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Vaginal air and/or stool passage (Ch. 1)
Colovaginal and colovesical fistula (619.1, 596.1) (Ch. 4)
Rectovaginal fistula (619.1) (Ch. 4)
Rectovaginal fistula repair—advancement flap (Ch. 5)
General perioperative management—anorectal (Ch. 7)
RECTOVAGINAL FISTULA REPAIR—RECTOVAGINOTOMY WITH LAYERED
CLOSURE
Principle
Complete transection of the perineal body between the rectal and vaginal fistula opening with excision of the epithelialized
fistula tract and layered closure and reconstruction. Advantage: better exposure and more controlled closure of the various
layers; disadvantage: more serious defect in cases of infection/dehiscence. Since a relevant rectovaginal fistula results in
functional incontinence, transection/reconstruction of the sphincter muscle typically is well tolerated and not noticed as a
disadvantage.
Method is appropriate for low- to mid-level fistulae. High fistula (colovaginal) needs to be ruled out or managed through an
abdominal approach. Fecal diversion commonly is not necessary unless patient is very symptomatic before the repair or as a
result of complications with dehiscence.
Alternatives
Placement of a cutting seton.
Endorectal advancement flap.
Insertion of collagen plug.
Interposition of muscle flap (bulbocavernosus, gracilis).
Indication
Symptomatic low to mid-level rectovaginal fistula, preferably preexisting sphincter defect.
Preparatory Considerations
Fecal diversion if patient is very symptomatic and local area is not ready for repair (< 3–6 months postformation).
In elective cases, prior colonic evaluation per guidelines.
Clinical examination often sufficient; combination with imaging studies if anatomy is unclear.
Administration of full bowel cleansing before operation. IV antibiotic prophylaxis with continuation for 5 days. Disinfection of
rectum and vagina with povidone-iodine solution.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages—
superior view with comfortable access for surgeon/assistant. Lithotomy position for transvaginal approach.
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2. Pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve
relaxation of anal sphincter muscles.
3. Insertion of anal retractor and reassessment of fistula.
4. Insertion of probe into fistula and division of whole perineal body with electrocautery. As various tissue levels are
divided, marking corresponding tissues (eg, sphincter muscle) on either side with sutures.
5. Excision of epithelialized fistula tract and mucosal mobilization on rectal and vaginal side.
6. Layered closure, making sure both mucosal edges evert rather than invert. Reconstruction of sphincter muscle with
3–4 interrupted Vicryl sutures.
7. Maturation of mucosal sides, closure of skin with subcuticular sutures.
Anatomic Structures at Risk
Sphincter muscle.
Aftercare
Stool management with softeners/fibers to avoid too soft/too hard bowel movements.
Pain medication.
Sitz baths.
Complications
Bleeding, urinary retention, infection, flap dehiscence with reopening of potentially larger fistula, need for colostomy,
incontinence to stool/gas, delayed wound healing, pain.
Rare: pelvic/perineal sepsis.
Cross-Reference
Vaginal air and/or stool passage (Ch. 1)
Colovaginal and colovesical fistula (619.1, 596.1) (Ch. 4)
Rectovaginal fistula (619.1) (Ch. 4)
Rectovaginal fistula repair—advancement flap (Ch. 5)
General perioperative management—anorectal (Ch. 7)
RECTOVAGINAL FISTULA REPAIR—MUSCLE FLAP INTERPOSITION
Principle
Perineal repair of the rectovaginal fistula with interposition of well-vascularized tissue to achieve separation of the two
compartments and improve local wound healing. Typically indicated when local tissue quality is less than optimal
(postradiation, postsurgical, recurrent fistula). Muscle generally is well suited as long as it can be adequately mobilized while
maintaining its blood supply. Options for muscle flap include:
Bulbocavernosus muscle (Martius flap).
Gracilis muscle.
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Gluteus muscle.
Access through the perineum, separation of rectum and vagina with layered closure of each of them. Tunneled insertion of
the muscle flap from its harvest site and interposition to keep the two sutured mucosal layers separate from each other. This
type of local repair typically is reserved for high risk low- to mid-level fistulae. High fistula (colovaginal) typically is
manageable without a flap. Fecal diversion commonly is not necessary unless the patient is very symptomatic.
Alternatives
Repair with endorectal advancement flap.
Placement of a cutting seton.
Rectovaginotomy with layered closure of defect.
Insertion of collagen plug.
Interposition of a collagen sheet.
Indication
Symptomatic low- to mid-level rectovaginal fistula.
Preparatory Considerations
Fecal diversion if patient is very symptomatic and local area is not ready for repair (< 3–6 months postformation).
In elective cases, prior colonic evaluation per guidelines.
Administration of full bowel cleansing before operation. Single shot IV antibiotic prophylaxis, depending on findings to be
continued for 5 days. Disinfection of rectum and vagina with povidone-iodine solution.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages—
superior view with comfortable access for surgeon/assistant. Lithotomy position for transvaginal approach.
2. Pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve
relaxation of anal sphincter muscles.
3. Insertion of anal retractor and reassessment of fistula.
4. Transverse incision to perineum (as anterior as possible).
5. Dissection of rectovaginal septum to level of puborectalis muscle. Injury to rectum and/or vagina must be avoided,
but obviously both sides will end up with a defect once rectovaginal fistula is transected.
6. Limited excision of primary opening, removal of remnants of epithelialized tract within muscle layer.
7. Layered closure and maturation of both mucosal sides, making sure both mucosal edges rather evert toward their
lumen than invert.
8. Muscle mobilization:
a. Bulbocavernosus muscle: paralabial longitudinal incision, dissection through relatively vascular tissue layer,
identification and mobilization of bulbocavernosus muscle. Anterior transection, verification of preserved blood
supply.
b. Gracilis muscle: three longitudinal medial incisions (or one complete incision), identification of muscle
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through proximal incision. Careful mobilization toward proximal neurovascular pedicle. Distal muscle
mobilization. Disconnection of tendon as distally as possible.
c. Gluteus muscle: curved lateral parasacral incision, identification of posterior edge of gluteus muscle and its
broad insertion to sacrococcygeal junction. Mobilization of a portion of muscle. Avoid avulsion of neurovascular
pedicle near ischial tuberosity.
9. Creation of tunnel from harvest site to perineum.
10. Interposition of mobilized muscle flap and fixation of its tip on opposite side; loose fixation of muscle body in
perineum to avoid shifting of its position.
11. Irrigation of wound with diluted povidone-iodine (1:10). Hemostasis.
12. Subcutaneous approximation sutures.
13. Closure of skin incision(s).
Anatomic Structures at Risk
Integrity of rectovaginal septum. Vascular pedicles.
Aftercare
Stool management with softeners/fibers to avoid too soft/too hard bowel movements.
Pain medication.
Sitz baths.
Mobilization depending on harvest site.
Complications
Bleeding, urinary retention, infection, flap necrosis and/or dehiscence with reopening of potentially larger fistula, need for
colostomy, incontinence to stool/gas, delayed wound healing, pain. Rare: pelvic/perineal sepsis.
Cross-Reference
Vaginal air and/or stool passage (Ch. 1)
Colovaginal and colovesical fistula (619.1, 596.1) (Ch. 4)
Rectovaginal fistula (619.1) (Ch. 4)
Rectovaginal fistula repair—advancement flap (Ch. 5)
General perioperative management—anorectal (Ch. 7)
RECTOCELE REPAIR
Principle
Elective correction and reinforcement of anterior rectal wall herniation using one of three different approaches: transanal,
transperineal, or transvaginal. Reinforcement of rectovaginal septum either with plication of muscle layer or implantation of
collagen sheet. Selection of approach is primarily a matter of the surgeon's preference. Transanal approach overall is very
well tolerated, with low pain level and low infection risk.
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Setting
Inpatient (selected outpatient?), OR procedure.
Alternatives
Transabdominal pelvic floor suspension.
Indication
Symptomatic rectocele.
Not indicated: "innocent bystander" rectocele (incidental finding).
Preparatory Considerations
Full/partial colonic evaluation for all elective cases according to guidelines.
Bowel cleansing: full or at least two Fleet enemas.
Prophylactic antibiotics.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages for
approaches A and B—superior view with comfortable access for surgeon/assistant, decreased vascular congestion;
lithotomy position for approach C.
(A) Transanal Approach
2. Pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve
relaxation of anal sphincter muscles.
3. Insertion of Lone Star retractor.
4. Electrocautery marking of dotted line outlining broad-based U-flap in anterior circumference with apex near dentate
line, and circumferential incision of mucosa.
5. Careful dissection of mucosa off underlying white muscular layer using cautery and traction on mucosa: if in correct
plane there should be virtually no bleeding.
6. Placement of clamps on mobilized mucosa and distal traction, continuation of mucosal mobilization with continuous
change of working site back and forth to where most tension.
7. Dissection to be continued until upper edge of rectocele reached.
8. Laying of 3–5 absorbable proximodistal sutures to muscular layer to obtain transverse plication of proximal to distal
edge of rectocele.
9. Stepwise resection of mobilized mucosa (typical > 6 cm length) while performing full-thickness tension-free
reapproximation of proximal end to distal edge. Maturing of mucosa.
10. Removal of Lone Star retractor.
(B) Transperineal Approach
2. Transverse incision to perineum.
3. Careful dissection of rectovaginal plane, making sure not to injure rectum and/or vagina; dissection continued until
past proximal edge of rectocele.
4. Reinforcement of anterior rectal wall/rectovaginal septum:
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a. Lateral approximation of puborectalis muscle with several interrupted stitches.
or
b. Placement of collagen sheet, attaching it with a series of interrupted sutures to keep it in position.
5. Irrigation and perfect hemostasis.
6. Closure of incision in layers.
(C) Transvaginal Approach
2. Insertion of vaginal retractor for exposure of posterior wall.
3. Longitudinal insertion of posterior vaginal wall mucosa (electrocautery) and lateral mobilization.
4. Maintenance of good hemostasis.
5. Placement of collagen sheet, attaching it with a series of interrupted sutures to keep it in position.
6. Resection of redundant vaginal wall/mucosa.
7. Longitudinal closure of incision.
Anatomic Structures at Risk
Rectovaginal septum, sphincter complex.
Aftercare
Regular diet as tolerated 6 hours postanesthesia. Maintenance of soft stools (fibers, stool softener, etc).
Complications
Recurrent rectocele.
Bleeding (surgeon-dependent).
Anastomotic dehiscence.
Infection, abscess/fistula formation, infected foreign body (particularly if nonbiologic material used).
Formation of rectovaginal fistula
need for colostomy.
Stricture formation.
Worsening fecal incontinence.
Dyspareunia (vaginal approach).
Cross-Reference
Constipation (Ch. 1)
Defecating proctogram (defecography) (Ch. 2)
Magnetic Resonance Imaging (MRI) (Ch. 2)
Pelvic floor dysfunction (618.X) (Ch. 4)
Rectal prolapse—perineal Delorme repair (Ch. 5)
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General perioperative management—anorectal (Ch. 7)
RECTAL PROLAPSE—PERINEAL DELORME REPAIR
Principle
Elective resection of redundant distal rectal mucosa and reanastomosis with plication of preserved muscular layer (Figure 5–
10). Considered the least invasive procedure, but carries the overall highest recurrence risk. In incontinent patients, Delorme
may potentially provide a theoretical benefit of bulking up the muscle complex (plication). However, successful correction of
prolapse alone is expected to improve sphincter function in 70% of patients.
Figure 5–10.
Rectal prolapse repair in Delorme technique.
Setting
Inpatient (selected outpatient?), OR procedure.
Alternatives
Sigmoid resection with/without rectopexy—laparoscopic or open.
Rectopexy only—laparoscopic or open.
Perineal Altemeier repair.
Thiersch procedure.
Indication
Full-thickness (or mucosal) rectal prolapse.
Preparatory Considerations
Full colonic evaluation for all elective cases.
Bowel cleansing: full or at least two Fleet enemas.
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Prophylactic antibiotics.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages—
superior view with comfortable access for surgeon/assistant, decreased vascular congestion.
2. Pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve
relaxation of anal sphincter muscles.
3. Insertion of dry sponge, followed by slow traction on sponge, will reveal tissue prolapse.
4. Insertion of Lone Star retractor.
5. Electrocautery marking of dotted line 1 cm proximal to dentate line and circumferential incision of mucosa.
6. Slow dissection of mucosa off underlying white muscular layer using cautery and traction on mucosa (Figure 5–10):
if in correct plane there should be virtually no bleeding.
7. Placement of clamps on mobilized mucosa and distal traction with continuation of mucosal mobilization with
continuous change of working site circumferentially around where most tension.
8. Dissection to be continued until no further protrusion.
9. Simultaneous stepwise resection of mobilized mucosa while eight muscle-plicating absorbable mucomuscular
sutures are laid but not yet tied: important to take same number of steps (eg, 3–4) for all individual sutures.
10. Removal of Lone Star retractor and sequential tying of sutures.
11. Complete maturation of mucosal anastomosis using one to three interrupted chromic sutures in between each
Vicryl suture.
Anatomic Structures at Risk
Hemorrhoidal plexus, rectovaginal septum, muscularis propria/rectal wall with accidental full-thickness resection (Altemeier)
instead of mucosal resection.
Aftercare
Regular diet as tolerated 6 hours postanesthesia. Maintenance of soft stools (fibers, stool softener, etc).
Complications
Recurrent prolapse.
Bleeding (surgeon-dependent).
Anastomotic dehiscence.
Abscess/fistula formation.
Formation of rectovaginal fistula
need for colostomy.
Stricture formation.
Worsening fecal incontinence.
Cross-Reference
Prolapse (Ch. 1)
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Defecating proctogram (defecography) (Ch. 2)
Magnetic Resonance Imaging (MRI) (Ch. 2)
Hemorrhoids (455.X) (Ch. 4)
Pelvic floor dysfunction (618.X) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
Rectal prolapse—perineal Altemeier repair (Ch. 5)
General perioperative management—anorectal (Ch. 7)
RECTAL PROLAPSE—PERINEAL ALTEMEIER REPAIR
Principle
Perineal proctectomy with full-thickness resection, including vascular ligation of redundant distal rectum, reanastomosis with
coloanal anastomosis. Procedure of choice as emergency operation for incarcerated prolapse. Disadvantage: interruption of
blood flow from the distal to the proximal rectum. Higher recurrence risk than in abdominal procedures. In incontinent
patients, may be combined with levatorplasty. However, correction of prolapse alone is expected to improve sphincter
function in 70% of patients.
Setting
Inpatient, OR procedure.
Alternatives
Sigmoid resection with/without rectopexy—laparoscopic or open.
Rectopexy only—laparoscopic or open.
Perineal Delorme repair.
Thiersch procedure.
Indication
Full-thickness (or mucosal) rectal prolapse.
Incarcerated prolapse.
Preparatory Considerations
Full colonic evaluation for all elective cases.
Bowel cleansing: full or at least two Fleet enemas.
Prophylactic antibiotics.
Surgical Steps
1. Patient positioning: any position, but prone jackknife position with buttocks taped aside has several advantages—
superior view with comfortable access for surgeon/assistant, decreased vascular congestion.
AccessSurgery | Print: Chapter 5. Operative Techniques
file:///C|/...op/ADRIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%205_%20Operative%20Techniques.htm[9/5/2009 19:16:57]
2. Pudendal/perianal nerve block with 15–20 cc of local anesthetic in addition to general anesthesia to improve
relaxation of anal sphincter muscles.
3. Insertion of dry sponge, followed by slow traction on sponge will reveal tissue prolapse.
4. Insertion of Lone Star retractor.
5. Electrocautery marking of dotted line in viable tissue roughly 1 cm proximal to dentate line (appears "more distal" in
prolapsed rectum) and circumferential transection of rectal wall.
6. Delivering of all redundant bowel (elective procedure); avoid excessive resection in emergency situation.
7. Creation of mesenteric window at level of anal verge and mesenteric/mesorectal devascularization with clamps and
ligatures.
8. Possible plication of levator muscles.
9. Coloanal anastomosis: stepwise transection of delivered/prolapsed bowel at level of anal verge while securing bowel
in place with interrupted seromuscular sutures and subsequent complete maturation of mucosal layer.
Anatomic Structures at Risk
Hemorrhoidal plexus, rectovaginal septum, colonic blood supply (watershed areas).
Aftercare
Regular diet as tolerated 6 hours postanesthesia. Maintenance of soft stools (fibers, stool softener, etc).
Complications
Recurrent prolapse.
Bleeding (surgeon-dependent).
Anastomotic dehiscence.
Abscess/fistula formation.
Formation of rectovaginal fistula
need for colostomy.
Stricture formation.
Worsening fecal incontinence.
Cross-Reference
Prolapse (Ch. 1)
Defecating proctogram (defecography) (Ch. 2)
Magnetic Resonance Imaging (MRI) (Ch. 2)
Hemorrhoids (455.X) (Ch. 4)
Pelvic floor dysfunction (618.X) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
Rectal prolapse—perineal Delorme repair (Ch. 5)
General perioperative management—anorectal (Ch. 7)