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CONTRAINDICATIONS

Therearenoabsolutecontraindicationsforimplantationofbiologicmesh withtheexceptionofthoseindividualswhoopposeanytransplantationof nonautologoustissueonthegroundsofethicalorreligiousconcerns.A documentedpriorallergicreactiontoporcinetissuealsorepresentsa contraindicationtoinsertion.
PREPARATIONOFTHEPATIENT
DiagnosisandControlofLocalSepsis
Theauthorrecommendsaninitialexaminationunderanesthesiato determinetheanatomyofthetractandtoaddressanylocalsepsis. Abscessesshouldbedrainedandoneshouldconsidertheinsertionofa drainingsetonifacavityexistsand/orifbranchingofthetractis identified.Thesetonshouldassistincontractionorsecondaryhealingof suchacavitysuchthatafibroustractresults.Thefistulashouldbeableto epithelialize,giventheshortdistancebetweenthetwoorgans.
Ifpostobstetricorposttraumatic,endoanalultrasoundorpelvicMRI shouldbeperformedtoassesstheintegrityoftheanalsphinctermuscles. Thepresenceofadefectnecessitatessphincteroplastyasanintegral aspectofrepairoftherectovaginalfistulaeitherviaaperinealincisionor byepisioproctotomy.Repairoftheanalsphinctersincluding levatorplastythroughatransvaginalapproachhasalsobeendescribed, buttheauthorhasnopersonalexperiencewithsuchatechniqueand prefersaperinealapproachtoarectovaginalfistulawithanassociated anteriorsphincterdefect.
Theuseofadivertingstomacontinuestobedebated.Severalfactors influencethedecisiontoperformadiversion,preferablyasalaparoscopic loopileostomy.First,ifthepatientexperiencesseveredifficultieswith personalhygieneandvaginitissecondarytofecalcontamination,a diversionofferspalliationandreliefofmostfecaldischarge.Second,in casesoffistulasassociatedwithCrohn’sdiseaseandactiveproctitisfecal diversionofthefecalstreamoftenreducesmucosalinflammation.There arereportsofspontaneoushealingofrectovaginalfistulawithdiversion alone,butIwouldnotsuggestthatthisbeconsideredacurative treatment.
Themostcompellingargumentforfecaldiversionofcoursewouldbe improvedsuccessfulhealingofarepair.Itseemslogicalthatdiminishing themicrobialburdenofaconstantfecalstreamandthereductionofthe mechanicalforcesexperiencedbytherectalandanalwallsduring defecationmightbeadvantageoustohealingofacomplexsofttissue woundsuchasarectovaginalfistula.However,theroleofadiverting stomapriortorepairhasnotbeenprospectivelystudiedandmost authorsresistmakingstrongstatementsregardingitspotentialimpacton successfulrepair.Priorfailedrepairhasbeenidentifiedasapredictorfor subsequentfailureofrepeatrepair.Clearly,thebestopportunityoddsfor successisattheinitialrepair,andtherefore,theargumentshouldbe madeforonetoconsiderutilizingallmeanspossibletoensurethe
successofthefirstrepairincludingthepotentialroleoffecaldiversion. Thereisnoclearevidencetosupporttheroutinediversionway.
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Certainly,patientsaredismayedatthesuggestion,andstomacreation hasmorbidityandtheprospectsofanadditionaloperationtoclosethe stoma.Theauthorincreasinglyfavorsearlydiversionespeciallyin patientswithcasesofCrohn’sdisease-relatedrectovaginalfistulasand/or inwhominitialafterafailedrepairfailed.
Waiting,fortissuestohealandinflammationtodiminish,improvesthe dissectionoftissueplanesatdefinitiveoperation.Ideally,anintervalof3 monthspriortoanattemptedrepairisencouraged.Inadditionto considerationoffecaldiversionandintervaltorepair,otherpertinent issuesshouldbeaddressedpriortosurgicalrepairofarectovaginal fistula.Smokingcessationshouldbestronglysuggestedastobacco smokinghasbeenshowntobeapredictorforfailureoftherepairof rectovaginalfistula.Nutritionaldeficienciesshouldbecorrectedand optimizationofthemedicaltreatmentofCrohn’sdiseaseundertaken.
Bowelpreparationintheundivertedpatientshouldbeundertaken, bothoralmechanicalantibioticsaswellasmechanical.Adistalrectal washoutisperformedwithantibioticsalinesolution;eveninthecase whenthepatienthasadivertingstoma,theauthorstillperformsdistal rectalwashouttoevacuateresidualstoolandmucous.Intravenous antibioticsareadministered.Generalanesthesiaispreferredthoughnot mandatory.
OPERATIVETECHNIQUE
PositioningofthePatient
Dorsallithotomypositioninpaddedstirrupsispreferredtotransvaginal approachfortherepairofarectovaginalfistula.Ifthepatientisobese,a widesilktapeisusedtoassistinspreadingthebuttocksandexposingthe perineum.Abladdercatheterisinserted.Povidonepreparationofthe operativefieldincludingvaginalandrectalorificesisundertaken(Figs.
12-1and12-2).
FIGURE12-1Dorsallithotomypositionbuttockstaped
apart(tapenotvisible).
FIGURE12-2Rectovaginalfistula—low,small.
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OperativeTechnique
Examinationunderanesthesiaisthenperformedwithheadlight illuminationusingaSawyerretractor(Fig.12-3)inthevaginalvault.The vaginalmucosaldefectisidentifiedandthetractdemonstratedwith fistulaprobesinsertedtoidentifytheinternalopeningintherectum.A FansslerorChelsea—Eatonanalretractoristheninsertedintotheanal canaltoidentifytherectalmucosaldefectwithattentionastothelocation oftheinternalopeningreferabletothedentatelineaswellastothe conditionofthemucosa(presenceorabsenceofinflammation).ALone Starretractoristhenassembledandusedtoretractthevaginalintroitus (Fig.12-4)afterwhichtheSawyerretractorisreinserted.
FIGURE12-3Rectovaginalfistulaintubatedwithlacrimal
ductprobe.
FIGURE12-4LoneStarretractorandIntestinasizer.
Alocalanesthetic(1%lidocaineand0.25%bupivicainewith1% epinephrine)isinfiltratedinthevaginalmucosaandwall(Figs.12-5and
12-6).Removaloftheepitheliumofthefistulabut,moreimportantlythe
scarencirclingthefistulaobliteratesthelayersofthetissueofthevagina andrectum.Thescarshouldbeexcised,releasingthecontractionofthe layersandfacilitatesallowingidentificationofthediscretelayerstobe repaired.Placementofanintestinalsizerintheanalcanalprovidesanen faceviewofthefistula(Figs.12-7and12-8).Thesizeralsoactsto stabilizethesofttissuesforexcisioninaperpendicularplane.Oneshould anticipatethatthedefect,previouslycontractedbythescar,willenlarge. Suchreleasehowever....Thisisagainessentialforthelayersofthewall oftherespectiveorganstoseparateandthusbeidentifiedforrepair.
FIGURE12-5Raytecsponge—probeinsertedthenplace
transanally,digitalpressure—presentsfistulaenface.
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FIGURE12-6Injectlocalwithepinephrine.
FIGURE12-7Fistulaintubatedwithlacrimalductprobe
placedthroughsponge.
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