Video Surgical Treatment of Rectovaginal Fistula Play Pause Previous Next 1 of 200 slides Volume Quality 720P 540P 270P Fullscreen Captions Transcript Chapters Slides Surgical Treatment of Rectovaginal Fistula Overview Dr. Cannon disusses Surgical Treatment of Rectovaginal Fistula. [MUSIC PLAYING] LISA MARIE CANNON, MD: So we're going to go through a brief overview of surgical treatment of rectovaginal fistula today, starting with some of the anatomy and classification of fistula, and moving on to workup of fistula, and then move through some surgical treatment options-- both local and abdominal-- address some more complex issues with rectovaginal fistula, and finally make some conclusions. So the rectovaginal septum is a elongated hourglass of strong connective tissue separating the rectum from the vagina. It lies in a weak coronal plane, that Dr. Valaitis very nicely illustrated in the last talk. It ranges from 0.2 to three millimeters thick. Now the vagina and rectum are really two reservoirs-- one of them real reservoir and one of them a potential reservoir. And the concepts of path of least resistance and relative distal obstruction being what they are, if fistula were to occur in the rectovaginal septum, you can imagine this could be difficult to heal with the egress of rectal contents coming out through the vagina instead of the rectum. There are a number of ways to characterize rectovaginal fistulas. The location of rectovaginal fistula can be useful in planning repair. In high fistulas, the opening is near the cervix or associated with the vaginal cuff, if the patient has status post-hysterectomy. These are often best approached via an abdominal repair, which we'll get to later. In low fistulas, the opening is near the vaginal fourchette, or the dentate line. Fistula less than 2.5 centimeters are considered small and those greater than 0.5 centimeters are considered large. Now this size class is rather arbitrary, but the general concept is that the larger the fistula, the more complex and more difficult to get these to heal, because the track tends to be very short, because the septum is very thin. Sphincter trauma is most often associated with obstetric injury, but all patients should be assessed for symptoms of fecal incontinence at their initial evaluation. If incontinence is present, this should be distinguished from fistula strainage through the vagina. Any suspicion of concomitant sphincter injury should be evaluated with either in doing an ultrasound or MRI and myometry. And if a defect is present, perform a concomitant sphincteroplasty during operative repair. When to document whether the patient has had a recurrent fistula and what interventions they may have had in the past. Recurrent fistulas are considered complex always because tissue scarring can lead to decreased blood supply in the area and limit options for further repair. By far the most common etiology of rectovaginal fistula is obstetric trauma caused by third or fourth degree lacerations, or from over aggressive episiotomy. These involve concurrent sphincter injury, with tearing of the bulbocavernosus muscle, the perinineal body, and the sphincter complex, as illustrated here. Manifestations of the fistula can be immediate-- as with fourth degree tears-- but more commonly appear seven to 10 days later, either after inadequate repair or with associated infection. Prolonged labor and subsequent necrosis of the rectovaginal septum can also lead to high obstetric fistula. These are more common in developing countries and-- I don't have it in my talk-- but we just learned pessary erosion is another etiology of high fistula as well. Malignancy and radiation therapy for malignancy can result in rectovaginal fistula. Fistula may be the presenting symptom in some cases. Here, you can appreciate a cervical cancer resulting in high rectovaginal fistula, as illustrated by the arrow. Rectovaginal fistula can result from direct extension by anal rectal, cervical, vaginal, or uterine cancers, or fistula can develop after radiation therapy for these cancers. Radiation therapy-- as we know-- results in proctitis, which over time can lead to ulceration and fistula formation. Rectovaginal fistula is present in 10% of patients with Crohn's disease. Fistula in general is present in more patients with Crohn's disease, but specific to rectovaginal. It can also occure in severe ulcerative colitis. Again-- because associated proctitis-- rectovaginal fistula and IBD are always considered complex, and these are notoriously difficult to heal. Iatrogenic rectovaginal fistula is a sobering complication of pelvic surgery. These can unfortunately occur in a number of ways. So the posterior vaginal wall can be incorporated into a stapled anastomosis when the ends are mated, if not properly separated free. Dissection itself-- either during perianal cases or pelvic cases-- can lead to fistula formation. And unrecognized rectal NG in other non-rectal cases-- such as hysterectomy-- can lead to fistula. Prevention is truly key for these types of fistulas. So ensuring dissection of the rectovaginal septum, distal to the level of your rectal transection can help avoid these injuries, and always helping the vagina prior to any staple fire. Finally, benign cryptoglandular disease-- or other inflammatory disease-- can be a positive rectovaginal fistula. And colovaginal fistula, though not the topic of this talk, can occur in complicated diverticulitis-- as illustrated in this figure-- more commonly in women status post-hysterectomy. The presentation of rectovaginal fistula is often obvious with drainage of stool or passage of flatus through the vagina. It's very disturbing to women. Taking appropriate history, in order to associate the presence of a fistula with any of the previously mentioned etiologies we've already discussed. Ask the patient directly about obstetric and surgical history, radiation exposure, presence of IBD, or no malignancy. Physical exams should start with a thorough external exam and then examine for signs of local sepsis such as fluctuants or inflammation that would prompt an exam under anesthesia, with possible draining seton placement prior to definitive repair. The side of the fistula can usually be identified on either vaginal or rectal exam, or you at least may be able to appreciate a palpable dimple or induration in the area where the fistula would be. If this is not obvious methylene blue tests can aid in localization. Patient is placed in prone positioning and a tampon inserted into the vagina. Methylene blue is then instilled into the rectum, and staining of the tampon can help you discern the level of the fistula on the vaginal side, and help you localize it. Vaginography or CT can also be utilized to identify fistula. Next, classify the fistula in the terms that we've already discussed-- location, size, sphincter involvement, recurrence-- whether or not it's a recurrent fistula-- as well as ideology. Purpose of these assessments is, of course, to aid in operative planning and approach, as well as divide the patient appropriately, in terms of their risk of recurrence after repair. Make an assessment of the surrounding tissue integrity, previous scarring from prior procedures, and finally ask the patient, again, directly about fecal incontinence. The first step to any approach of rectovaginal vaginal fistula repair is to control sepsis as present. This is most easily accomplished with exam under anesthesia and seton placement. If sepsis cannot be controlled with seton placement alone, consider preemptive diversion on a case-by-case basis. Following successful placement of a seton, delay definitive repair until local tissue integrity can be optimized. This may take months, and the women need to be appropriately counseled as to the importance of this step in order to restore tissue health. There are two basic approaches to surgical repair of rectovaginal fistula-- one being perineal, or local repair, and the other being abdominal. We'll cover them briefly. The first general approach to fistula repair is perineal, or local repair. The simplest method of this is utilization of Fibrin glue in a manner identical to treatment of other fistula-in-ano. Results are extremely poor with frequent recurrence, but because this approach has minimal risk and the success is greater than zero, it can be an option. Perineal proctectomy-- or lay-open technique with layered closure-- is a technique identical to repair of fourth degree perineal lacerations. It's only appropriate for a low fistulas. The repair involves reapproximating the anal mucosa followed by the anal sphincter muscles, reconstuction of the perineal body enclosure of the vaginal mucosa. While intentionally creating a fourth degree laceration requires some muster, several studies report greater than 80% percent success-- which is sort of a topping-out percentage rate for success-- with good functional results. And inherent to this repair is concurrent sphincter repair. The next most complex [INAUDIBLE] involves excision of the fistula tract, including a button of mucosa encompassing the opening, followed by lateral mobilization with re-approximation of all these layers. This can be accomplished via vaginal or transanal approach. So after excising the fistula tract, you'll dissect [INAUDIBLE] on the rectal side and advance some rectum over to offset your ultimate layers of closure. Similar methods can be used with a curvilinear incision directly over the perineal body, with transperineal dissection to dissect apart the rectum and vagina, excision of the fistulus tract, closure of both of the apertures, and consideration for tissue transfer intermission to bulk up this repair. All of these approaches, again, are useful if sphincteroplasty is needed. Advancement flap is one of the more commonly-used local repairs. While the positioning approach for rectal and vaginal repairs is different, the method of repair is similar. So for rectal advancement flap, the patient is usually placed prone jackknife. Mucosa and submucosa is then elevated with a mixture of lidocaine and epinephrine, and your dissection is carried [INAUDIBLE] about four centimeters. And what you want is really a trapezoid-shaped flap that's very broad based, so that you don't compromise the blood flow to the tip of your flap. Once you've elevated your flap, you're going to excise the most distal portion, which includes your fistula. You'll then clean out the fistula tract itself and close it, and then sequentially suture the flap down, then covering fistula tract. Now again, a similar approach can be used from the vaginal side. Success is varied, based on etiology and series. Ann Lowry looked at this in 1988, and reported an 88% success rate in first time repairs. But if it was the patient's third attempt at fistula repair, success rate was only around 55%. Neil Hyman-- who was just here-- looked at repair of complex rectovaginal fistula-- well complex fistula, not limited to rectovaginal fistula-- and reported 81% initial healing rate with this approach. However in the select Crohn's disease population, the success rate was only around 50%. A rectal approach should reasonably avoid an active proctitis at the level of the fistula, or in patients with anorectal stenosis. And the general tenet for success is to avoid this approach in patients with these pathologies. Abdominal approach for rectovaginal fistula is suitable for high rectovaginal fistulas or when the rectum is unsuitable because of radiation change, IBD or neoplasia needs to be excised. In simple repair, one will mobilize the rectum off the rectovaginal septum and take down the fistula. And then if the local tissue is very normal-- example in some high obstetric fistulas-- one can perform a layered closure of the vagina and rectum and then put in an omental interposition to separate the suture lines. Often the local tissue will not be normal, and LAR with resection past the level of the fistula can be appropriate. So these are just a couple more complex abdominal approaches. The [INAUDIBLE] repair is suitable for mid to high fistula, and involves removing the rectum but leaving a submucosal muscular tube. And then threading-- after doing your resection the rectum past the level of the fistula-- you'll thread the normal healthy colon through this muscular sleeve and perform an anastomosis. The [INAUDIBLE] approach, which is pictured here, involves abdominal mobilization to bring distal colon through an inverted anus, which has been completely removed anal mucosa, and then temporarily securing it. It's a delayed anastomosis and can be indicated when local sepsis would otherwise necessitate diversion. Once the anorectal cuff has healed to the serosa of the exteriorized colon, the colon is trimmed and the anal anastomosis is completed. This is usually three days later. The anastomosis usually retracts itself back into the anal canal, but some degree of ectropion can persist. These operations are infrequently performed in the general colorectal population of surgeons. [INAUDIBLE] position uses a well vascularized pedicle of local fatty tissue-- in this case the bulbocavernosus muscle-- and the labial fat pad to reinforce perineal repair. After excising the fistula, the bulbocavernosus muscle and labia fat pad will mobilize, the rectal side of the fistula can be repaired, and then the pedicle-- shown here where the star-- is pulled through the tunnel and sutured in place. You can also use the gracilis, the sartorius, gluteal muscles for similar flaps. These tend to be more bulky, and unless one has special experience in mobilizing these flaps, generally the plastics team is involved in helping us create these flaps. In the event of a recurrent fistula, the first step is to control any local sepsis, and the second step should be to reevaluate for any alternative etiology. Have I missed a cancer? Does this case actually have IBD? Then consider the full armamentarium of repair methods. And method of first repair does not necessarily abrogate any future methods, meaning it doesn't matter which one you did first, usually you can try another method or the same method. With persistence, most patients can achieve successful repair, but that does depend on the original etiology. This is a study at 2001, which Amy Halverson and Tracy Hall were part of. That-- you probably can't read these numbers-- but obstetric injury, if after repeat attempts, you can usually achieve 100% repair. But in Crohn's disease, the success rate is much lower, even after repeat attempts. In Crohn's disease, no single approach has emerged as the best method of repair in rectovaginal fistula. Rectal advancement, vaginal advancement, fibrin glue, and other methods have all been utilized. Primary [INAUDIBLE] with the first attempt can be achieved, but the success rate is lower-- probably around 50% percent in many studies. Overall success increases with repeat attempts, but ultimately, at least 6% of these patients are going to require proctectomy. While there's not one best approach, I would emphasize counseling the patient about need for repeat attempts in order to achieve definitive closure. Proctitis has been isolated as a predictor of failure. If the fistula is low and the proximal rectum is relatively spared, transanal advancement sleeve flap can be considered. I believe Dr. Reid had a picture of this in one of his slides. This technique involves developing a submucosal advancement flap starting at the dentate line, excising circumferentially diseased rectum and then advancing healthy proximal rectum down to the anoderm. So in conclusion, rectovaginal fistula is a distressing and debilitating process for women. Operative approaches depend on fistula characterization and etiology. Control of sepsis is the first step to any successful repair. Identification of sphincter injury is important. You should individualize the decision to divert, but diversion does not necessarily guarantee success in your repair approach. And if at first you fail, try again. Thank you. Published June 2, 2015 Created by
