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ANAL AND PERIANAL REGION 31
BOX 6-1: Specific Areas of Focus During History Taking
• Symptoms(e.g.,gas,stool,anddrainageofpurulentuidfrom
the vagina)
• Dyspareunia/perinealpain
• Recurrenturinarytractinfections
• Bowelhabits
• Pastpelvicandanalsurgery(includingobstetricalhistoryand
any prior pelvic irradiation)
• Chronicdiseasesandmedicationsthataectbowelhabits
BOX 6-2: Outline of Treatment Options
Medical
Control diarrhea
Treat Crohn disease when present
Nonsurgical Closure
Fistula plug
Surgical Closure
Anal Approach
Rectal advancement ap
Advancement sleeve ap (may also include a transabdominal ap-
proach along with the transanal approach; if the transabdominal approach is used, the patient may need a delayed coloanal
anastomosis [Turnbull-Cutait procedure])
Transvaginal Approach
Vaginal ap
Perineal Approach
Ligation of the intersphincteric stula tract
Episioproctotomy
Interposition of tissue
+ Gracilis muscle
+ Martius ap
Surgery may not be the best option for women with a small internal opening and minimal symptoms. It is important to remember
that surgery could make the situation and symptoms worse, as well
as create additional scarring. If Crohn disease is present, it should
be treated or managed surgically before embarking on a surgical
course to close the stula. Additionally, diarrhea should be under
optimal control. Occasionally a diverting stoma (typically an ileostomy) is required for the tissue to become supple enough to perform a repair, particularly when the stula is related to radiation.
Hyperbaric oxygen treatment may improve radiated or scarred tissue to a sucient degree to permit a repair to be attempted. Use of a
vaginal hormone cream for a month before performing a repair also
may improve the elasticity of tissues in postmenopausal women.
larger outweigh the symptoms. Some methods of treating diarrhea
include titration of insoluble ber and loperamide. Biopsy ndings that are positive for collagenous or microcytic colitis warrant
appropriate medical treatment, which is outside of the scope of this
chapter.
Medical treatment, including antibiotics and biologic therapy for
an RVF related to Crohn disease, will sometimes lead to closure of the
stula. More commonly, the stula is situated at the base of an ulcer.
Medical treatment may change the quality of the anal canal from an
inamed ulcer to a dry scar, which in turn may permit closure to be
considered.
Nonsurgical Closure
Fistula Plug
Failure of a stula plug carries minimal risk. Dislodgement of the
plug can be an early cause of failure, and thus when a plug is used to
treat an RVF, it is modied through the addition of a button that is
sewn into the mucosa and submucosa on the anal side. is button
stabilizes the plug to reduce chances of dislodgement. A short or epithelialized tract is not ideal for a plug closure. In the operating room,
the tract is lightly debrided with gauze or a brush and then ushed
with hydrogen peroxide. e size of the plug is chosen based on the
stula size, and the plug is prepared according to the manufacturer’s
specications. e tapered end of the plug is pulled from the anal
side to the vaginal side so that the button rests against the anorectal
wall. e plug is stabilized with a 2-0 polyglycolic acid suture placed
deeply through the anal tissue, the plug, and the button holes. e
button should remain at against the rectoanal wall aer the sutures
are placed. Excess plug material is trimmed from the vaginal side.
Adequate space between the plug and the external opening is necessary to allow for drainage. Postoperatively, for about 4 weeks, the
patient is advised to avoid strenuous activity and liing more than
20 pounds. Additionally, sexual intercourse, baths, swimming, and
soaking of the anal area are to be avoided for 4 weeks, although showers are permitted. Aer defecation, wet toilet paper can be used, but
use of wipes containing chemicals should be avoided. Drainage and
spotting of blood are expected, but upon detection of anything more
extensive, patients are advised to call their doctor. Mineral oil or other
stool soeners are used to prevent patients from straining to defecate.
Use of antibiotics is controversial; however, in my unit we prescribe
oral ciprooxacin for 7 days and application of metronidazole cream
to the external opening twice daily for 7 days.
Fibrin Glue
Instillation of brin glue into the tract has been described to close an
anal stula. is option typically is not favored because RVF tracts are
usually short and, overall, results are dismal when brin glue is used
with any type of anal stula. However, the risks of this treatment are
low. Use of brin glue under a ap repair has also been entertained,
but few positive data regarding this approach have been reported.
TREATMENT OPTIONS
Options for treatment (Box 6-2) are classied as medical, nonsurgical
closure, or surgical closure. e route for closure is accomplished via
the vagina, perineum, anus, or abdomen or through a combination
of these approaches.
Medical
For some patients, management of diarrhea will improve the situation to the extent that the risks of surgery and of making the hole
Surgical Closure
Anal Approach
Rectal Advancement Flap
e integrity of the anal sphincter is probably one of the most important aspects to consider when contemplating the choice of surgical
repair. If the sphincter is intact and the stula is above the dentate line,
an advancement rectal ap procedure can be peformed. Although
this repair can be performed in any position, the prone jackknife
Rectovaginal Fistula32
position provides optimal exposure. I prefer full bowel preparation,
use of intravenous (IV) antibiotics, and having a Foley catheter in
place during the procedure. Unless the tract is completely dry and
epithelialized, I also prefer that a draining seton be in place for a
month prior to closure, which facilitates elimination of any sepsis or
entrapped uid in the tract and improves the pliability of the tissues.
e ap starts a few millimeters distal to the internal opening,
and the arc for the ap is about 180 degrees. e anal canal mucosa
is carefully removed, avoiding injury to the internal anal sphincter.
e ap then becomes full thickness of rectum cephalad to the anal
sphincter complex. Mobilization of the rectum from the rectovaginal septum continues until the distal end can be advanced without
tension to the opposite cut edge on the distal anal canal. e stula
is cored out and closed in layers with gure-of-8, 3-0 polyglycolic
acid sutures. e internal opening is closed from the anal side only.
e use of a UR 5–type needle facilitates the ability to obtain a deep
suture in the conned space of the anal canal to close the opening.
Usually the closure is performed from cephalad to caudad in several
layers using gure-of-8 sutures. e vaginal or perineal side will be
le open, and sometimes the external opening is enlarged to ensure
adequate drainage. e distal tip of the ap, which includes the area
of the internal opening, is trimmed. e goal is to advance full-thickness rectum distally. To reduce tension at the suture line, one or two
simple sutures may be incorporated beneath the ap. One bite (not
full thickness) is placed through the tissue on the undersurface and
the other is placed through the distal cut edge in the anal canal. en,
aer ensuring hemostasis, the ap is advanced to the distal cut edge
and sewn in place with 3-0 polyglycolic acid sutures. e middle
sutures are placed rst with deep, simple, full-thickness bites. Sewing
is then carried laterally on each side to complete the suture line. Some
variations in ap construction include short bursts of running suture
to close the two edges, minimal mobilization of the ap with more of
a layered closure, and orientation of the ap longitudinally (instead
of the semicircle).
Postoperatively, in patients without a diverting stoma, restricting oral intake for 2 to 3 days may delay passage of stool over the
fresh sutures. e perineal area is examined on postoperative day 1
to assess for swelling and bruising. If signicant swelling or bruising
is present, a delay in the removal of the Foley catheter until postoperative day 2 is considered. Although preoperative administration
of antibiotics is universal, considerable variation exists regarding
the postoperative use of antibiotics, from none to 7 days. I favor
administration of IV antibiotics while the patient is in the hospital
and then completion of a total 5- to 7-day course of oral antibiotics.
ere is also no consensus regarding activity limitations. Although
some surgeons curtail activity and prescribe bed rest for postoperative days 1 to 2 in order to avoid pulling on the suture line, I
allow patients to be out of bed but ask them to avoid sitting as much
as possible. No scientic evidence exists for any of these activity
restrictions.
Care aer hospital discharge sometimes can be more important
than the postoperative care provided in the hospital in facilitating
success. Patients are encouraged to walk and go up steps but to li
no more than the weight of a gallon of milk. ey can sit on a pillow but not on a doughnut, which spreads the buttocks and pulls
on the perineal skin. If they do not have a proximal stoma, I ask
them to ingest an ounce of mineral oil daily along with insoluble
ber. While they are in the hospital, I do not allow them to eat until
the day of discharge. On the day of their discharge they are given
a solid diet, their rst dose of mineral oil, and the oral antibiotic.
If they do not have a stool by 2 to 3 days aer discharge from the
hospital, I ask them to ingest an ounce of milk of magnesia daily
until they have a bowel movement. Patients are in regular phone
contact with my nurse to ensure that constipation is avoided. I also
allow patients to take showers but instruct them to avoid taking
baths for 2 to 3 weeks because a bath seems to make the anal skin
waterlogged.
e nurse continues to be in regular phone contact with the
patient, and any concerns regarding pain or pressure are immediately
addressed, usually at an oce visit. At times, performing an examination with use of an anesthetic is necessary to investigate the source of
the pain and verify the absence of trapped uid. On several occasions,
making a counter incision to allow drainage lateral to the ap has
prevented the ap from being lied o when patients presented with
new pain or pressure.
Successful closure of an RVF with a rectal advancement ap can
be expected in about 65% of women. Smoking and Crohn disease
have been associated with failure of this procedure.
Advancement Sleeve Flap
In some women, signicant scarring in the anal canal or anal canal
stenosis precludes use of an advancement rectal ap. In these situations, use of an advancement sleeve ap is considered. e perioperative preparation is the same as for the advancement rectal ap. e
procedure diers in that a full circle of anal canal mucosa is excised,
starting anteriorly a few millimeters distal to the internal opening.
e incisional line for the posterior half of the sleeve is the dentate
line. e mucosectomy is continued cephalad to the top of the anal
sphincter; the dissection is then carried laterally so that a full thickness of rectum is mobilized. e plane that is entered is the same
one utilized when performing an Altemeier procedure (i.e., a perineal proctosigmoidectomy). However, when performing the Altemeier procedure, the plane is typically a little more redundant and
stretched out from the prolapse. Mobilization continues cephalad
until the sleeve will advance to the neodentate line without tension.
Closure of the internal opening is performed in the same manner
as for the rectal advancement ap. Because of the possibility that
uid may become trapped beneath the ap, I insert a 10-mm drain
that lies beneath the ap, comes out the buttock laterally (inserted
using a trocar), and connects to a red-top test tube or bulb to exert
negative pressure. I am amazed at the amount of serous uid that is
collected during the rst 2 to 3 days—sometimes as much as 20 mL
daily. I remove the drain when the output is about 5 mL in a 24-hour
period. e anterior proximal edge of the ap is trimmed and the
ap is advanced down and sewn to the neodentate line as outlined
for the advancement rectal ap. Because mobilization for a sleeve ap
is more extensive, a diverting stoma is typically placed. Otherwise,
the postoperative care is the same as that previously outlined for the
advancement rectal ap.
A sleeve is useful in persons with Crohn disease because signicant anal canal scarring and tissue xation may be present. e
mucosectomy removes the scarred anal canal tissue, and provided the
rectum has little to no inammation, healthy tissue can be brought
into the area. e success rate of the sleeve is about 65%, with similar
results for Crohn and non-Crohn etiologies.
In some cases the circumferential rectal ap will not reach the
neodentate line. When this situation is encountered, the patient
will need to be turned onto her back and placed in stirrups, and an
abdominal approach is added to gain sucient length. is procedure entails mobilizing the rectum circumferentially. I try to avoid
dividing the inferior mesentery artery and vein until I am sure it
is needed for sucient mobilization and reach. However, I do not
hesitate to divide the artery and vein or mobilize the splenic exure to augment length and avoid tension on the anastomosis. When
the abdominal approach is added, an ileostomy is almost always
performed.
Turnbull-Cutait Anastomosis
A Turnbull-Cutait staged colo-anal anastomosis, which is a variation of the abdominal mobilization of the rectum, may improve
chances of successful closure of the stula. e dierence is that
maturation of the anastomosis is delayed for 5 to 7 days as opposed
ANAL AND PERIANAL REGION 33
to suturing it at the initial operation. is approach allows two raw
surfaces to seal before sutures are placed through the bowel. is
approach may be favored when the internal os will be close to the
suture line.
Aer the mucosectomy, abdominal rectal mobilization, and
closure of internal os are performed, eight sutures of 3-0 polyglycolic acid are placed in the cardinal positions around the anus.
ese sutures are placed with deep bites from the outside of the
anoderm to the inside of the raw cut surface and pinned out radially to avoid tangling. e healthy bleeding cut edge of the distal
bowel (usually rectum) is then brought out the anus and positioned so the bowel is extruded 5 to 10 cm from the anal verge. e
bowel is wrapped with petroleum jelly (e.g., Vaseline)-impregnated
gauze. Next, the sutures are unpinned and wrapped around the
(now Vaseline covered) extruded bowel, and all is held in place
via wrapping with Kerlix gauze, which is stabilized with clips or
simple sutures. When this approach is used, an ileostomy is always
performed.
e patient recovers on the nursing oor and is able to walk and
sit. e only caveat is that most women retain their Foley catheter
until aer stage 2. Aer 5 to 7 days, the patient is returned to the
operating room and placed in the lithotomy position, the gauze is
carefully unwrapped, and the sutures are pinned out radially around
the anus. By this time the serosa of the bowel has adhered to the raw
surface created in the anal canal. Great care is taken to avoid disrupting this attachment. e bowel is amputated at least 1 cm distal to
the anal opening, and the sutures are placed through the cut edge
of the bowel and tied. I prefer to add short bursts of running suture
to further stabilize and seal the anastomosis. When the anastomosis
is completed, a small amount of ectropion exists that typically will
retract into the anal canal within 6 months. Amputating the bowel
more proximally increases the risk of disrupting the seal between the
bowel and the anal canal.
Before closing the stoma, I routinely examine the anesthetized
patient to ensure the stula is closed and everything has healed.
Transvaginal Approach
When the transvaginal approach is used, with the patient in the
lithotomy position, the posterior vaginal mucosa is mobilized starting distal to the stula opening and extending several centimeters
proximally. Although most reports indicate that a semicircular
vaginal ap is utilized, some surgeons use a linear ap. e tract is
excised and closed in layers with 3-0 absorbable suture. Some reports
emphasize the use of several layers of pursestring sutures for closure,
whereas other reports indicate that closure is performed with gureof-8 sutures. Care is taken to avoid shortening the vagina or creating
an uneven surface along the posterior vaginal wall because each consequence can contribute to dyspareunia.
One reported advantage of this approach in persons with Crohn
disease, especially if some element of inammation is present, is that
the anal area is undisturbed.
Perineal Approach
Ligation of the Intersphincteric Fistula Tract
If the tract is in the upper anal sphincter region, then a ligation of
the intersphincteric stula tract can be performed. is technique
does not divide any anal muscle, and data are accumulating regarding the results for closure with this approach. (A more detailed
description of this approach for non-RVF anal stula can be found
in Chapter 5).
Episioproctotomy
When a woman who had a previous vaginal delivery has an anterior
sphincter defect (no matter the cause of the RVF), an episioproctotomy
is recommended. It is important to remember that the patient can
have a wide intact perineal body but a weak, decient, or scarred
sphincter. erefore, unless the sphincter is clearly defective, an anal
ultrasound is invaluable in detecting an anal sphincter defect.
e preparation is the same as for the advancement rectal ap.
With the patient in the prone position, a probe is placed through the
stula tract and an incision is made over the probe. Sometimes the
length of skin that will be divided is daunting, but remembering that
no or minimal muscle will be divided is key. e muscle ends are dissected out and the internal and external sphincter muscles that have
been joined by scarring are le in place. Some dissection is required
in the rectovaginal septum to debride the epithelialized stula tract
and allow the sphincter repair space to lie at aer sutures are tied.
e sphincter is totally debrided, and hemostasis is ensured. Crossing
the sphincter over in a vest-over-pants type fashion (i.e., le over right
versus right over le) will allow visualization of the optimal setup for
repair. e goals are for the overlapped muscle repair to lie at and as
much dead space as possible to be obliterated. Aer determination of
the optimal overlap, attention is turned to the rectal mucosa, which
is closed rst. Starting at the cephalad aspect, far-far-near-near 2-0
or 3-0 polyglycolic acid sutures are placed in the rectal mucosa. e
aim is precise approximation of the mucosa. ese sutures are placed
until about the level of the dentate line and tied down. It is important to place these sutures rst because visualization will be decreased
aer the muscle overlap, making precise placement impossible. Next,
using 2-0 polydioxanone sutures, a vest-over-pants type repair is performed to overlap the muscle; then the free edge of muscle from the
overlap can be tacked down with 2-0 polydioxanone suture. e rectal mucosa is then closed to the level of the perineal skin, stopping
at about the anal verge. Next, the apex of the vaginal defect is closed
with mattress sutures of 2-0 polyglycolic acid. Depending on the
amount of dead space, I will loosely approximate the vaginal closure,
because if uid has accumulated, I want it to drain out the vaginal
side rather than the anal side. Care is taken to line up the hymenal
ring during the vaginal closure. e perineal skin from the introitus
to the anal verge is also usually (but not always, depending on the
amount of dead space) le open for drainage.
Postoperative care is similar to that for the rectal sleeve ap. is
approach does not require a diverting stoma, although if the repair is
a repeat procedure or if it is unusually complex, use of a stoma may
be considered. Careful postoperative monitoring is key to improving success. Any reports of pressure or increased pain or concerns
about uid accumulation require an examination aer induction
of anesthesia to drain trapped uid and prevent it from coming out
the anorectal suture line. On many occasions, a local physician has
prescribed antibiotics for these symptoms, and when I nally see the
patient, she will report that uid or drainage came from the anus,
which relieved her symptoms but was associated with recurrent RVF
symptoms. Preventing drainage of this uid from the anorectal suture
line may help avoid a recurrence.
If a stoma has been placed, about 2 to 3 months later I examine the
anesthetized patient prior to closing the stoma. Any granulation tissue found along any suture line raises suspicion for a persistent stula
and mandates a very careful examination.
With this approach, closure of the stula has been reported in
nearly 80% of cases when the cause was obstetrical or cryptoglandular.
Tissue Interposition
. Placement of muscle (typically the gracilis) between the
Gracilis
rectum and vagina via a transperineal approach is an option when
the patient has a lot of scarring in the anal canal and the goal is to
bring in healthy tissue with a good blood supply. For this procedure
I team up with a plastic surgeon, who mobilizes the gracilis. I prefer
that the patient be positioned in the prone jackknife position to allow precise dissection in the rectovaginal plane. e plastic surgeons
I have worked with have adapted and can mobilize the muscle in
the prone position, but I ensure they are present for the positioning,
Rectovaginal Fistula34
prepping, and draping. One must be sure the tunnel from the leg to
the space in the rectovaginal septum is wide and does not impinge
on the muscle or its blood supply. In the rectovaginal septal mobilization, a wide transverse incision is made over the perineal body
between the anus and vagina. is mobilization is carried at least 2
to 3 cm cephalad to the stula tract. e anal and vaginal openings
are closed from inside the rectovaginal septum with 2-0 or 3-0 polyglycolic acid mattress sutures. Sutures are next placed cephalad to the
opening on the rectal side but are not tied, usually at each corner of
the space that results from the transverse mobilization. en the gracilis muscle is brought through the groin tunnel and oriented so the
at surface of the muscle lies at against the rectum and the previously placed sutures are brought through the muscle and tied. Other
sutures are placed around the repaired rectal hole and tied down,
always maintaining a at surface of the muscle that is sitting against
the rectum. If the muscle has a lot of bulk, the remaining muscle is
secured with sutures. e perineal skin may be le open or loosely
approximated with absorbable sutures. Because it is important to
prevent uid accumulation, a Penrose drain is positioned along the
muscle on the vaginal side to promote uid drainage. A stoma is almost always used.
Postoperative care and restrictions are usually dictated by the leg
incision (i.e., they are determined by the plastic surgeon). ere is
usually a drain in the donor muscle bed along the medial surface
of the thigh. Typically, the patient is instructed to avoid liing and
strenuous activity for 4 weeks. Showers are permitted, but baths and
swimming should be avoided until granulation tissue forms over and
seals all suture lines.
Gracilis interposition is typically reserved for cases in which multiple previous attempts to repair the stula have failed and for stulas
that are radiation induced or related to cancer excision. Success rates
of 60% to 75% have been reported.
Martius
healthy tissue into the area. e patient is usually in the lithotomy position during the procedure. A vertical incision is made over the labia
majora to expose the bulbocavernosus fat pad beneath. Mobilization
begins from the lateral aspect of each side of the incision working
medially. e fat pad is mobilized o the fascia covering the urogenital diaphragm posteriorly and the labia minora and bulbocavernosus
muscle medially. e lateral blood supply is sacriced. Aer the tube
of fatty tissue is circularly mobilized, dissection is carried cephalad
and superiorly (away from the perineum), and the vessels and blood
supply are divided. Hence the blood supply for this brofatty ap
is from the perineal branches of the internal pudendal artery that
remains attached at the most inferior aspect. A generous tunnel is
made in the subcutaneous tissue to carefully deliver the bulky fat
pad into the wound. Orientation must be assessed to ensure it is not
twisted, which could reduce blood ow and lead to ischemia. e
Martius gra can be used to augment a sphincter overlap, or in place
of the gracilis, and is placed in the rectovaginal septum to separate
the anorectal and vaginal openings. A Penrose drain is placed in the
labia, and the area of the donor site is closed in layers with absorbable sutures. e labial skin is then closed. Optimally when using this
approach, the bulk of the fat pad will reach to completely cover the
repaired opening. However, this can be a limitation because some
women have small, thin labial fat pads. e skin over the perineal
area is closed as described for the gracilis interposition.
. e Martius ap is another procedure that brings
SPECIAL CONSIDERATIONS
Use of a Stoma
In some cases a stoma is necessary for symptom control and is
retained until a repair has been performed successfully. In other
patients, a stoma is performed to protect a repaired area, although
the use of a diverting stoma does not guarantee success. It is always
considered, especially for repeat repairs, and the patient is nearly
always warned of this possibility and undergoes preoperative marking. Other indications for a stoma include a technically dicult procedure or an advanced procedure (such as a sleeve, Turnbull-Cutait
anastomosis, or gracilis interposition).
Postoperative Care
Lack of attention to details in postoperative care can lead to failure
of the repair. For patients without a stoma, the passage of a hard or
dicult stool can sabotage a repair. erefore, close communication
with the patient is necessary. In addition, any reports of increased or
new pain or pressure should be investigated because sometimes they
signal trapped uid, and evacuation in the operating room without
allowing this uid to drain out of the anal region will be the dierence
between recurrence and success.
Sexual Function/Vaginal Dryness
Dyspareunia aer repair of an RVF is not uncommon. Sutures that narrow the vagina to less than two nger breaths or leave a rough, humped
surface on the rectal side can increase the chances of painful intercourse.
Some women naturally are afraid that intercourse will be painful and
thus lubrication during arousal is insucient. Counseling about when
they can resume sexual intercourse (aer the area is healed, which can
take up to 3 months) can reduce some of these problems. Liberal use
of water-soluble lubrication during the rst attempts at intercourse and
avoiding the missionary position in favor of the woman being on top
to control the degree of penetration are useful tips. If problems persist,
then advanced counseling from an expert is warranted.
Recurrence
Persistence or recurrence of the stula can be emotionally devastating. When the stula persists or recurs, starting over with a review of
the operative note and examination of the entire area (almost starting
from scratch) is necessary. An examination aer induction of anesthesia
is considered to obtain a full picture of the trajectory of the tract because
it may have changed. Placement of a stoma is more strongly considered,
along with use of an advanced type of repair as the next surgical intervention. A repeat repair should not be attempted until the tissue is so and
pliable, and thus placement of a draining seton for sepsis drainage should
be considered. One should avoid performing multiple advancement ap
repairs in succession, which usually leads to unusable scar tissue and limits further choices. Referral to a specialty center may be a better choice.
Biologic Mesh
of the openings at the anal and vaginal side, followed by placement
of a biologic material, has been reported. Loose or no approximation
of the perineal skin at closure is recommended because signicant
drainage occurs that can last for several weeks. Although some surgeons are enthusiastic about this procedure, I have not embraced it
because aerward the tissue takes on a cardboard-like nature, and if
the procedure fails, any further repair is then hampered by the inexibility of the tissue.
. Dissection in the rectovaginal plane and closure
CONCLUSION
Because RVFs present special challenges, a careful history and physical evaluation are required to determine the correct treatment plan.
It is important to remember that not all patients require surgical
treatment; the risks and benets must be weighed. Surgical therapy
is customized, which means the surgeon must be familiar with different techniques of repair. An algorithm to consider when planning
surgical therapy is provided in Figure 6-1.
ANAL AND PERIANAL REGION 35
History and physical examination
Possible examination under anesthesia
Possible anal ultrasound
Soft tissue, sepsis controlled
Sphincter intact
Good tissue
Good tissue
Minimal scarring
Minimal scarring
Rectal
advancement
flap
FIGURE 6-1 Algorithm for repair of a rectovaginal fistula.
Loss of tissue
Scarred
Recurrent RVF
Sleeve advancement
Transanal
Be ready for transabdominal
mobilization if needed
Abdominal approach
with internal os very
close to suture line
Turnbull-Cutait
S u g g e S t e d R e a d i n g
El-Gazzaz G, Hull T, Mignanelli E, etal. Analysis of function and predictors of
failure in women undergoing repair of Crohn’s related rectovaginal stula.
J Gastrointest Surg. 2010;5:824–829.
El-Gazzaz G, Hull TL, Mignanelli E, etal. Obstetric and cryptoglandular rec-
tovaginal stulas: long-term surgical outcome; quality of life; and sexual
function. J Gastrointest Surg. 2010;11:1758–1763.
Hull TL, ed. Posterior Pelvic Floor Abnormalities. Philadelphia: Elsevier/Saun-
ders; 2011.
Hull TL, El-Gazzaz G, Gurland B, etal. Surgeons should not hesitate to per-
form episioproctotomy for rectovaginal stula secondary to cryptoglandular or obstetrical origin. Dis Colon Rectum. 2011;1:54–59.
Sphincter defect
Episioproctotomy
Severe scarring
Several recurrences
Fistula in mid or distal
rectum
Tissue interposition
Lefevre JH, Bretagnol F, Maggiori L, etal. Operative results and quality of life
aer gracilis muscle transposition for recurrent rectovaginal stula. Dis
Colon Rectum. 2009;7:1290–1295.
Marchesa P, Hull TL, Fazio VW. Advancement sleeve aps for treatment of
severe perianal Crohn’s disease. Br J Surg. 1998;12:1695–1698.
Pinto RA, Peterson TV, Shawki S, etal. Are there predictors of outcome fol-
lowing rectovaginal stula repair? Dis Colon Rectum. 2010;9:1240–1247.
Schouten WR, Oom DM. Rectal sleeve advancement for the treatment of per-
sistent rectovaginal stulas. Tech Coloproctol. 2009;4:289–294.
Tro j a A, Kase P, El-Sourani N, et al. Treatment of recurrent rectovaginal/
pouch-vaginal stulas by gracilis muscle transposition—a single center
experience. J Visc Surg. 2013;6:379–382.
P S
Tim Slack, Graham Newstead, and Mark Muhlmann
ETIOLOGY
Pilonidal disease is a common infection that occurs around haircontaining sinuses in the natal cle. It usually presents in young men,
and if it is not managed correctly, it tends to persist or recur. e disease and its treatments are a signicant burden on patients, caregivers, and society, oen resulting in signicant loss of time from work
with persistent symptoms, a continuing need for wound care, and
frequent trips to health care providers for follow-up.
In 1833, Herbert Mayo rst described a hair-containing sinus in the
natal cle. Initially thought to be congenital in origin, pilonidal sinus disease is now widely accepted to be an acquired condition that originates
when healthy hair penetrates the skin through either a preformed sinus/
hair follicle or by creating new sinuses. Subsequently, foreign body reaction, epithelialization of tracts, and chronic infection become the hallmarks of disease, leading either to chronic sinuses or recurring abscesses.
Loose hair, frictional force, and vulnerable skin are the main factors that lead to hair insertion and sinus formation. Contributing risk
factors are hirsutism, obesity (a deep natal cle), a sedentary lifestyle
or occupation, and macerated natal cle skin. Oen there is a family
history of pilonidal disease.
PRESENTATION
A pilonidal sinus, which is found within the cephalad aspect of
the gluteal cle, consists of a midline pit (sinus opening) and an
epithelium-lined tract. e sinus usually contains hair, and the
sinuses lead to a pilonidal cyst cavity within the subcutaneous fat.
ese cyst cavities are lined by chronic granulation tissue and contain debris and, frequently, hair shas. Multiple midline pits may be
present, as well as secondary openings or stulae laterally.
e dierential diagnosis of natal cle infection includes hidradenitis
suppurativa, Crohn disease, stula-in-ano, and infected skin furuncles.
TREATMENT
Asymptomatic Pilonidal Sinus
Surgery is not recommended for asymptomatic pits. Maintenance of
regional hygiene, appropriate weight loss, and consideration of depilation have been promoted, but simple observation is usually all that
is required.
Pilonidal Abscess
A pilonidal abscess requires drainage. Management options (Fig. 7-1)
include a midline incision with excision of the central pits (deroong)
36
or an o-midline incision. Avoiding a wound in the depths of the
natal cle (with its moist, anaerobic environment and ongoing frictional forces) is the preferred option because the alternative leaves a
wound in the midline that is more likely to accumulate further loose
hairs.
Overall, a midline incision for deroong and drainage of a pilonidal abscess takes longer to heal and requires more time o work,
more dressing changes, and more extensive follow-up, with no
proven impact on reducing recurrence compared with an o-midline
incision and drainage procedure. An o-midline incision should be
placed on the side of any secondary openings within the boundaries
of any potential subsequent excisions.
Successful healing can be expected in 60% to 80% of cases aer
incision and drainage of a rst-episode acute pilonidal abscess. If a
wound has failed to heal by 10 weeks, it is unlikely to do so. Adding curettage to o-midline drainage removes debris, hair, and the
granulation tissue lining the pilonidal cavity. Curettage is associated
with an even higher rate of complete healing, as well as lower rates of
disease recurrence.
Recurrent disease aer complete healing occurs in approximately
10% to 15% of patients. Overall, about 30% to 50% of patients will
ultimately require a denitive excisional procedure.
A recent series reviewed the outcomes of patients with simple
acute pilonidal abscesses (no skin necrosis, sepsis, diabetes, or immunocompromise) who had their abscess drained via needle aspiration
and were discharged the same day with a prescription for oral antibiotics (cephalexin and metronidazole). A total of 95% returned to
normal activities, including work, within 24 hours, with no aercare
requirements. e aim was for patients to return for elective surgery,
but whereas half underwent formal excision about 7 weeks later,
many others had no sign of recurrence at follow-up.
Chronic Pilonidal Sinus
A chronic pilonidal sinus generally occurs aer an acute abscess; the
source of the infection is the hair-containing subcutaneous cavity.
e hair acts as a foreign body and allows the infection to persist and
recur. Management (Fig. 7-2) is aimed at removing the hair and the
granulations so the source of the infection is gone.
NONOPERATIVE MANAGEMENT
Hair Removal
Meticulous regional hair control by shaving, waxing, or laser treatment has been promoted as a conservative nonoperative approach
for chronic sinuses, as well as an adjunct to surgical management
in an attempt to reduce recurrence. However, more recently a large
ANAL AND PERIANAL REGION 37
study revealed a higher rate of disease recurrence over 10 years in
patients who obeyed postoperative instructions to regularly shave the
region compared with those who didn’t (30.1% vs. 19.7%). Consideration of alternatives such as laser depilation rather than shaving,
which may damage the skin and encourage recurrent disease, may
be worthwhile.
SURGERY
Lateral Drainage, Curettage, and Midline Pit Excision
Bascom described the simple technique of lateral drainage, curettage, and midline pit excision, similar to Lord and Millar’s midline
pit excision and cavity cleansing as described in 1965. A small, vertical o-midline incision centered over the abscess/cyst cavity allows
curettage and is le open for drainage. e midline pits are excised,
and the 2- to 4-mm excision sites are sutured. e procedure can be
Most cases
Off-midline incision,
drainage, and cavity
curettage
FIGURE 7-1 Management of a pilonidal abscess.
Small, superficial abscess
Aspiration and oral
antibiotics (consider in
very selected cases)
performed as day surgery with use of a local anesthetic. In Bascom’s
study of 161 patients, only one day of work was missed, no wound
dressings were required, and the mean time to complete wound healing was 3 weeks. A 14% recurrence rate was seen, with the majority of
recurrences occurring within the mean follow-up of 3.5 years.
A larger study published a variation on Bascom’s “pit-picking”
procedure and showed good results. All openings and tracts were
cored out with skin trephines (from 2 mm up to 9 mm in diameter).
Curved forceps or curettes, as well as cotton swabs dipped in hydrogen peroxide, were introduced via the trephines to clear the cavities
of hair, debris, and granulation tissue. All wounds were le open and
no packing was needed. e recurrence rate at 5 years was about 13%.
Local Excision and Healing by Secondary Intention
Local excision and healing by secondary intention, a simple and
reproducible technique, is widely practiced. It involves regular outpatient visits, initially painful dressing changes, and for patients with
larger wounds, a signicant time o work. e average healing time
is well over 2 months. Marsupialization, by suturing the skin edges to
the wound base, was added to wide excision with the goal of creating
a smaller wound that will heal more quickly. Negative pressure dressings have been used to facilitate faster healing.
Wounds that are present aer excision and primary midline closure heal signicantly faster than do wounds that are present aer
excision without closure. However, aer open healing, a recurrence
is less likely to occur. When directly compared with midline closure
aer excision, open healing is associated with an estimated 60%
reduction in the risk of recurrent disease.
Local excision and open healing will always be an option in the
setting of recurrent disease and sepsis. However, there is no guarantee
Asymptomatic midline pits
Conservative management
Lateral drainage
and pit excision
Symptomatic sinuses
Simple
Off midline
Nonexcisional
techniques
Pro: Outpatient procedure
under local anesthesia
Con: Highest recurrence
rates
Recurrent/complex pilonidal sinus disease
Repeat
Karydakis or
cleft lift
procedure
Karydakis
procedure
Rhomboid
excision and
modified
Limberg flap
repair
Complex
In midline
Excisional techniques
Pro: Lowest recurrence
rates
Con: Requires general
anesthesia
Cleft lift
procedure
Local excision
and healing by
secondary
intention
FIGURE 7-2 Management of chronic pilonidal sinus disease.
Pilonidal SinuS38
A
B
FIGURE 7-3 Karydakis procedure. A, Cross-sectional view depicting wide local excision to sacrococcygeal fascia, full-thickness flap mobilization,
and fixation of the flap to the sacrococcygeal fascia, closing the defect. B, The eccentric elliptical incision, with the shaded area indicating the mobilized flap, and the final off-midline wound.
of success because the patient is still le with a deep natal cle and
vulnerable skin for the duration of the healing process, with the
associated risk of recurrence.
Excision and Wound Closure: Midline or Off-Midline
than 10% of patients. Most other series using this technique, or subtle
variations thereof, have achieved recurrence rates of 5% or less.
Karydakis believed that most recurrences were preventable with
better technique because they occurred when the nal suture line
crossed the midline, permitting hair insertion. e procedure can be
repeated in the event of a recurrence.
Closure?
If excisional surgery is required for chronic pilonidal disease, the
one principle that provides a clear benet is to close the wound o
the midline rather than directly in the midline of the gluteal cle.
Wounds o the midline have consistently been associated with faster
healing times and lower rates of wound morbidity and recurrence.
For studies with follow-up longer than 12 months, the recurrence rate
for o-midline closure was 1.4%, compared with 10.3% with midline
closure. Nine patients would need to be treated with excision and omidline closure to prevent one wound infection, and 11 would need
to be treated in this manner to prevent one recurrence.
FLAP-BASED PROCEDURES
Karydakis Procedure
Karydakis developed a local advancement ap technique, with the
fundamental objective of stopping hair insertion by eliminating the
causative factors. is technique involves attening of the natal cle
and lateralizing the wound o midline. Of the ap-based procedures,
it is generally believed to be the easiest to learn.
e procedure consists of an eccentric (based on the side of any
secondary openings or induration), biconcave excision of the midline pits and associated sinus cavity down to the sacrococcygeal
fascia. A full-thickness ap is then mobilized from the median side of
the wound. Suturing the base of the ap to the sacrococcygeal fascia
closes the defect, and skin is closed o midline (Fig. 7-3). Modications of this technique include creating a smaller ap depth of only
1 cm and omitting the step of suturing the deep layer of the fullthickness ap to the sacrococcygeal fascia in an attempt to further
maximize the chance of attening the gluteal cle.
Karydakis’ personal series of more than 7000 patients with 95%
complete follow-up lasting as long as 20 years had an impressive
recurrence rate of less than 2% and wound complications in fewer
Cleft Lift Procedure
e cle li procedure was proposed by Bascom and Bascom as a
treatment for recurrent disease aer a “pit-picking” simple procedure. e principles are similar to a Karydakis procedure (attening the natal cle and keeping the wound o the midline), but there
are some major dierences in technique. Fat is not excised, and fat
mobilization is not required. It was believed that the deep tissue damage was not the primary cause of nonhealing and thus should not be
excised but rather that the shape of the natal cle is the major issue.
e mission of the cle li procedure is removal of the deep natal
cle and its associated warm, moist, bacteria-laden environment. e
pilonidal cavity is opened aer excising skin from one side. e cavity
is scrubbed free of debris with gauze. Tense cavity contractures are
incised, but the cavity wall is not excised. e gluteal fat is allowed
to appose naturally. A supercial skin ap from the healthy side is
mobilized, and an o-midline closure is performed (Fig. 7-4).
In a small study of patients with refractory disease (with 223
previous surgical procedures among them), 95% were healed aer a
single cle li procedure. ree patients required a second or third
cle li procedure, but eventually all healed with no recurrence at an
average follow-up of 30 months.
Rhomboid Excision and Flap Repair
e rhomboid excision and ap repair excisional technique starts
with a full-thickness rhomboid incision. e fascia-cutaneous ap
is created by incising fat down to the gluteal fascia. Some variations
in rhomboid excisions and ap repairs exist, the most popular of
which is the Limberg ap. e upper part of the wound does cross
the midline but should be well out of the depths of the gluteal cle.
e inferior apex of the rhombic excision is in the midline at a depth,
but an asymmetrical rhomboid (a modied Limberg ap) sited 1 to
2 cm lateral to the midline on the opposite side to the donor ap will
ANAL AND PERIANAL REGION 39
FIGURE 7-4 The cleft lift procedure. The bold lines are marked preoperatively with the patient standing. These “rim trails” are drawn where
the surface skin disappears into the chasm. With the buttocks taped apart, the ellipse of skin on the left is excised and the shaded area on the right
shows the skin to be undermined. The cross-sectional view depicts how only the diseased skin is excised; the gluteal fat is allowed to appose
naturally, and a thin skin flap is mobilized, allowing the final wound to sit off midline.
1
A
B
60
D
120
1
B
A
FIGURE 7-5 Rhomboid excision and modified Limberg flap repair. Note that the inferior corner of the rhomboid is located off midline.
Also note that bilateral secondary openings could potentially be included in the rhomboid excision while still being able to achieve a final wound
with its inferior aspect off midline.
avoid this scenario and is the recommended technique (Fig. 7-5). e
modied Limberg ap can be successfully performed with a wound
complication rate of about 5% (resulting from seroma, infection, ap
necrosis, and dehiscence) and a recurrence rate of less than 5%. is
technique is recommended for use in complicated recurrent disease.
Complex bilateral secondary openings can be included in a single
rhomboid excision, which still allows a nal wound with its inferior
aspect o the midline.
1
D
aspect of the wound, well away from the midline. Not all studies
mentioned the indication for or timing of drain removal, but in most
series removal was undertaken aer 2 to 3 days, seemingly regardless
of drain output. Routine postoperative drainage is probably benecial
in reducing wound collections and the need for associated interventions (e.g., aspiration) but has little impact on reducing wound infection and recurrence rates. With good community nursing, the use of
a drain should not increase the length of hospital stay.
A meta-analysis of randomized trials comparing Limberg aps
and primary closure reported lower wound infection and dehiscence
with the Limberg ap and a trend toward fewer recurrences. However, the meta-analysis included only two trials where it was directly
compared with excision and o-midline closure (the Karydakis
procedure). Apart from achieving a lower wound infection rate in
one trial, overall there were no signicant dierences in outcomes
between techniques.
In general, the modied Limberg ap is more technically complex
to perform and probably oers no benet over the simpler excision
and o-midline closure (e.g., the Karydakis or cle li procedure).
CONCLUSION
Recently, calls have been made for surgeons who do not perform
adequate numbers of ap-based procedures to stop operating on
pilonidal disease. However, for most patients, the use of simple
measures improves outcome, and technically complex ap repairs
oer little additional benet. Careful treatment of an acute abscess
with o-midline drainage and cavity curettage can signicantly
reduce recurrences. When this approach is combined with use
of simple techniques such as pit excision, only a small number of
patients will have ongoing active disease. In such patients the rela-
ADJUNCTS TO OPERATIVE
MANAGEMENT
tively simple Karydakis and cle-li procedures can be performed,
and the modied Limberg ap can be reserved for the most complex
and dicult cases.
Cavity Drainage
Most major series recommend the use of a drain. Karydakis recommended a simple Penrose drain, but in most other series a suction
drain was used. e best exit point for the drain is at the cephalad
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