2006 - Rectovaginal fistula repair using fascia graft of autologous abdominal muscles Pubblicato su:
V.M. Jasonni, A. La Marca, A. Manentiba The case of a 48-year-old patient with a rectova-ginal fistula (RVF) resulting from an obstetricinjury is described. A clinical examination revealed a 3-mm fistula located about 5 cm from the anal sphincter. The patient, who complained of an occasional brown discharge from the vagina,had unsuccessfully been operated on 4 years previously with a double-layer closure of the rectum and a monolayer closure of the vaginal mucosa. She gave her consent for a second surgical intervention. Surgery was performed using an autograft obtained from the abdominal fascia. A small (2-cm) transverse suprapubic incision was made to obtain the patch. To remove the surrounding fibrous tissue and sufficiently mobilize the rectum from the vaginal mucosa, the vagina was dissected from the rectum to 2 cm above and laterally to the fistula. The rectum was then closed with a double layer of interrupted 2/0 PDS sutures, and the autograft was patched on these sutures with a few drops of cyanoacrylic glue. The vaginal mucosa was then sutured to cover the patch with interrupted monolayer stitches (1/0 Vicryl; Ethicon,Somerville, NJ).Postoperative care included antibiotic treatment for 5 days. One year later, the patient was symptom free.The primary repair of a RVF is associated with a success rate ranging between 70% and 97%, but the rate decreases to 55% after a third attempt.Regardless of the selected surgical technique, a RVF should be adequately exposed and a wide mobilization of the rectum from the vagina should be obtained to prevent any tension at the suture line. Tension will impair healing and the fistula will generally reopen shortly after repair. In the case of secondary surgery, however, native tissue can be insufficient for a wide tissue mobilization and the blood supply can also be insufficient. Bulky muscle flaps, and more recently an obturator fasciocutaneous thigh flap, as well as trans-plants of biocompatible mesh or porcine dermalgraft have been used to improve surgical results. In the present case, an autotransplant from the abdominal fascia was used, with cyanoacrylic glue to reinforce the suture line of the rectum and fix the patch. Autologous tissue is anallergic and devoid of the risk of being rejected, and the very small supra-pubic incision needed to obtain the fascia is minimally invasive. This technique should be considered a surgical option for the repair of recurrent fistulas.