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92
abc
Fig. 7.11 ( a – c) Simple fi stulotomy with primary repair
a
bc
F.Q . Parray
Fig. 7.12 ( a – d) Fistulotomy with perineoproctotomy with layered closure
prefer it because of avoiding the dissection in
diseased rectum and have reported excellent
results (Bauer et al. 1991 ).
previous transanal and transvaginal procedures
have failed. This procedure is again carried out in
lithotomy position under spinal anesthesia with a
catheter in. The fi stula tract and all tissue above it
7.6.2.3 Transperineal Approaches
are cut (Fig. 7.12a ). Fistula tract completely
excised and sent for histology. The rectal and
7.6.2.3.1 Simple Fistulotomy
This technique is best suited for anovaginal fi stula in which there is no involvement of sphincter. But if the same treatment is applied to RVFs,
it may result in fecal incontinence depending
upon the position of the fi stula (Fig. 7.11a–c ).
Most of the authors describe it only to discourage
its application in this disease entity.
vaginal mucosal layers are dissected away from
the sphincter muscle and the septum and repaired
as separate layers (Fig. 7.12b–d ).
The rectal wall can be strengthened by one
more layer of imbricating suture. The external
sphincter muscle should be repaired in an overlapping fashion after mobilizing the muscle from
its lateral attachments in ischiorectal fossa. This
avoids tension on repair and failure rates are
7.6.2.3.2 Fistulotomy with Perineoproctotomy with Layered Closure
This approach is ideally suited for women who
have a coexisting sphincter defect and where
markedly decreased. Success rates for this procedure are in the range of 85–100 % (Mazier et al.
1995 ; Pepe et al. 1987 ; Tancer et al. 1990 ; Watson
and Phillips 1995 ). This approach provides
excellent exposure and complete identifi cation of
7 Rectovaginal Fistulas
a
93
b
c
Fig. 7.13 ( a – d) Transsphincteric approach for RVF repair
fi stula and all its extensions. This surgery also
permits layer-wise closure of perineal body.
7.6.2.3.3 Perineal Repair with Levatoroplasty
Patient is placed in lithotomy position and catheterized. A transverse perineal incision is made
midway between the posterior fourchette and the
anus. The intact sphincter is identifi ed and preserved by passing a tape underneath it. The fi stula track is identifi ed and excised and sent for
histology. The vaginal defect as well as the anal
defect is closed. The levators are mobilized by
proximal dissection in the rectovaginal septum
and approximated across the midline as levatoroplasty. This acts as a buttress of healthy and vascularized tissue between vaginal and anal repair.
The perineal body is also reconstructed by resuturing the transverse perinei muscles, and the
skin is closed over the drain.
d
7.6.2.4 Transsphincteric Approach
This route is used more frequently for rectourethral fi stulas. It has not gained that much popularity in treating RVF. This approach is also known
by the name of Kraske or Mason approach. It is a
good approach for midzone fi stula 6–8 cm from
anal verge. Transanal route at this level invariably
fails to provide a good access. Transsphincteric
approach can however lead to incontinence if
there is already a preexisting anterior sphincter
defi ciency, and therefore, this approach should
be avoided in such patients (Kilpatrick and YorkMason
1969 ; Thompson et al. 1982 ).
The patient is catheterized and placed in prone
jackknife position with the buttocks strapped
apart. The incision is made in the posterior half
circumference of the rectum through the sphincters (Fig. 7.13a ). All the layers of the rectum are
cut and fi stula completely exposed and cut
(Fig. 7.13b ). The rectal muscle is separated from
94
F.Q . Parray
the rectovaginal septum and the vaginal defect is
closed. The rectal wall is used to close the residual defect after placating the septum. Posteriorly,
the incised layers like posterior rectal wall,
sphincters, and the skin are closed in separate
layers (Fig. 7.13c ).
7.6.2.5 Repair with Biological Agents
Biological agents like fi brin glue and Surgisis
have been used quite often in the treatment of
anal fi stulas with variable outcomes, but in RV
fi stulas, there are still very few reports about the
use of such biological agents (Schwander et al
2009 ). Some authors cite the reason that
biological agents work more effectively in long
tracks which is usually not true for RV fi stulas
where the tract is usually very short (Sklow
2007 ). Even some colorectal surgeons prefer to
use fi brin glue in persistent recurrent fi stulas to
avoid the morbidity of extensive surgeries and
some positive evidence from literature (Abel
et al. 1993 ), even though there are reports of the
use of fi brin glue endoscopically in some studies
(Lange et al. 1990 ; Shibata et al. 1999 ).
7.6.2.6 Tissue Transfer Procedures
Many tissue transfer techniques like the gracilis,
sartorius, rectus, gluteus, and bulbocavernosus
muscles and the omentum are used all over the
world by gynecologists, colorectal surgeons, and
plastic surgeons to deal with recurrent, diffi cult,
and postirradiated less vascularized areas. Usual
repairs are invariably doomed to failure in such
situations. The basic aim of these procedures is to
provide a well-vascularized and tension-free
healthy tissue in the area of repair.
7.6.2.6.1 Gracilis Transfer
The procedure may be performed by the already
defi ned transanal or transvaginal approach. In the
repair of a postradiation RVF, many will prefer
a transvaginal approach because of the fact that
vaginal tissues are less affected by radiation. In
these tissue transfers, one has to really take care
of the blood supply of the tissue to be transferred.
The blood supply of gracilis muscle is based on
the obturator artery and vein which are located at
a distance of 5–8 cm from the groin crease and
enter the muscle on its under surface. The muscle
has a long length and can be mobilized easily to
cover the defect of RVF. In lithotomy position,
a transperineal incision is made and dissection
carried out underneath vaginal mucosa. A few
transverse incisions are made on medial aspect
of the leg after marking the gracilis muscle; the
tendon of gracilis is identifi ed by its round tendon
and cut on a long transfi xing suture. The muscle
is released all around and tunneled in the subcutaneous tissue toward the perineum except the
fi rst 10 cm to preserve its blood supply. After the
fi stula is excised, the rectum is closed, and the
transferred gracilis is placed on the suture line
of closure site and anchored to opposite ischial
tuberosity (Hibbard 1978 ).
7.6.2.6.2 Martius Flap Repair
This type of repair is again tried by some surgeons to repair the RVF secondary to radiation.
This fl ap repair is also known by the name of bulbocavernosus muscle fl ap repair. This procedure
is carried out in lithotomy position. A transperineal incision is made, vaginal mucosa elevated,
and fi stula track dissected out. The rectal defect
is closed. A longitudinal incision is made in the
labia majora and dissection of the bulbocavernosus muscle and its adjacent labial fat pad is performed. The said muscle gets its blood supply
from the perineal branches of the pudendal artery.
The harvested fl ap is tunneled underneath the
vaginal mucosa and sutured to the rectal wall on
the repaired defect. Last of all, the defect in the
vaginal mucosa is closed (Fig.
7.14a, b ). For sav-
ing the fl ap from infection, many would recommend a covering stoma in conjunction with this
repair or other types of tissue transposition
(Martius 1956 ).
7.6.2.7 Transabdominal Approaches
Various approaches per abdomen have been
described in literature to deal with high, midzone,
and recurrent RV fi stula or fi stula secondary to
IBD, malignancy, or radiation.
7 Rectovaginal Fistulas
ab
95
Fig. 7.14 ( a , b ) Martius fl ap repair
7.6.2.8 Fistula Division
This is the simplest abdominal operation to deal
with RV fi stula provided the tissues surrounding
the rectum and vagina are healthy. In this surgery,
the rectovaginal septum is dissected and the fi stula is divided. The rectum and vagina thus separated are closed primarily without bowel
resection. Ideal is to interpose some healthy tissue like pedicled omentum between the two
repairs. The interposition of healthy tissue buttresses the repairs and decreases the chances of
recurrence. Good results have been reported
when fi stula is not large and the tissues to be
closed are healthy (Taylor
2013 ).
7.6.2.8.1 Coloanal Sleeve Reconstruction
This surgery is considered to be an ideal surgery
for recurrent, midzone or a fi stula as a result of
tissue loss in the rectovaginal septum (Cuthbertson
1986 ). The procedure was fi rst described by
Parks and colleagues (Parks et al. 1978 ). This
procedure involves a complete mobilization of
the descending colon, sigmoid colon, and rectum
and may be at times splenic fl exure after a laparotomy. The posterior rectal dissection is continued up to anorectal angle. The fi stula site is
dissected usually with a lot of diffi culty but preferably with a cuff of the vagina on the rectum.
Dissection is continued all around below the fi stula site, and the rectum is incised at anorectal
junction circumferentially. Then the rectal stump
is delivered per abdomen, and all the diseased
parts of the rectum are excised depending on the
site of fi stula. The perineal surgeon excises the
mucosa in the anorectal stump. The colon is then
delivered per anus and sutured to dentate line
using a standard perianal technique. Some surgeons prefer the use of stapled anastomosis without mucosectomy. It is always advisable to have a
covering stoma in these patients which can be
closed after 8–12 weeks after the anastomosis
has healed completely.
96
F.Q . Parray
7.6.2.8.2 Bricker Patch
This procedure has also been employed to repair
radiation-induced RVFs. In this procedure, a
laparotomy is performed, and the rectosigmoid
colon is mobilized, and RVF is exposed and
divided. The rectosigmoid is divided above the
fi stula. The proximal end is brought out as a
stoma. The distal end of rectosigmoid is turned
down, and the open end is anastamosed to the
rectal opening of fi stula, thus creating an internal loop draining through the anus. After couple
of months of rest to the distal loop, the healing is accelerated which should be established
radiologically. Then the colon continuity is
reestablished by anastamosing the disengaged
colostomy to the apex of patch loop in an end to
side fashion. Even though this procedure looks
less morbid than resectional approaches, but still
some surgeons will prefer to resect the radiation damage bowel for better long-term results
(Taylor 2013 ).
The biggest disadvantage of the procedure is
that postradiation bowel may develop bleeding
and stricture on follow-up.
7.6.2.8.3 Stoma
The option of only a diversion in the form of a
colostomy or an ileostomy might be a good
option in elderly patients with multiple comorbidities with postradiation RVFs. The diversion
of stool and gas will provide the patients a better
QOL.
7.7 Complications
7.7.1 Complications of Local Repairs
7.7.1.1 Bleeding
If it occurs underneath the fl ap, postoperative
infection followed by recurrence is usually seen.
Ideally to prevent this complication, go for a
meticulous hemostasis.
7.7.1.2 Infection
It is usually a dreadful complication and results
in a failed repair and a recurrence. A proper preoperative antibiotic therapy, intraoperative gentle
dissection, good hemostasis, postoperative antibiotic, and proper wound dressings will usually
decrease the incidence of infection.
7.7.1.3 Urinary Retention
Urinary retention usually may be associated
with any perineal surgeries. Pain is the other
causative factor for retention, so ideal would
be to remove the catheter, at least, after 48 h
and cover the patients with good postoperative
analgesia.
7.7.1.4 Recurrence
Some fi stula repairs in spite of all precautions are
bound to recur. However, an individualized
proper selection of the procedure will decrease
this complication markedly.
7.6.2.9 Laparoscopic Repair
Laparoscopic repair of RVF is still not a very
popular or a widely accepted technique, even
though at present we do get some of the reports of
successful repairs of high fi stulas laparoscopically (Parmar et al. 2013 ). At present, we agree
that laparoscopic repair of high RVF is feasible in
selected patients but would require proper identifi cation of tissue planes and good laparoscopic
suturing technique (Kumaran et al. 2005 ). This
technique will become more acceptable only
once larger studies are conducted to assess the
outcome of this technique.
7.7.2 Complications of Abdominal Repairs
7.7.2.1 Bleeding
Extensive dissection around the fi stula site may
result in intraoperative or postoperative bleeding.
This complication can be prevented by a meticulous hemostasis.
7.7.2.2 Infection
Infections in the form of wound infection and
pelvic sepsis may be seen in 5–7 % of patients.
7 Rectovaginal Fistulas
97
7.7.2.3 Enterocutaneous Fistula
It may result because of anastomotic leak and
grossly increase the morbidity.
7.7.2.4 Recurrence
Like all other repairs, abdominal repairs may also
fail in some patients and lead to recurrence.
Surgeons experience, proper patient selection,
and proper procedure selection will go a long
way to decrease the recurrence rates.
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http://emedicine. med-
Anorectal Injuries
Satish B. Dharap
8
8.1 Introduction
The anorectum being in continuity with the colon
and bearing similar contents is often treated like
the colon. However, the rectum is muscular, thick
walled, and more capacious. It is located deep
inside the pelvic cavity and is well protected by
the levator ani muscles, with the support of fat
cushions all around particularly in both ischiorectal fossae. These features make anorectal injuries less common. They are very rare following
blunt trauma as the muscular, capacious rectum
does not give way easily. Because of rich blood
supply from three sources and being the site of
portosystemic anastomosis, rectal tears can be
associated with considerable blood loss. There is
a risk of incontinence following anorectal injury
because of associated injuries to the complex
continence mechanism surrounding it.
In case of colonic injury, the treatment paradigm has shifted from mandatory diversion to
primary closure without diversion. Colostomy is
reserved for selected group of patients. However,
optimal management of anorectal injuries is still
a matter of dilemma and debate.
S. B. Dharap
Department of General Surgery, L.T.M. Medical
College & L.T.M. General Hospital ,
Dr. Babasaheb Ambedkar Road Sion (West) ,
Mumbai , Maharashtra , India
drdharap@hotmail.com
e-mail:
8.2 Etiology
8.2.1 Trauma
Both blunt and penetrating mechanisms can
cause injury to the anorectum. Injuries due to
penetrating mechanisms are more common than
blunt injuries(Brunner and Shatney 1987 ;
Shatnawi and Bani-Hani 2006 ).
8.2.1.1 Blunt Anorectal Trauma
Being well protected within the bony pelvis, blunt
injuries involving the anorectum essentially are
due to high-energy impact like run-over injury,
crash injury after road traffi c crashes, or fall from
height. It is a devastating injury with fractured
pelvis, massive hemorrhage, and associated genitourinary injury. Degloving or avulsion injuries
involving the perineum are often associated with
such impacts. Immediate risks to life are due to
bleeding from pelvic fracture and sepsis due to
contamination. Rectal injury related to seat belt
has also been reported (Hefny et al.
2010 ).
8.2.1.2 Penetrating Anorectal Trauma
Injuries due to gunshot wounds are less common
in civilian practice in India and are more often
seen in military settings and in societies where it
is easy to carry fi rearms. Anorectal injuries due
to low-velocity weapons like knives and swords
are liable to be missed unless the surgeon carries
out a thorough clinical examination.
© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_8
99
100
S.B. Dharap
8.2.1.3 Blast Injury
Shrapnel following a blast can also injure the anorectum. Traditionally, these have been war injuries
but may be encountered in civilian practice following acts of terrorism (Almogy et al. 2002 ).
8.2.2 Anorectal Foreign Bodies
Anorectal foreign bodies or “impalements” are not
uncommon and at times may be a cause of full-thickness rectal laceration needing a laparotomy. It may be
an act of autoeroticism and such patient often seeks
medical help late due to embarrassment.
8.2.3 Obstetric Injury
Perineal tear can occur during delivery. When it
involves the anal sphincter, it is termed as thirddegree perineal tear, and when the anal epithelium is breached, it is called fourth-degree tear.
8.2.4 Iatrogenic Injuries
Perforation due to enema catheter is uncommon
but an easily preventable cause. The rectum can be
injured during operations in a nearby vicinity, viz.,
uterine curettage, hysterectomy, vaginoplasty, radical prostatectomy, etc. Rectal perforations have
also been reported during rigid and fl exible colonoscopy – both diagnostic and therapeutic.
8.2.5 Sexual Assault
Forceful anal intercourse can cause perianal and
anal lacerations but is rarely full thickness unless
some foreign body is also inserted.
obstruction, relief of compromised breathing,
and rapid control of bleeding and fl uid resuscitation (primary survey and resuscitation). After primary survey, history of mechanism of injury
(penetrating trauma to lower torso, history suggestive of fracture pelvis, i.e., fall from height,
run-over, or crash injury) should be ascertained.
History of injury to the perineum or bleeding
from there should suggest possibility of anorectal
injury.
Anorectal injuries can be missed unless there
is thorough examination. Complete exposure of
the body (including private parts), logroll, examination of the perineum and genitals, and digital
rectal examination (DRE) must be carried out in
all major trauma patients particularly whenever
the mechanism suggests anorectal injury (Porter
and Ursic
men, perineum, and groin area must be thoroughly inspected for the wounds of entry or exit
in case of penetrating trauma. A remotely located
wound of entry may also cause injury to the anorectum. Perineal laceration encroaching on the
anal verge, presence of blood, palpable laceration, loss of integrity of the anorectum, or palpable bare pelvic bone fragments on DRE are
indicative of rectal injury. DRE can also reveal
presence of some foreign body. Injury to the urethra and genitalia must be inspected for associated injury. All patients also need a complete
secondary survey, i.e., complete head to toe
examination. Pelvic compression test may suggest associated pelvic fracture. Abdominal guarding may be observed in patients with peritonitis.
approach depends upon patient’s hemodynamic
stability.
2001 ). The gluteal region, lower abdo-
Having suspected anorectal injury, further
8.3.1 Unstable Patient
8.3 Diagnosis of Anorectal Trauma
While evaluating any trauma patient, the priority
is recognition and management of immediate
life-threatening conditions, i.e., relief of airway
A patient who remains in a state of shock or
crashes again despite fl uid resuscitation is a nonresponder or a transient responder. This indicates
ongoing blood loss, and the surgeon has to swiftly
decide about the need for a lifesaving laparotomy. In a patient with penetrating abdominal
trauma, immediate laparotomy is recommended
8 Anorectal Injuries
101
in presence of shock, evisceration, or highvelocity weapon use.
In an unstable patient with blunt trauma, only
bedside imaging is possible, viz., portable chest
and pelvic X-rays and focussed assessment by
sonography in trauma (FAST). Pelvic X-ray may
show evidence of pelvic fracture, presence of foreign body, or bullets. Rectal injury should be suspected in the presence of widened symphysis and
sacroiliac joint disruption (Aihara et al. 2002 ).
Laparotomy is indicated whenever DRE suggests
rectal injury or if FAST reveals the presence of free
fl uid or if free fl ow of blood is obtained on the diagnostic peritoneal aspirate. Transfer of an unstable
patient to radiology suite for CT scan or other
radiological investigations is not recommended.
In an unstable patient, principles of damage
control laparotomy (DCL) are followed.
Hemorrhage control is given the priority over
treatment of hollow viscus perforation which is
tackled only after reasonable control of gross
bleeding. Diversion, stapling, or ligation of the
perforated bowel is recommended over formal
anastomosis. This is followed by temporary closure of the abdomen. Patient is shifted to intensive care unit for correction of deathly triad of
hypothermia, coagulopathy, and acidosis.
Re-exploration is carried out 48–72 h later with
removal of packs which might have been inserted
for hemorrhage control along with defi nitive
repair if feasible and formal closure of the laparotomy wound.
Identifi cation of anorectal injuries during
DCL surgery may be diffi cult. As major part of
the rectum is extraperitoneal and located deep in
the pelvis, rectal injuries may be missed even
during surgery unless the rectum is mobilized
fully as during low anterior resection. As this
extensive mobilization of the rectum is not advisable in an unstable patient, it may be preferable to
carry out diversion (colostomy) if rectal injury is
strongly suspected clinically.
Management of rectal injury in patients with
blunt trauma and pelvic fracture is challenging.
Laparotomy is indicated in patients with a fractured pelvis, if there is evidence of rectal injury
on DRE or when hemoperitoneum is suspected
(Heetved
2007 ).
The immediate risk is bleeding from pelvic
fracture, which is often stabilized by application of
pelvic binder or an external fi xator (EF). Preperitoneal pelvic packing (PPP) is a recently
accepted method for operative control of pelvic
hemorrhage. If facilities are available angioembolization can be attempted for bleeding from
pelvic fracture after pre-peritoneal pelvic packing
and external fi xation (PPP + EF) (Burlew et al.
2011 ). Pelvic fracture with rectal injury may be
associated with urethral and vaginal injuries. It is
best not to disturb the pelvic hematoma by further
dissection, and the surgeon should resort to simple
diverting colostomy and suprapubic cystostomy.
8.3.2 Stable Patient
If the patient is hemodynamically stable, the following investigations can be done to confi rm the
presence of anorectal injury:
Proctoscopy: Rectal injury diagnosed clinically
can be further ascertained by rigid proctos-
copy, which can be performed even during the
operation should the need arise. Presence of
gross blood, mucosal hematoma, and lacera-
tion are indicative of rectal injury.
Plain X-rays: They are useful to locate foreign
bodies including bullets and to understand the
trajectory of the penetrating weapon.
Contrast X-rays: X-ray taken after enema of
water-soluble contrast has been used, but
today it is largely replaced by contrast-
enhanced CT scan (CECT)
CECT scan: In a stable patient with normal renal
functions, CT scan of the abdomen with triple
contrast (oral, rectal, and intravenous) is help-
ful in diagnosing rectal injury. Presence of air
or contrast extravasation in pre- and perirectal
space confi rms full-thickness rectal injury. It
may also indicate the location of rectal injury
along with presence and severity of other
internal injuries (Anderson and Soto
CT scan has lower incidence of missed injury
and may help in avoiding DRE, which is
unpleasant to the patient (Johnson et al. 2008 ;
Leaphart et al. 2006 ).
2008 ).