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PREOPERATIVEPLANNING
HistoryandPhysicalExamination
Adetailedevaluationisthekeyfirststepintheassessmentofapatient withasuspectedRVF,includingahistoryofinflammatoryboweldisease, diverticulardisease,colorectalorvulvarcancers,asignificantobstetrical perinealinjury,previouspelvicfloorsurgicalprocedures,orradiation therapy.Thedegreeofcontinenceshouldbeassessed.Ingeneral,the successofanRVFrepairisrelatedmoretotheunderlyingetiologyand associatedpatientfactorsthantothetechniqueofmanagement.
Physicalexaminationshouldincludetheinspectionofthevagina,anus, andperineum.Perinealbodythicknesscanbemeasuredordetermined bybidigitalexamination.Therestingtoneoftheanusandtheamountof voluntarysqueezeareassessedbydigitalrectalexamination.Defectsin thedistalanalmucosacanbefrequentlypalpatedduringthispartofthe examination.Carefulexaminationofthelowerposteriorvaginashouldbe performedwiththehelpofaspeculumorretractortoidentifyany mucosaldefects.Anoscopicorproctoscopic,examinationfrequently providesusefulinformationregardingtheetiologyandanatomyofthe fistula.Instrumentssuchaslacrimalductprobescanbeusedtoidentifya fistuloustract(Fig.11-1).Complextracts,multiplefistulae,anddraining sinusescanfrequentlybeidentifiedduringthismaneuver.
FIGURE11-1Lacrimalductprobe(s)canbeusedto
clearlyidentifyfistulatract(s)andintraoperativelyassistin completetractexcision.
RadiologicEvaluation
Radiographicevaluation,includingcomputerizedtomographywithoral andtransanalcontrastormagneticresonanceimagingmaybehelpful, butunlikelytohelpidentifyafistulanotapparentduringpelvic examination.Transanalultrasonographycanprovideimportant informationregardingthepresenceofanRVF,especiallywhenhydrogen peroxideisinfusedintoasuspectedfistulousopening.Ultrasonography canbeusedtoidentifydefectsoftheinternalandexternalanal sphincters,whichisparticularlyimportantwhenthefistulaisrelatedto obstetrictrauma.
TimingoftheSurgery
RVFsassociatedwithobstetrictraumamaypresenteitherimmediately postpartumfromanunrecognizedinjuryor7–10dayslater,aftera breakdownorfailureoftheprimaryrepairofanobstetricinjury.For patientswithverysmallacuteobstetricfistulas,aperiodofobservationis indicatedasasmallnumberofthesefistulasmayspontaneouslyclose.
ForpatientswithRVFsfromothercauses,itisimportanttohavea periodofmedicalmanagement(includingantibiotics,immune modulators,andsetonplacement)toallowanyacuteinflammationofthe fistulatoresolveandtooptimizetheconditionofthelocaltissuesthatis usedintherepair.

SURGERY

WhyaTransperinealApproach?
Thechoiceofatransperinealapproachislargelybasedonsurgeon training.Colorectalsurgeonswhoareaccustomedtothepronejackknife positiontypicallypreferthetransanalapproachandmaybechallengedin visualizinganatomyfromthevaginalorperinealapproach.Gynecologists aremorecomfortableperformingatransvaginalortransperineal approach,duetotheirpreviousobstetricalcareexperience.Inmy opinion,thisapproachallowsforgoodvisualizationoftheentiretract andfacilitatesitscompleteexcisionandclosureinmultiplelayers.A recentsurveyofurogynecologictrainingcentersrevealedthat10% performedthetransperinealapproachastheirprimaryapproach, whereas59%usedsimplefistulectomywithorwithoutMartiusgraftand 23%transphinctericrepair.
Positioning
TransperinealrepairofRVFscanbeperformedwiththepatientin lithotomyorpronejackknifeposition.Lithotomyispreferredbymost urogynecologists,asthedefectcanbemoreeasilyvisualizedduring surgicaldissection.Pronejackknifepositioningmaybemoreappropriate forLIFTproceduresortransanaladvancementflaps.
Anesthesia
Theanesthetictechniqueselectedisatthediscretionofthepatient,the surgeon,andtheanesthesiologist.Perioperativeantibioticsshouldbe givenasforanypelvicreconstructivesurgery.
ExaminationunderAnesthesia
Beforemakinganincision,acarefulexaminationunderanesthesia shouldbeperformedtoconfirmfindingsandsurgicalplan,andtofind anyunidentifiedtracts.Theuseofprobesisveryhelpfulduringthis examination(Fig.11-1).Leavingtheprobesinplaceduringtheinitialpart oftheprocedureisveryhelpfultoascertainthattheentirefistuloustract isremoved.Oncesatisfactorymappingofthefistulaetract(s)is completed,theareatobedissectedshouldbeinfiltratedwitha hemostaticsolutionsuchas1%Lidocainewithepinephrine1:200,000to reducebleeding,whichcanobscurevisibilityandreducechancesof
hematomaformation.
Dissection
Atransverseorverticalincisionismadeoverthemidportionofthe perinealbodywithdissectionperformedthroughtheperineal subcutaneoustissuelaterallyforapproximately2cmandsuperiorly betweenthevaginalfibromuscularisandmucosatoasiteatleast1cm aboveandoneithersideofthefistuloustract.Thefistulacanthenbe circumscribedwhileprovidingtractionwithalongAllisclampplacedon thevaginalopeningandlacrimalductprobe(Fig.11-2).Thesurgeoncan placehisorherindexfingerintherectumtoidentifytherectalendofthe tractandhelpinincisingtherectalmucosawithasatisfactorymarginto allowforoptimizedtension-freeclosureandhealing.Thismaneuver allowsfortheentirefistulatracttoberemovedintact(Fig.11-3).
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RVFistula-Transperineal
FIGURE11-2TractionwithanAllisclampplacedonthe
fistulatractwithlacrimalductprobeallowsforcompletetract excision.
FIGURE11-3Operator’sindexfingerintherectumhelps
identifyrectalmucosaledgesforclosure.
IfaLIFTprocedureistobeperformed,theperinealdissectionis continuedintheintersphinctericplanemobilizingtheinternalsphincter andrectalmucosaposteriorlythroughapproximatelyone-thirdofthe circumferenceoftheanusandrectum.Whenthefistulatractis encountered,itistransectedinthisplane.Thedissectioninthe rectovaginalseptumiscontinuedforatleast2cmproximaltothe transectedfistulatractandextendedlaterallytoidentifythelevatorani muscles.
ClosureofSurgicalSite
Oncethefistulaiscompletelyexcised,therectalmucosaopeningisclosed with3/0interrupted,absorbablesutures(Fig.11-4).Therectal muscularisisthenclosedwiththesamesutureineitherarunningoran interruptedpattern(Fig.11-5).Ifthereisanassociatedsphinctericinjury,
anend-to-endoroverlappingsphincteroplastycanbeperformed.The perinealbodymusculaturecanthenbeapproximatedinthemidlinewith 2-0or1absorbablesutures.Ifthevaginalfibromuscularisisdeficient,a biologicgraftcanbeimplanted(asinaLIFTprocedure)tocreatea neorectovaginalseptum(Fig.11-6).Theimplantshouldbesutured laterally,proximately,anddistallywithmultiple,interrupted3/0 absorbablesuturestopreventmigration.Thisisprimarilyneededin recurrentrepairs.Variousbiologicmaterialshavebeenused,including humandermis,smallintestinalsubmucosa(SIS),andothercollagen matrixbiomeshmaterials(Fig.11-6).Syntheticpolypropylenegrafts shouldbeavoidedinthisbodysite.Ifabiologicgraftistobeused,our preferenceisforanon–cross-linkedcollagenmatrixsuchasbovine pericardium,porcinedermis,orSIS—whichwillbefullyintegratedinto thehosttissuewithin9months.
FIGURE11-4Initiallayerclosureincorporatesrectal
mucosa.
FIGURE11-5Rectalmuscularisclosureasthesecond
closurelayer.
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FIGURE11-6Abioprostheticissuturedtocompletely
covertheclosureofeachendofthefistulatractwithatleast1 cmofoverlap.
Analternativetoabiologicgraft,especiallyinradiatedorlarge­diameterfistulasistheuseofalabialMartiusflap.Thisentailsalabial incisiontoisolateavascularizedfatpadthatcanthenbetunneledunder thelabialskinontothefistularepairsitetoaddbulkandvascularityto therepairsite(Fig.11-7).Successoftherepaircanbeenhanced,but donorsitepainanddyspareuniahavebeenreported.
FIGURE11-7AMartiusfatpadgraftcanbeusedto
enhancetissuemassandprovidevascularitytotheRVF repair.
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