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39137 Management of Rectovaginal Fistula
Transvaginal Repair
Transvaginal (TV) approach is suitable for small
low RVF. The vaginal mucosa is incised around
the fistula ostium, and the fistula is closed with
sutures imbricating the soft tissue towards the
anorectum. The vaginal mucosa is then re-approximated. Rahman et al. [25] described their
results in 39 patients undergoing TV repair for
low RVF and reported a 100 % success rate with
this approach. This is a particularly appealing approach in patients with CD as dissection in the
diseased rectum can be avoided. Bauer et
reported their results for 13 patients with CD who
underwent repair of RVF by a TV approach. All
patients had a diverting intestinal stoma either as
part of the initial step in the staged management
of intractable perianal disease or concurrent with
the repair of the RVF. Each of the patients had
low or middle septal fistulas. Fistulas were eradicated in 12 of the 13 women and did not recur
during the follow-up period, which averaged
months (9–68 months).
50
al. [26
]
Fistulotomy
The use of fistulotomy to treat RVFs is associated
with a prohibitive rate of fecal incontinence and
is mentioned only to discourage its application.
Ligation of Intersphincteric Fistula Tract
A recently popularized surgical treatment for fistula in ano has been adapted to treat RVF. The
ligation of intersphincteric fistula tract (LIFT)
involves dissection in a bloodless plane between
the internal and external anal sphincters beyond
the fistula tract. The tract is then ligated and
closed on both the rectal and perianal side. The
intersphincteric dissection is then closed at the
skin. High success rates after LIFT treatment
of fistula in ano are encouraging (60–94 %) [27,
28], but experience with LIFT treatment of RVF
is still limited.
Biological Agents: Fibrin Glue and Fistula Plug
Although there have been various reports of
successful outcomes in treating anorectal fistulas with biological agents such as fibrin glue
[29] and fistula plug [30], the literature is lim-
ited to small series. In one small study, four of
five patients with RVFs treated with fibrin glue
were healed [31]. In different series of reports by
Loungnarath et
outcome in three patients treated with fibrin glue
for RVF. A commonly used type of bioprosthetic
fistula plug is made from porcine intestinal submucosa. It is placed through the RVF tract and
it is trimmed at both the rectal and vaginal ends
when it exceeds the length of the fistula. The
plug is then secured with absorbable sutures in a
figure-of-eight fashion on the rectal side and the
vaginal side is left open for drainage. Experience
with this technique in patients with RVFs is limited [33]. Trials that compare rectal mucosal flap
advancement to bioprosthetic plug placement for
the treatment of fistula in ano are ongoing [34].
Smaller studies show that bioprosthetic plugs are
more successful in the treatment of simple anorectal fistulas compared with the complicated
ones [35]. Recent modifications to the bioprosthetic to accommodate anatomic features of a
RVF may make this approach more successful
[36]; however, additional experience is needed
to determine the efficacy of bioprosthetics in the
use of RVF treatment.
] ,there was one successful
al. [32
Miscellaneous
The use of autologous stem cells to treat RVFs
[37], as well as circular stapler, which has only
been published in one case report, are other
two options to treat RVFs [38]. Furthermore
D’Ambrosio et al. [39] reported the first case series for the treatment of RVFs by transanal endoscopic microsurgery and Lamazza et al. [40]
suggested the use of endoscopic-covered stent to
treat patients with RVFs and fecal diversion.
Tissue Transfer Procedures
The purpose of tissue transfer procedures in patients with RVFs is to provide healthy, tension
free, well-vascularized tissue to support the repair. A multitude of tissue transfers are described
including the gracilis, rectus, gluteus, and bulbocavernosus muscles [41–45]. We describe the
two most widely used techniques.
392 D. Scoglio and A. Fichera
Gracilis Muscle Interposition Flap
The gracilis muscle is mobilized based on the
proximal major pedicle of the medial femoral circumflex artery after ligation of the distal
non-dominant vascular pedicle. A subcutaneous
tunnel is created between the thigh incision and
the perineum, and the distal end of the muscle is
tunneled under the skin to the perineal wound.
The gracilis is interposed between the rectum and
vagina without tension after the fistula is closed.
The proximal end of the muscle is tunneled between the rectum and vagina and tacked 3 cm
above the suture lines of both the rectal and vaginal defects and down to the opening of the perineal wound. Meticulous hemostasis is achieved.
The thigh and perineal wounds are closed primarily after placing drains. The gracilis muscle
is an excellent option,because it is a functionally
rudimentary muscle, and thus expendable without noticeable functional deficits. Furthermore,
it is easily mobilized with adequate length, and
has a dominant vascular pedicle proximally that
is convenient for perineal transposition allowing
transfer of the distal end to the upper RVS without tension on its vascular pedicle. Several studies have shown high success rates as when the
gracilis is used to close RVFs [41, 46, 47].
Zmoraet al. [41] reported their experience with
gracilis muscle interposition. The authors included five patients with a RVF and one patient with
a pouch-vaginal fistula who underwent this repair with favorable results. All patients had fecal
diversion as a step preliminary to or concurrent
with fistula repair. Five of the six repairs healed
completely after the reversal of the fecal diversion. One patient with severe crohn’sproctitis
failed and had a persistent RVF.
Martius Flap
The principles of repair involve transposing a
pedicle graft harvested from the labia majora
through a subcutaneous tunnel [48]. The graft
overlies the rectal closure and separates the rectal
and vaginal walls, filling in the dead space and
stimulating tissue growth and healing. Patients
with uncontrolled perineal sepsis or severe fecal
soiling should undergo fecal diversion. Repair of
the fistula should not be attempted until perineal
sepsis and inflammation resolves. A vertical incision is made in the perineum or in the posterior
vaginal wall (Fig. 37.4) and is carried out to the
inferior margin of the fistula. Local anesthetic is
injected into the RVS for hemostasis and tissue
dissection. The posterior vaginal wall is sharply
mobilized from the rectum. Wide mobilization
of the rectum and vagina is necessary so that a
multilayer closure can be performed, and reapproximation of the tissue surfaces can occur
without any tension. Local anesthetic is injected
into the labia majora. A vertical incision is made
in the labia majora to expose the bulbocavernosus fat pad. The borders of dissection include the
labial crural fold laterally, the labia minora and
the bulbocavernosus muscle medially, and the
Colles’ fascia covering the urogenital diaphragm
posteriorly. A flap harvest is accomplished in a
lateral to medial fashion. For RVF repair, the
blood supply to the graft is based on the posterior vessels, which includes the perineal branch
of the pudendal artery. The entire thickness of the
fibro adipose flap is included in a small Penrose
drain. Gentle downward traction is applied to aid
in the dissection. The graft is transected superiorly. The operator should not divide the pedicle
graft until it has been determined that adequate
length has been developed. A hemostat is then
used to transfer the fibro adipose pad from the
harvest site, through the tunnel, to the level of the
fistula repair. It’s very important not to twist the
graft, and to ensure that it is properly oriented.
The fistula tract is excised. The vaginal wall is
re-approximated with reabsorbable sutures. This
should be a tension free repair. The rectal edges
are also freshened up and the rectal mucosa is approximated with absorbable sutures. The flap sits
between the rectum and the vagina. The sphincter
muscles are re-approximated. The flap is gently
sutured into position. Hemostasis is obtained, the
wound is irrigated, and the perineal skin is then
closed. A small drain is left to keep the wound
open. The labial skin is closed in two layers with
absorbable sutures. A Penrose drain is left at the
inferior border of the incision for drainage. Success rates range from 60 to 100 % [44, 45, 49–52].
Kin et al. [48] reported a series of five patients
with a mean age of 48.4 years (range 32–64).
39337 Management of Rectovaginal Fistula
Fig. 37.4 Martius flap technique. a Curved incision of
the posterior vaginal wall and suture of the fistula; vertical
incision in the labia majora to expose the bulbocavernosus
fat pad, b exposition of the fibro-adipose pad, c the pad is
Etiologies of the fistulas were: obstetric, iatrogenic (after hysterectomy), CD, cryptoglandular, and idiopathic. The patients had undergone
a mean of 2.6 (range 1–5) prior repairs. Of the
total of 13 prior attempted repairs, eight were advancement flaps, two were episio-proctotomies,
two were fistula plugs, and one was an interposition mesh graft. Three of the five had diverting
ileostomies prior to the Martius flap procedure;
one underwent diverting ileostomy at the time
of the Martius flap procedure. The time from the
first symptoms to the first attempted repair was
a mean of 14.4 months (range 2–31 months). All
repairs involved either sphincteroplasty or perineoplasty in addition to the flap repair. Mean
follow-up was 25.6 months (range 3–44). There
were no cases of wound complications, recur-
transferred from the harvest site, through the tunnel, to the
level of the fistula repair, d final suture of the vaginal wall
and the labia majora. (Courtesy of Dr. Daniele Scoglio)
rence, or functional complications such as dyspareunia. Three of the four patients who had
undergone diverting ileostomy have undergone
ileostomy reversal. Patients often have associated asymptomatic sphincter defects that should
be repaired at the time of fistula repair.
White et al. [44] performed 14 Martius procedures on 12 patients with radiation-induced
RVFs. Eleven patients had successful closure
of their fistulas with this procedure, and no operative complications occurred. Aartsen and Sindram [45] reported results in 20 patients with
radiation-induced RVF. In this study, nine procedures were done without and 14 procedures with
a Martius flap. After a mean follow-up of around
10 years, the success rate of fistula repair was 5
of 9 (55 %) and 13 of 14 (93 %), respectively.
394 D. Scoglio and A. Fichera
Abdominal Procedure
High RVFs are usually approached through an
abdominal procedure. There are several approaches, and this type of repair depends on the
location, etiology, and quality of the affected tissues. If the tissues surrounding the rectum and
vagina are minimally affected, dissection of the
RVS with simple closure of each fistula opening in several layers can be performed. The coloanal sleeve anastomosis procedure, described
by Parks et
the rectum below the fistula site with the mobilization of descending and sigmoid colon with a
coloanal anastomosis in the setting of a mucosectomy. The need for a mucosectomy is negated
with the advent of the double-stapled approach.
Nowacki [54] reported functionally good results
in 18 of 23 patients undergoing the procedure for
radiation-induced RVFs. In addition, Cooke and
Wellsted [55] reported a 93
patients. Another approach to dealing
radiation-induced RVF is the patch anastomosis
reported by Bricker and Johnston [56]. First described in five patients, the technique essentially
relies on the proximal part of the colon as a vascular pedicle graft, used as a patch to close the
rectal defect and to provide circumference to relieve any associated stricture. Supplying the area
with a sound, vascular sigmoid pedicle graft, improves the tissue vitality locally; it restores rectal function to a near normal pre-radiation level
and preserves the previously intact sphincter
muscles. Steichen et
using stapling devices with good results. The use
of laparoscopic approaches has been reported
only in a few case reports [58–60]. Schwenk et
al. [58] reported on a case in which laparoscopic
resection of a high RVF with primary intracorporeal anastomosis and an omental flap was performed with a good outcome. Kumaran et al. [60]
reported on a successful repair of a high RVF performed laparoscopically. However, further studies involving larger numbers are needed to state
conclusively that laparoscopic approaches are
safe and feasible.
al. [53
], involves the dissection of
% success rate in 55
with the
al. [57
] reported the repair
Transperineal Omental Flap
With the transperineal omental flap, the greater
omentum is first mobilized, beginning at the hepatic flexure and extending to the oral third of the
greater curvature of the stomach maintaining the
arterial arcade so that the omentum arterial supply is preserved. The second step is the transabdominal mobilization of the rectum and vagina.
If a simultaneous deep anterior rectal resection
is planned, the mobilization of the rectum is performed circularly in the typical manner. At the
level of the anterior peritoneal reflection, an incision is made and the rectovaginal space is opened
up. Ventral displacement of the vagina with a
vaginal manipulator may be helpful in facilitating the dissection in the correct plane. An excessive tension may lead to larger defects and should
be avoided. Then debridement of the fistula tracts
is performed. The wound edges are approximated
by interrupted absorbable sutures. When a rectal
resection is indicated, the level of the resection is
determined by the underlying pathology as well
as the location of the fistula. It is important to
avoid overlapping suture/staple lines that significantly increase the risk of recurrence.
A transrectal and/or transvaginalomental flap
reconstruction is then performed during the perianal part of operation. A horizontal perineal skin
incision is performed directly above the sphincter. Further dissection results in the opening of
the rectovaginal space from the perineal access as
well. The mobilized greater omentum is carefully
delivered in the space through the defect. Proper flap orientation is critical to assure excellent
vascularization of the flap. The omentum is then
secured to the subcutaneous tissue within the
neoperineum. Schloericke et al. [61] from Germany have described for the first time this technique and have reported a success rate of 100
at a median
of nine patients affected by low- or mid- RVFs.
Eight of the nine patients received were diverted.
Minor complications were observed in two patients such as prolonged postoperative ileus and
pulmonary complication. Delayed wound healing, urinary retention, and fecal impaction were
not observed. Major complications included an
follow-up of 22
months in
%
a group
39537 Management of Rectovaginal Fistula
anastomotic leak after low anterior resection that
was treated conservatively and a persistent fistula
repaired by a combined plug placement and mucosal advancement flap.
Perioperative Management
Wound Management and Perioperative
Complications
Complications following RVF surgery are generally similar to those following other anal procedures [62]. Primarily repair of RVFs is associated with a risk of local infection and subsequent
suture dehiscence resulting in persistence/recurrence of the fistula. Relevant postoperative complications include dyspareunia resulting from
vaginal stenosis due to scar formation [63]. It has
been reported in up to 25
tients [41, 64].
Postoperative Dietary Manipulation
Dietary postoperative management after complex RVF repair is the subject of ongoing controversy. It is the general belief that avoiding
the passage of stool through a fresh wound may
benefit the healing process. This particularly applies to cases, where a sphincter repair has been
performed. No definitive data on this topic are
currently available. The same is true for the role
of perioperative and/or postoperative antibiotic
use [29].
Fecal Diversion
While a diverting ostomy is rarely required in
the context of anal fistula surgery [65], the rate
is much higher in RVFs, although no definitive
studies are currently available. Fecal diversion
is beneficial in the presence of fecal soiling and
active inflammation. A stoma may already be in
place for the treatment of the primary pathology.
The social, physical, and psychological burden
on the patient resulting from local inflammation
and the amount of fecal discharge through the vagina is an important consideration.
% of sexually active pa
-
Conclusion
Various surgical procedures have been described
with variable results. Initially and most commonly, the RVFs are approached through the
perineum. The transperineal approach allows
simultaneous anal sphincter reconstruction. The
use of a mucosal advancement flap repair is appropriate for simple RVFs. Its success rate depends on the etiology of the fistula, with better
results in patients with obstetrical injuries than in
patients with inflammatory bowel disease or radiation induced fistulas. Higher failure rates have
been reported in patients who have undergone
two or more previous repairs. Closure can also be
achieved through the interposition of autologous
tissue (Martius flap, gracilis muscle) or biomaterials. An autologous tissue is predominantly used
in complex or recurrent fistulas. In high fistulas,
abdominal approaches are more commonly used.
Key Points to Avoid Complications
1. Timing of surgery. Operating on a patient with
active inflammation and undrained sepsis will
invariably lead to intraoperative bleeding and
postop infection resulting in failure of the re-
pair.
2. Mechanical bowel prep. Adequate intraop-
erative visualization is mandatory to properly
dissectin the right plane and achieve hemosta-
sis.
3. Proper position on the operating table. If ap-
proaching the patient from the rectal-site-
prone jackknife position is critical, likewise
if approaching through the vagina, the patient
should be in lithotomy position.
4. Meticulous hemostasis during the dissection
and when leaving the operating room. He-
matomas will invariably lead to failure of the
flap.
5. Consulting with the appropriate specialists to
assist you in the procedure (i.e.,gynecology,
plastic surgery, reconstructive urology, etc.).
396 D. Scoglio and A. Fichera
Key Points on Diagnosis and/or Managing Complications
1. Increasing pain following the surgery should
prompt an examination under anesthesia with
the drainage of the hematoma and/or sepsis.
2. Pelvic magnetic resonance imaging (MRI)
will aid in diagnosing a problem, but it should
be considered only complementary to surgical
intervention.
3. Consider fecal diversion to limit sepsis and
further disruption of the repair.
4. In the presence of postoperative perianal sepsis, a broad-spectrum antibiotics should be
considered.
5. In the presence of septic postoperative complication, adequate debridement, management
of associated comorbidities (i.e.,Crohn’s disease), nutritional support, and consideration
for fecal diversion are all effective strategies
to optimize timing of further surgery for a definitive repair.
Conflict of Interest The authors declare no conflict of interest.No funds, grants or support was
received to complete the study.
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Management of Presacral/ Pelvic Bleeding
Sanket Srinivasa and Andrew G. Hill
38
Introduction
Presacral or pelvic bleeding is a rare but potentially catastrophic intraoperative surgical emergency, which may be encountered during rectal
dissection. It is characterised by high-volume
bleeding, which is difficult to control with conventional means and can lead rapidly to hypovolaemic shock and death. The reported incidence
varies from 4.6 to 9.4 % in open surgery, and it
is likely that the incidence is equivalent during
laparoscopic and robotic resection [1, 2]. Even
in high-volume institutions, this incidence may
equate to an individual surgeon dealing with
significant pelvic bleeding as infrequently as
once every year. The uncommon nature of this
problem, however, makes it imperative that all
surgeons who operate in the pelvis, particularly
those who may not do so regularly, understand
the basis, significance and prompt management
of this problem and formulate an individualised
plan in line with personal preference and availability of necessary aids within their institution
(Fig. 38.1).
A. G. Hill () · S. Srinivasa
Middlemore Hospital, Department of Surgery,
University of Auckland, Auckland, New Zealand
e-mail: ahill@middlemore.co.nz
Anatomy
The vascular anatomy of the pelvis is variable.
Cadaveric studies have demonstrated inconsistent anatomical variations even when studying
relatively small samples [3]. Significant bleeding, however, occurs from either the presacral
venous plexus or the basivertebral veins. The
two are linked and provide a connection between
the inferior vena cava and the vertebral venous
system. Vascular injury results in pronounced
bleeding since the veins are part of an avalvular
system. The veins are intrinsically friable due to
their low-pressure, high-capacitance characteristics. Moreover, since patients are often in the
modified Lloyd-Davis position for access to the
pelvis, the distal presacral veins that are most
vulnerable to injury lie in the lowest position and
may have 2–3 times higher hydrostatic pressure
than the inferior vena cava [4]. During in vitro
experiments, the rate of bleeding from a vein
2–4 mm in diameter has been shown to be over
1 l/min [4].
The presacral venous plexus is formed by the
middle sacral, lateral sacral and communicating
veins and is the distal continuation of the anterior
branches of the external vertebral venous plexus.
The basivertebral veins penetrate sacral foramina
from S3 to S5 and penetrate through the spongiosa
of the sacral bone via a series of canals acting as
a venous sinus [4]. The intrasacral canal venous
plexus can be considered to be a terminal part of
the vertebral venous system, thereby explaining
the massive bleeding seen upon injury. Since the
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_38,
© Springer Science+Business Media New York 2015
399
400 S. Srinivasa and A. G. Hill
Fig. 38.1 Algorithm for management of presacral bleed-
ing. PSV presacral veins, BVV basivertebral veins, APC
argon plasma coagulation. Note that the techniques used
for BVV bleeding can also be used for PSV bleeding
adventitia of the veins is blended to sacral periosteum at the foraminal opening, when the veins
are lacerated during dissection, they retract into
the sacral foramen. The basivertebral veins end
in the presacral venous plexus anteriorly.
Patterns of Injury
As mentioned above, the key anatomical structures that contribute to significant bleeding lie
posteriorly in the pelvis. Thus, a breach in the
presacral fascia increases the risk of injury to venous structures with consequent bleeding. Therefore, although anterior rectal mobilisation can be
more technically challenging, the risk of bleeding
is greatest during posterior rectal dissection.
An oncologically sound operation requires
dissection between the fascia propria of the rectum and the presacral fascia to ensure a total
mesorectal excision (TME) [5]. However, this
can be difficult for a number of reasons. It can
be difficult to visualise the correct anatomical
plane in patients who have had preoperative radiation or previous pelvic surgery with secondary adhesions. Recurrent or advanced malignancy can pose similar problems. Obese patients
or those with a narrow pelvis can pose difficulties in achieving optimal access. Moreover, for
surgeons beginning to perform laparoscopic or
robotic TME, the learning curve may also lead
to inaccuracies in dissection. A higher rate of
intraoperative bleeding has been demonstrated
in the context of laparoscopic colonic resection,
and previous reports have also suggested that
surgeon’s inexperience may contribute to an increased risk of pelvic bleeding [2, 6].
Qinyao et al. have demonstrated the patterns
of injury encountered during rectal dissection [4].
This includes the now largely abandoned practice
of blunt mobilisation of the rectum posteriorly.
Other reasons include laceration of the presacral
fascia or clamping bleeding vessels on the presacral fascia and avulsing them with or without
periosteum. The authors make a specific distinction between injury to the presacral venous plexus or to basivertebral veins [4].
It is important to acknowledge that increasing surgical intervention for advanced or locally
recurrent pelvic malignancies has led to more
radical and en bloc, non-anatomical resections.
These operations are of longer duration and are
characterised by greater blood loss in general and
resections including sacrectomy, or pelvic sidewall dissections may involve high-volume, brisk
bleeding due to non-traditional patterns of injury
[7]. Nonetheless, the principles of management
remain the same.
Management
The likelihood of encountering significant pelvic
bleeding is highest in a patient with numerous
unfavourable characteristics (obese, narrow pelvis, advanced malignancy). Thus, the operation
is likely to be difficult to begin with, and it is
likely that by the time bleeding is encountered,
the surgeon may already be physically tired and