Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult
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1094 Section XIV • Gynecology
STEP 3: OPERATIVE STEPS
1. INCISION
◆ The Lone Star Retractor and stays are applied, and the proposed surgical fi eld is injected
with vasopressin.
◆ The perineal incision line is marked at the junction of the vagina and perineum
(Figure 99-2). (If there is defi cient perineum, a modifi ed cruciate incision will allow a
Z-plasty.)
◆ The initial incision is made with needle-tip electrocautery set on a pure cutting current
(Figure 99-3).
CHAPTER 99 • Repair of Rectovaginal Fistulae 1095
Rectovaginal fistula
FIGURE 99 –2
Fistula
FIGURE 99 –3
1096 Section XIV • Gynecology
2. DISSECTION
◆ The rectovaginal space is dissected sharply to the fi stula tract.
◆ Sharp dissection against a fi nger in the rectum helps avoid inadvertently buttonholing the
rectum.
◆ After a plane is developed, Sklar Pratt clamps often supply a better grasp of the tissue than
Allis clamps (Figures 99-4 and 99-5).
◆ For further ease of dissection, the vagina is incised in the midline and the dissection is
continued.
Incision
FIGURE 99 –5
Fistula
Incision
FIGURE 99 –4
CHAPTER 99 • Repair of Rectovaginal Fistulae 1097
◆ The fi stula edges may be trimmed to ensure well-vascularized tissue.
◆ However, care must be taken on the rectal side to avoid removing excessive tissue
(Figures 99-6 and 99-7).
Fistula
FIGURE 99 –6
Sharp dissection
FIGURE 99 –7
1098 Section XIV • Gynecology
◆ As the dissection continues, the smooth shiny rectovaginal fascia (the fi bromuscular layer of
the vagina) is identifi ed, and the separation of the planes becomes easier (Figure 99-8).
◆ The dissection continues to the posterior fornix (Figures 99-9 and 99-10).
Fistula
Rectovaginal fascia
FIGURE 99 –10
FIGURE 99 –8 FIGURE 99 –9
CHAPTER 99 • Repair of Rectovaginal Fistulae 1099
◆ The retracted ends of the anal sphincter are sharply dissected from the surrounding scar,
with care given to avoid the posterior lateral neurovascular bundles (Figure 99-11).
◆ Extension of the initial incision into the ischioanal fat can aid in identifying the outer
margin of the anal sphincter (Figure 99-12).
◆ Both ends of the anal sphincter are identifi ed.
Rectovaginal fascia
FIGURE 99 –11
Fistula
Rectovaginal fascia
FIGURE 99 –12
1100 Section XIV • Gynecology
◆ The labium majus is incised to obtain the Martius bulbocavernosus fat pad (Figure 99-13).
◆ In this case, the blood supply from the external pudendal artery is ligated.
◆ The internal pudendal artery provides the blood supply inferiorly.
◆ The fl ap is largely composed of adipose tissue, because the muscle is not very prominent
(Figure 99-14).
CHAPTER 99 • Repair of Rectovaginal Fistulae 1101
Anal sphincter muscle
FIGURE 99 –14
Incise for anal sphincter muscle
Fistula
Rectovaginal fascia
Incise for
bulbocavernosus muscle
FIGURE 99 –13
1102 Section XIV • Gynecology
3. CLOSURE
◆ The rectal mucosa is closed with an absorbable, monofi lament 000 continuous suture from
inside the rectum so that the knots are expelled out of the rectum (Figure 99-15).
◆ In this case, there is insuffi cient internal anal sphincter to imbricate as a second layer, so the
pedicled graft is applied to improve the integrity of the repair (Figure 99-16).
Bulbocavernosus muscle
FIGURE 99 –16
Anal sphincter muscle
Incise labium majus for
bulbocavernosus muscle
FIGURE 99 –15
CHAPTER 99 • Repair of Rectovaginal Fistulae 1103
◆ Overlapping sphincteroplasty is performed with 000 delayed absorbable monofi lament
sutures (Figures 99-17 and 99-18).
FIGURE 99 –17
FIGURE 99 –18