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RectoVaginal Fistulas

RectoVaginal Fistulas

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RectoVaginal Fistulas

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  1. RectoVaginal Fistulas Omar Felix, MD

  2. Etiology • Obstetric injury • Most frequent cause • Appear 7-10 days after delivery • Occur after 3rd or 4th degree laceration • Very common in developing countries • Due to necrosis of rectovaginal septum from prolonged labor.

  3. Obstetric injury

  4. Etiology • Infection • Inflammatory bowel disease • Crohn’s > Ulcerative Colitis • Operative Trauma • Vaginal wall incorporated in anastamosis • abscess secondary to anastamotic leak • Radiation • Sexual Assault

  5. Evaluation • Identification of the fistula site • Assessment of surrounding tissue

  6. Identification of Fistula Site • Most times readily visualized on exam • Sometimes may be elusive • Methylene Blue Test • Saline Instillation

  7. Identification of Fistula Site • Radiological tests • Vaginography • CT scans • MRI • Ultrasound

  8. Gastrogaffin Enema

  9. Axial MRI

  10. Sagittal MRI

  11. Assessment of Local Tissue • Elicit symptoms of incontinence • MRI or Ultrasound assess anal sphincter • Evaluation of GI tract with colonoscopy and contrast studies. • Biopsies

  12. Classification • Daniels • Low: rectal opening at dentate line • Middle • High: vaginal opening at cervix • Simple vs Complex • Simple are small (<2.5cm), low, due to trauma/inf • Complex are large, high, due to IBD, radiation, malig.

  13. Management • Conservative • Small fistulas • Minimal symptoms • Optimizing bowel function • Controlling diarrhea • Surgical techniques

  14. Surgical techniques • Local Repairs • Fibrin Sealant • Advancement Flaps • Rectal Sleeve Advancement • Excision of Fistula with layered Closure • Perineo-Proctotomy • Inversion of Fistula

  15. Advancement Flap

  16. Excision with Layered Closure

  17. Inversion technique

  18. Surgical techniques • Complex Repairs • Tissue Interposition • Muscle: most common is sphincteroplasty • Bowel: • low anterior resection • Sleeve coloanal technique

  19. Tissue Interposition