparoscopic-assisted rectovaginal mobilization. J
Laparoendosc Adv Surg Tech A. 1997;7:379–383.
2
Соседние файлы в папке Библиотека им академика М.И. Перельмана