Introduction
Rectovaginal fistulas might develop as a result of vaginal tears during childbirth and pelvic surgeries. These fistulae might lead to leakage of gas or stool from the vagina. These fistulae can be completely treated with a repair surgery to close the fistula. Rectovaginal fistulas can develop as a result of various conditions like obstetric trauma, carcinoma, infections, radiation, and inflammatory bowel disease. These fistulae might affect the individual both psychologically and sexually. The quality of life of patients is usually low because of the distress and social limitations due to urine leakage.
The recurrence of fistulas has a negative impact on the patients; therefore, it is essential to cure the fistula during the initial attempt with minimally invasive surgery. A rectovaginal fistula is regarded as a surgical challenge as it has a low success rate and difficulty in repair.
What Are Rectovaginal Fistulas?
Rectovaginal fistulas are atypical epithelial-lined connections between the rectum and vagina. Rectovaginal fistulas can create issues for both the patient and the surgeon. The symptoms are irritating and embarrassing, and there is a high failure rate after repair. Treatment options for rectovaginal fistula include medical therapy, plugs (biosynthetic devices that help to promote healing and prevent the recurrence of fistulas), advancement flaps, fistula ligation, and tissue interposition.
What Are the Principles of Rectovaginal Fistula Repair?
For rectovaginal fistula repair, some basic principles must be followed. First and foremost, the orifice must be located correctly to make sure that the fistula and the surrounding structures are properly exposed. Further, the procedure includes
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Total excision of the fistula and scar tissue including mesh.
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Proper mobilization of the bladder or rectum from the vagina.
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Closure of the bladder, vagina, and rectum in separate layers.
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The interposition of a well-vascularized autograft tissue between the vagina and bladder or rectum.
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Tension-free suture of the bladder and rectum.
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Electric coagulation hemostasis on all sides of the orifice and continuous drainage must be prevented postoperatively.
In case of severe pelvic adhesions, the double J catheters can help protect the ureters during the operation. However, the placement of double J catheters can cause a high rate of urinary tract infections; therefore, it is not used in most cases.
In some cases, double-cavity cannulas were placed near the seam of the rectum for irrigation and drainage. It helped keep the repair tissue clean and prevent potential leakage. Some studies show that the success rate of surgeries is high without double-cavity cannulas, suggesting that it is also not a routine step. The urethral catheter is usually placed for 7 to 21 days after rectovaginal fistula repair, depending on the size of the orifice. A cystography (an imaging test that helps to diagnose problems in the bladder) examination is performed during follow-up.
The majority of the management of a rectovaginal fistula is based on the location, size, cause, sphincter and anal function, and overall health of the patient. It also depends on the skill and judgment of the surgeon. Treatment of a rectovaginal fistula is usually surgical and depends on the fistula in different individuals. For high fistulas, the transabdominal approach is the standard surgical procedure. Various surgical techniques have been introduced including
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Fistula division.
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Fistula closure with or without bowel resection.
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Use of local flaps, like bulbocavernosus flaps, and various muscle flaps for repair of large defects.
What Is Laparoscopy?
Laparoscopic surgery is also known as minimally invasive surgery or keyhole surgery. Laparoscopy is a type of surgical technique used by a surgeon to access the inside of the abdomen and pelvis without making a large incision in the skin.
Laparoscopy helps to avoid large incisions during the surgery with the use of an instrument called a laparoscope. A laparoscopy is a small tube that has a camera and a light source that shows images of the inside of the abdomen or pelvis on a television monitor. The advantages of this technique include:
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Reduced pain and bleeding after the operation.
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Short hospital stay and faster recovery time.
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Decreased scarring.
What Is the Laparoscopic Approach for Rectovaginal Fistula?
Laparoscopic management of rectovaginal fistulas is still in its initial stage. Only a few surgeons have performed laparoscopic-assisted surgeries for rectovaginal fistulas. A complete laparoscopic repair is still rarely seen, owing to the complexity of the procedure. It is believed that a simple high rectovaginal fistula can be repaired with the help of laparoscopic surgery after carefully assessing the patient and the fistula.
Laparoscopic repair of the rectovaginal fistula has the advantages of minimal access surgery, such as less postoperative pain, minimal wound complications, and early recovery.
To achieve complete laparoscopic repair, the following points must be noted:
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Good laparoscopic experience with proper identification of the tissue planes and the fistulous tract.
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Careful and precise surgical technique is required to accomplish this.
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Good bowel preparation is important for avoiding fecal contamination of the operative area.
The success of rectovaginal repair also depends on the skill and experience of the surgeon, especially in patients with complex urologic disease. The additional injury must be avoided by carefully separating the rectum and bladder wall to maintain a proper blood supply.
The position of well-vascularized flaps is also essential in achieving successful repair of the fistula.
Conclusion
Laparoscopic repair of the rectovaginal fistula usually requires proper identification of tissue planes and is quite demanding. A proper experience in advanced laparoscopic technique is required. It is believed that laparoscopic resection of simple high rectovaginal fistula with primary intracorporeal closure is viable and can be considered in certain cases as an alternative to open surgery. However, further studies are required to confirm the safety and long-term results of laparoscopic repair of the rectovaginal fistula.
To conclude, laparoscopic repair of the rectovaginal fistula is an effective, safe, and minimally invasive procedure for treating iatrogenic fistulas. In most patients, it offers a good alternative to the transabdominal approach. However, in advanced laparoscopic skills, intracorporeal suturing (the knot is made inside the abdominal cavity with the help of two instruments, which can be two needle holders or forceps) and pelvic surgery are needed.
