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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_953_Библиотеки_им_академика_М_И_Перельмана.pdf
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FIGURE13-1A.Vaginalincisionismadeatthelevelof
theRVFalongthemidlinelongitudinalaxisoftheposterior vaginalwall.B.Vaginalwallisdissectedfromtherectum,the internalopeningintherectumisexcised,andthedefect closedtransverselywithinterrupted3/0Vicrylsuture (Ethicon).C.Thevaginalwallisclosedlongitudinallywith interrupted2/0Vicrylsuture.
TechniqueofVaginalAdvancementFlap
Thistechniqueiscloselysimilartothepreviouslydescribedtechnique. Theonlydifferenceisthecreationofavaginalflaptoclosethedefectwith somehealthyvaginaltissue.
Thistransvaginalapproachwithflapisatechniqueespeciallyusedin patientswithCrohn’srelatedfistulaforwhichtheuseofnondiseased, soft,andpliabletissuescanbeinteresting.Thistechniquemayalsobea goodsurgicaloptioninpatientswithassociatedanorectalstenosisor afterafailedpreviousRVFtransanalrepair.
Anincisionintheposteriorvaginalwallneartheintroituscanbeused
toobtainaU-shapedflapthatisraisedlaterallytotheischialtuberosities toprovideadequatemobility(Fig.13-2).
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FIGURE13-2A.Anincisionintheposteriorvaginalwall
neartheintroitusismadetoobtainvaginalwall’sU-shaped flap.B.Theflapisraisedtoprovideadequatemobilityandcut closetotheintroitus.C.Thevaginalflapisadvancedoverthe repairandsutured(3/0absorbablesuture)inplace.
Therectalandvaginalorificesofthefistulaareidentifiedandrepaired withabsorbablesutures(3/0Vicryl).Forsomesurgeons,thelevatorani muscleisalsoapproximatedinthemidlinewith2/0Vicryl.Thetipofthe vaginalflapisadvancedovertherepairandsutured(3/0absorbable suture)inplace.
POSTOPERATIVEMANAGEMENT
Thepatientismobilizedandallowedtoeatanddrinkfromday0, althoughthebladdercatheterisnotremovedbeforepostoperativeday3.
Thereisnoconsensusconcerningtheneedforsystematic postoperativeantibioticprophylaxisduringafewdaysafteroperation.In ourexperience,onlyintraoperativeantibioticsareadministered.

COMPLICATIONS

Hematomaformation,woundbreakdown,andrecurrencearethemost commoncomplicationsafterRVFtransvaginalrepair.Stricthemostasis andavoidanceoftractiononthetissues,atleastinpart,minimizesthese risks.
Incaseofpostoperativehematomawithorwithoutsepsis,examination undergeneralanesthesiacansometimesbeproposedtocleanthedefect toimprovelocalhealing,evenifRVFrecurs.However,noattemptof resuturingRVFisperformedatthistimeevenifarecurrentRVFis observed.
Mostofthetime,recurrenceoftheRVFisrapidlyobservedafterthe operation,duringthefirstfewweeksaftersurgery.Inthiscase,andifno sepsisisobserved,itiswisetowaitatleast8–10weeksbeforediscussing reoperation.Patientsreoperatedwithin3monthshavealowerhealing rate.
Reoperationafterthefailureofprevioustransvaginalrepairmay includeeitheranotherlocaltransanalrepair,orifalreadypreviously done,atemporarystomafollowedbyeitheratransanalortransvaginal repair.Followingtwofailures,gracilismuscleinterpositionispreferred.

RESULTS

AnRVFisconsideredhealedifthepatientisnotsymptomaticanylonger. Veryfewstudieshavebeenspecificallydevotedtotheseoperations. Furthermore,mostofthesestudiesincludedsmallnumbersofpatients.
DirectRVFClosure
Among14patientsoperatedforileovaginalfistulacomplicatingileal pouch-analanastomosisforulcerativecolitis,Burkeetal.reporteda43% successrateafteroneattemptanda79%generalsuccessrateaftertwoto threeattempts.
VaginalAdvancementFlaps
Asshownbyarecentsystematicreviewoftheliteratureperformedby Göttgensetal.,includingatotalof41patientstreatedwithvaginal advancementflap,resultswidelyvariedwithclosureratesbetween0% and93%.Theoverallsuccessrateofthevaginaladvancementflapwas 55%among41patients(Table13-1).Intheauthors’experience,including Crohn’sdiseaseandnon-Crohn’sdiseasepatients,thehealingratewas only10%.Definitionofhealingandfollow-upvariedconsiderablyinthe reportedpapers.
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TABLE13-1
RecentReportedSeriesofTransvaginalApproachWithoutMeshInterpositionfortheTreatmentof
RectovaginalFistula
Author
Yearof
publication
No.of
patients
Typeof
study
Follow-up
(mo)
Healing
rate(%)
Disease
cause
Radclife 1988 4 Retrospective Unclear 50 CD
Sher 1991 14 Retrospective 55 93 CD
Wise 1991 40 Retrospective Unclear 95 T
O’Leary 1998 1 Retrospective 38 0 CD
Windsor 2000 4 Retrospective 30 75 CD
Penninckx 2001 13 Retrospective 40 54 CD
Queralto 2012 5 Retrospective 30 60 CD
Total 41 55
CD,Crohn’sdisease;T,traumatic/obstetric/iatrogenic.
InalargeseriesofRVF,Perezetal.fromClevelandClinicFlorida reporteda60%rateofsuccessforallproceduresperformedby transvaginalapproach.
Finally,Ruffoloetal.intheirsystematicreviewonadvancementflaps forRVFinCrohn’sdiseaseshowedthattheprimaryfistulaclosurerate was69%aftervaginaladvancementflapandthattherewasnosignificant differenceintermsofrecurrencebetweenrectaladvancementflapand vaginaladvancementflapforRVFinCrohn’sdisease.

CONCLUSIONS

TransvaginalapproachcanbeproposedforthetreatmentofRVFas eitherdirectclosureorvaginalflapadvancement.Veryfewstudiesare availableconcerningthesetechniques,andreportedhealingratesvaried considerablyfrom0%to90%,makingcomparisonsbetweendifferent techniquesofRVFrepairverydifficult.Thelargestseriesreported40– 60%healingrates,makingthisapproachapossiblealternativeto transanalapproachfortheprimarysurgicaltreatmentofRVF.
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