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Vaginal Injury During Stapled Anastomosis
Feza H. Remzi and Volkan Ozben
36
Introduction
We have witnessed the evolution of the stapler
technology in the field of colorectal surgery
within the last three decades. Improvements in
technical innovations have allowed the surgeons
to be able to create easier and safer stapled ultralow colorectal (CRA), coloanal (CAA) and
ileal-pouch anal anastomosis (IPAA). However,
our innovative spirit of pushing the limits of low
pelvic anastomosis on behalf of our patients has
inevitably brought some complications with it.
Vaginal injury during stapled anastomosis is a
rare, but devastating complication which can result in severe consequences if it is not recognized
and appropriately addressed at the time of surgery. The most common reasons for this complication are patient related factors such as narrow
pelvis or reoperative pelvic surgery and more
importantly lack of familiarity or respect for the
pelvic anatomy and dissection by surgeons. In
this chapter, we will share our experience on how
to avoid vaginal injury, and when it happens how
to fix this humbling and difficult complication.
F. H. Remzi ()
Department of Colorectal Surgery, Digestive Disease
Institute, Cleveland Clinic, 9500 Euclid Avenue, 30,
Cleveland, OH 44195, USA
e-mail: remzif@ccf.org
V. Ozben
Digestive Disease Institute, Cleveland Clinic,
Cleveland, OH, USA
How to Avoid Vaginal Injury
Anatomically, vaginal injury during stapled anastomosis can be classified as high level that involves the proximal two-third and low level that
involves the distal one-third of the vagina. The
most common reason for high level vaginal injury is unintentional incorporation of the vagina
into the stapled CRA or CAA due to inadequate
dissection/mobilization of the rectovaginal septum. Therefore, it is important to dissect at least
2 cm or so in the rectovaginal septum below the
level of the planned anastomosis.
During ultra-low stapled CRA, CAA or IPAA,
the lower third of the vagina can iatrogenically
be injured. A stapled ultra-low CRA/CAA or
IPAA can be constructed using either a doubleor a single-stapled technique. When technically
feasible, double-stapled anastomosis is the preferred technique in our practice. When a stapled
anastomosis is intended, we mark the level of
the planned anastomosis by performing a digital
rectal examination with the proximal interphalangeal joint resting at the anal verge and the tip
of the digit corresponding to the anorectal ring.
This maneuver, as shown in Fig. 36.1, helps us
to identify where to place the linear stapler device for double-stapled anastomosis or pursestring sutures for single-stapled anastomosis.
Also, bimanual examination (one finger placed
in the anal canal and the other in the abdomen)
can guide and orient us to the tumor location and
the corresponding distal line of transection in patients undergoing ultra-low stapled CRA/CAA
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_36,
© Springer Science+Business Media New York 2015
381
382 F. H. Remzi and V. Ozben
Fig. 36.1 Demonstration of the digital rectal examina-
tion. The tip of the finger corresponds to the anorectal
ring where the linear stapler is placed for double-stapled
anastomosis or purse-string sutured applied for single-stapled anastomosis. (Reprinted with permission, Cleveland
Clinic Center for Medical Art & Photography © 2014. All
rights reserved)
for rectal neoplasia. The double-stapled technique obviates the frustration of inserting pursestring sutures in the anorectum deep in the pelvis.
The disparity of the size of the bowel lumen is
also avoided. Double-stapled anastomosis is then
performed using a stapler, which removes an additional 1 cm of the distal ring. This 1 cm of distal
ring is the area of concern, where the vaginal wall
can accidentally get incorporated into the staple
line. For this reason, after inserting the circular
stapler into the anorectal stump, it is important to
advance the shaft of the stapler in a way that the
trocar traverses posterior to the staple line. This
can be facilitated by putting the index finger into
the anorectal staple line area from the abdominal
side and guiding the trocar just posterior to the
staple line on the anorectal stump (Fig. 36.2).
Another maneuver to avoid vaginal injury
is the retraction of the vagina anteriorly with
lighted deep pelvic retractors. This helps prevent
the redundant posterior vaginal wall from being
accidentally incorporated within the staple line
Fig. 36.2 In the double-stapled anastomosis, the trocar
of the stapler should traverse just posterior to the staple
line. This can be facilitated by putting the index finger
from the abdominal side and guiding the trocar posterior
to the staple line. (Reprinted with permission, Cleveland
Clinic Center for Medical Art & Photography © 2014. All
rights reserved)
38336 Vaginal Injury During Stapled Anastomosis
Fig. 36.3 Incorporation of the redundant posterior
vaginal wall within the staple line during double-stapled
anastomosis (this complication can be prevented by anterior retraction of the vagina with deep pelvic retractors).
(Reprinted with permission, Cleveland Clinic Center for
Medical Art & Photography © 2014. All rights reserved)
(Fig. 36.3). In addition to these, vaginal bougies
and/or obturators inserted via the perineal approach can delineate the anatomy, facilitate pelvic dissection and to avoid this complication in
reoperative pelvic surgery.
How to Fix Vaginal Injury
Most of the time, a high-level vaginal injury is
related to the inadequate anterior mobilization
of the rectum. Normally, rectal mobilization requires a minimum of 2 cm anterior dissection
below the level of planned anastomosis. Once
this complication happens, the surgeon should
take a pause and get a proper assistance. To fix
the problem, complete exposure of the operative
area should first be obtained even if this requires
Fig. 36.4 A high-level vaginal injury due to inadequate
mobilization of the rectum. In this circumstance, before
disconnecting the anastomosis, the rectum should be fully
mobilized posteriorly, laterally, and then anteriorly below
the level of injury. (Reprinted with permission, Cleveland
Clinic Center for Medical Art & Photography © 2014. All
rights reserved)
a conversion of a laparoscopic case to a full laparotomy. It would not be wise to tackle the area
of injury first even though it seems tempting for
the surgeon. The surgeon needs to strategize the
operative plan. In this case, the vaginal injury
has occurred due to inadequate rectal mobilization. Therefore, it is critical to fully mobilize
the rectum and further separate the rectovaginal
septum lower than the level of injury. In order to
accomplish this, the rectum should first be further mobilized posteriorly and laterally and then
the dissection should be continued to the anterior
side below the level of injury (Fig. 36.4). Only
then it is proper to disconnect the anastomosis,
where the vaginal injury has occurred. Attempting to disconnect the anastomosis prematurely
without full posterolateral and anterior rectal
mobilization lower than the area of injury can
further complicate the situation. This technique
minimizes the risk of further injury and/or enlarging vaginal defect by identifying the proper
tissue planes. Furthermore, it may also enable
384 F. H. Remzi and V. Ozben
Fig. 36.5 For a single-stapled anastomosis, after the cre-
ation of a small proctotomy at the anterior rectal wall and
placement of stay sutures, a purse-string is applied to the
the surgeon to do a second attempt of a double-stapled anastomosis. If a second attempt of
double-stapled anastomosis is not a possibility,
then a single-stapled anastomosis remains a very
good option as seen in Fig. 36.5. For this, after
identifying the vagina and separating it off the
anastomosis, a small proctotomy is made at the
anterior wall and stay sutures are placed. Starting from the anterior wall, a purse-string suture
is applied circumstantially around the anorectal
stump by hand and tied down over the trocar, and
then the gastrointestinal continuity is established
by creating a single-stapled anastomosis. If the
omentum is present, omental pedicle flap can be
used to patch the vaginal site following its primary repair.
In the presence of low-level vaginal injury,
however, the problem should be addressed with
a perineal approach since it can be extremely difficult to handle the problem from the abdominal
side. In the perineal approach, the anal verge is
everted with radially placed sutures at four quadrants as a first step to facilitate exposure. Then, a
small- or a medium-sized lighted anal retractor
is placed into the anal canal, the anastomosis is
anorectal stump and tied down over the trocar. (Reprinted
with permission, Cleveland Clinic Center for Medical Art
& Photography © 2014. All rights reserved)
taken down and separated from the vagina. Unless clinically indicated, there is no need to do a
mucosectomy since this may further complicate
the problem with reach issues and tension on the
anastomosis itself. After the completion of the
transperineal repair of the posterior vaginal wall,
we suggest performing a hand-sewn ultra-low
CAA or IPAA to the anal transitional zone.
Although it is important to repair this disastrous complication, it is also necessary for a surgeon to be able to recognize it at the time of the
original surgery. For this reason, examination of
the doughnuts for its intactness after the completion of anastomosis is very important. This also
needs to be complimented by checking the integrity of anastomosis with air insufflation test. If
there is any concern that the vagina is incorporated into the staple line, we strongly suggest taking
down and re-doing the anastomosis as explained
above. This complication is better avoided, and
if it occurs, fixed at the time of original surgery
rather than at a later date.
If the vaginal injury is not recognized at
the time of original surgery and it presents itself within the postoperative 7–10 days, our
38536 Vaginal Injury During Stapled Anastomosis
recommendation is to take the patient back to the
operating room. We suggest repairing the vaginal
injury and creating a proximal diverting ileostomy if it was not previously performed. However,
if the complication presents after 10–14 days,
we suggest creating a diverting ileostomy alone
since any attempt to repair this complication in
the presence of severe adhesions and inflammation would be futile and may potentially cause the
patient to end up with a permanent stoma. Therefore, after a clear, transparent, and fair communication with the patient, surgical repair of this
pathology can be performed 6 months after the
initial operation.
Sometimes it requires certain surgical dexterity and skills to handle this complication. This
may be the case either at the time of initial surgery or in delayed presentations. It is more than
acceptable in these circumstances to receive
more subspecialized help if it is available. If not,
it would be wise to retreat and refer the patient
for a more definitive repair 6
initial laparotomy
is to know when to retreat which is a sign of maturity and is not a sign of weakness!
In summary, vaginal injury during stapled
anastomosis is a rare and potentially a devastating complication if it is not recognized and addressed properly. This can happen to any surgeon
in their career. The aforementioned techniques
and tips may avoid this pathology and help surgeons repair it appropriately when it occurs.
. Our teaching in our institution
months after the
Key Points on How to Avoid Vaginal Injury
1. Adequate dissection of the rectovaginal septum below the level of planned anastomosis
2. Advancement of the stapler in the anorectum
under the guidance of the index finger
3. Extrusion of the trocar of the circular stapler
posterior to the staple line
4. Anterior retraction of the vagina with lighted
deep pelvic retractors during anastomosis
5. Use of vaginal bougies or obturators to delineate the anatomy and dissection in reoperative
surgery
Key Points on How to Diagnose
andManage Vaginal Injury
1. Examination of the doughnuts for intactness
and/or checking the integrity of anastomosis
2. Complete exposure of the operative area and
circumferential mobilization of the rectum
below the level of injury
3. Redo double-stapled anastomosis (if not possible, creation of a single-stapled anastomosis)
4. Transperineal repair of the vagina and handsewn ultra-low anastomosis in the presence of
low-level injury
5. Tailoring surgical repair according to the time
of its clinical presentation
Management of Rectovaginal Fistula
Daniele Scoglio and Alessandro Fichera
37
Introduction
A rectovaginal fistula (RVF) is defined as an abnormal epithelial-lined connection between the
rectum and vagina. It represents a debilitating
condition for patients and a challenge for surgeons. Successful management of RVFs must
take into account a variety of variables including the etiology, size, location of the fistula, and
patient’s comorbidities. RVFs are caused by a
variety of conditions, including obstetric injury,
cryptoglandular infection, inflammatory bowel
disease, rectal or vaginal surgery, radiation, neoplasia, or trauma [1].
Patients with RVFs typically present with
complaints of passage of flatus or feces from the
vagina. Recurrent urinary tract infections and
vaginitis with malodorous vaginal discharge may
also be the presenting complaint.
RVFs most commonly communicate with the
posterior vaginal wall. Classification of the fistula
helps to determine the appropriate therapy. Based
on the size, fistulas less than 2.5 cm in diameter
are considered small; those greater than 2.5 cm
are described as large. In addition, fistulas can be
classified as low, middle, or high on the basis of
their location. Fistulas that are in close proximity
to the posterior vaginal fourchette are considered
A. Fichera () · D. Scoglio
Department of Surgery, University of Washington Medical Center, 1959 NE Pacific St, Box 356410, Seattle, WA
98195, USA
e-mail: afichera@uw.edu
low. High fistulas are in proximity to the cervix,
and those that occur in between the cervix and
fourchette are considered middle RVFs. The fistulas that develop distal to the dentate line are referred as anovaginal fistulas (Fig. 37.1).
Examination under anesthesia is critical to
locate the fistula, assess the quality of surrounding tissue and the presence of associated pathology, with high fistulas being the most difficult to
diagnose. A palpable depression in the anterior
midline of the rectum, or a visible pit like defect
could be the only appreciable sign if the fistula is
small. These changes may be palpable or visible
on anoscopy. On vaginal examination, the darker
mucosa in the fistula track may be apparent, contrasting with the light vaginal mucosa [2]. There
may be visible stool or signs of vaginitis. Probing
the tract is very painful and should only be done
under anesthesia to avoid creating false tracts. An
assessment of anal sphincter integrity and function will assist in surgical planning. This may
be attainable with a good history and physical
examination; however, some women may have
difficulty in distinguishing incontinence from
fistulous drainage. Incontinence may be caused
by the fistula, an underlying disease state, or anal
sphincter defect. Determining the cause of incontinence is important prior to operative intervention for a RVF [3, 4]. Supplemental studies may
be necessary to confirm the presence of a fistula
or to determine the extent of underlying disease.
Endorectal and transvaginal ultrasounds may
be used to identify a low fistula tract [5, 6]. Alternatively, a vaginal tampon can be inserted
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_37,
© Springer Science+Business Media New York 2015
387
388 D. Scoglio and A. Fichera
Fig. 37.1 Rectovaginal fistula sites. a Low, b mid,
c high. (Modified from: http://en.wikipedia.org/wiki/
File:Rectovestibular_fistula_in_females.jpg by adding
arrows, letters, and a legend. Under creative commons attribution 2.0 generic license, we are free to modify it:This
is an open access article distributed under the terms of the
creative commons attribution license (http://creativecommons.org/licenses/by/2.0), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited)
followed by instillation of a methylene blue
enema. The tampon is removed after retaining
the enema for 15–20 min. If there is no staining, the diagnosis of RVFs is highly unlikely.
More proximal fistulas are best diagnosed with
vaginography, a barium enema or computed
tomography(CT)-scan with rectal contrast. An
endoscopy is necessary if inflammatory bowel
disease is suspected. Biopsies under anesthesia
are useful in patients with history of prior radiation to rule out malignancy. Manometry may be
used to determine functional sphincter defects in
the absence of an anatomic defect. Patients with
fistulas arising as a result of an obstetrical injury should be routinely evaluated for anatomic
sphincter defects. Rectal surgery has often been
associated with RVFs. Iatrogenic fistulas are reported in up to 10 % of low rectal anastomoses
[7, 8]. A risk factor appears to be the use of double stapling technique [7, 9, 10]. The use of preor postoperative external beam radiation plays a
role in fistula development and impairs healing
[11].
A spontaneous healing is very rare with the
exception of Crohn’s disease (CD) more recently
with the use of anti-tumor necrosis factor (TNF)
therapy, and surgical treatment is usually indicated due to the impact on the quality of life. The
choice of the surgical approach is controversial
and the results of surgical approaches are highly
variable. Furthermore, the majority of published
data on RVF pertains to CD [12–16].
The surgical approaches available are numerous, and they vary based on the etiology, location, size, quality of the surrounding tissue, and
previous attempted repairs. Surgical approaches
can be classified as either local or transabdominal. Local repairs are most useful for low to
middle RVFs and include transanal, transvaginal,
and perineal approaches. Abdominal operations
are usually reserved for high RVFs and may incorporate laparoscopy. The use of healthy muscle
or vascularized tissue for transposition is often
recommended.
General Principles
Timing is an important part of the surgical decision-making process. In the face of infection
or inflammation, it is critical to allow resolution
prior to repair. Antibiotic therapy, anti-TNF, or
immunosuppressive medications (in case of CD)
play an important role in surgical optimization.
While a recommended period of 3–6 months
on medical therapy has been suggested, surgery
should proceed only when surrounding tissues
appear reasonably healthy. The use of fecal diversion in preparation to definitive repair or as
an adjunct to the repair is also highly controversial and often reserved for recurrent cases after
failed surgical treatment, in the presence of CD
or after radiation. Preoperatively, the patient undergoes mechanical bowel preparation and receives antibiotics. Procedures may be performed
under local anesthetic with sedation, but spinal or
general anesthesia is typically preferred. Patients
are positioned based on the approach: i.e., for a
vaginal approach the patient is placed in a lithotomy position versus prone jackknife position for
a transanal approach with exposure facilitated by
taping the buttocks or using a Lone Star retractor. The anal canal and vagina are prepared with
povidone-iodine solution and a urinary catheter
38937 Management of Rectovaginal Fistula
Fig. 37.2 Mucosal advancement flap technique. a A flap
is created that includes mucosa, submucosa, and muscular layer; b curettage and closure of the internal opening;
is placed. Patients who require abdominal procedures are placed in the lithotomy position.
Local Repair
Mucosal Advancement Flap Repair
Advancement flaps are the most popular transanal procedure among colorectal surgeons. Many
variations exist; however, the general principle
remains the same: excision and closure of the
the distal part of the flap including the rectal opening is
c
excited; d the flap is advanced
tension. (Courtesy of Dr. Daniele Scoglio)
to close the defect without
rectal portion of the fistula and coverage with a
vascularized mucosal flap on the high-pressure
side of the fistula. The tract is identified by palpation and probing. The fistula tract is debrided
and excised. A flap is created that includes mucosa, submucosa, and muscle placed over re-approximated rectovaginal septum (RVS). The flap
base should be at least 2–3 times the width of the
apex to ensure adequate vascular supply. The flap
mobilization should continue 4–5 cm cephalad to
the fistula defect. These principles ensure a tensionless suture line (Figs. 37.2 and 37.3). Success
390 D. Scoglio and A. Fichera
Fig. 37.3 Mucosal advancement flap; intraoperative pic-
ture.The well-vascularized broad-based flap covers the
anal opening of the rectovaginal fistula
rates vary from 41 to 96 % (Table 37.1) [3, 17–
22]. This wide discrepancy may be explained by
differences in technique as well as patient selection. Complications are minor and infectious/
ischemic in nature. In patients reporting associated incontinence, which is usually secondary to
injury to the sphincter mechanism, a sphincteroplasty can be concurrently performed; thus, both
correcting the underlying sphincter defect and
interposing vascularized muscle in the RVS and
perineum.
Endorectal Advancement Flap with Muscular Plication (Anterior Levatorplasty)
A similar approach is the advancement flap
with plication of the muscular layer. An anterior
transverse incision is made distal to the internal
opening extending to the submucosa, and a Ushaped flap consisting of mucosa and submucosa is prepared. The dissection is carried out
in a cephalad direction until the entire flap can
be easily advanced distally. The distal part of
the flap, including the internal opening, is then
excised. The remaining track is curetted and the
internal opening is closed with a figure-of-eight
stitch using a reabsorbable suture (3.0 Vicryl). A
transverse plication of the muscular layer, internal anal sphincter and/or rectal muscular layer
depending on the height of the fistula is made
using an absorbable running suture. Finally, the
mucosal–submucosal flap is advanced to cover
the muscular plication and closed without tension with interrupted absorbable. This approach
can be used to treat RVFs without an anal sphincter defect. The goal is to create a second layer
of well-vascularized tissue, incorporating healthy
tissue under the flap. With this technique, de Parades et al. [23] reported a success rate of 65 %.
Transanal Sleeve Advancement Flap
This technique was described for the first time by
Hull and Fazio in 1997 [24] to treat anovaginal
fistula in patients with mild Crohn’s proctitis. It
is an invasive procedure that involves mobilization and resection of the distal rectum. Re-anastomosis, usually via a transanal manual suture, is
performed following the removal of the fistulabearing area. The procedure is primarily used in
patients with significant rectal-wall defects due
to chronic inflammatory bowel disease or following radiation therapy. In their study, Hull and
Fazio performed five sleeve advancement flaps.
Three of the five patients had stomas for fecal
diversion. Two stomas were closed without recurrence and the third patient had a recurrence,
then a repeat sleeve advancement flap before a
successful stoma closure. Of the two patients
without fecal diversion, one went on to have a
total proctocolectomy.
Table 37.1 Various suc-
cess rates of rectovaginal
fistula repair from selected
series
Author Year Patients# Success (%)
Wise [17] 1991 34 96
Kodner [18] 1993 71 88
Ozuner [19] 1996 52 65
Tsang [3] 1998 27 41
Sonoda [20] 2002 37 43
Mizrahi [21] 2002 32 56
Ellis [22] 2007 39 59