Posterior Vaginal Fornix, Or Perineally by Separation of Rectum and Vaginla Ul) to the Region of the Fistula

Home , Vaginal fornix

SACROCOCCYGEAL TRANSRECTAL APPROACH FOR REPAIR OF HIGH RECTOVAGINAL AND VESICOVAGINAL FISTULAE JOHN C. A. GERSTER, M.D. NEW YORK, N. Y. FIIOM TIlE DEPARTMENT OF SURGERY, NEW YORK POST GRADUATE MEDICAL SCHOOL, COLUIMBIA UNIvERSITY, SKIN AND CANCER DIVISION; DR. CARL EGGERS DIRECTOR lTIIE literature concerning the repair of persistent higlh rectovagiial listtilae deals witlh various methods of approach, either directly, tllrouglh the posterior vaginal fornix, or perineally by separation of rectum and vaginla ul) to the region of the fistula. In either case, dissection of the fistulous region with separate closure of the openings in rectum and vagina, attenll)ts at the same time, if feasible, to have the two closures not directly opposite onie another. Cutting the anal sphincter or temporarily paralyzing it by stretching, as well as temporary left inguinal colostomy, has been mentioned as useful in putting the operative field at rest until healing has takenl place. Suggestions have also been made for various transperitoneal abdominal pro- cedures with the same object in view. A recent experience seemed to sug- 0,est a more direct approach to this relatively inaccessible region. Case Report.-A case of low rectosigmoidal carcinoma was operated Uponl in the Skini anid Catncer Division of the New York Post Graduate Hospital August 2I, 1935. The patient was a rather emaciated woman of 54. The tumor was free anid its lower imiargini was just above the bottom of the pouch of Douglas. Through a medialn hiypo- gastric incision, the tumor-bearing loop was completely mobilized accordinig to tlhe pro- cedure of Miles, without, however, division of the inferior mesenteric vessels. The mobilized loop was then packed down inito the pelvis, the pelvic peritonieal diaphragm reestablished, and the abdomen closed. A Mikulicz "vorlagerung" of the mobilized tumor- bearing loop was performed through a sacral approach after removal of the coccyx.* Six days later, August 27, the tumor-bearing loop was amputated flush with the skin. On the tenith postoperative day, August 3I, a spur-crushing clamp was applied, which canme away at the end of seven days. The spur was, however, niot completely divided. WVith the index finlgers in the afferenit and efferent loops respectively, it was possible to brinig the finlger tips together with what seemed to be bowel between. Septemiiber ig, the clamp was again applied to this spur and at the enid of ten days it cut through, but the posterior fornix of the vagina had been caught in with the efferent loop, so that a high rectovaginal fistula, in the median line, fully five centimeters lolng resulted, with its upper end at the cervical wall. From the vaginal aspect, this rectovaginial fistula was fully three and one-half inches from the perineal margin of the posterior vagilnal wall. Through the sacral colostomy opening, however, the distanice was n1ot more thani three-quarters of an inch from the skin. Oni October 9, 1935, without enlargilng the sacral colostomy opening, it was a simple matter to expose the fistula, dissect the ani- terior rectal wall from the posterior vaginal wall, and to mobilize both for fully one-half inlc from the margins of the opening. The vaginal opening was then closed in two layers, with runninig sutures of chromiiicize(d catgtut. The rectal mucosa was readily * Kiittner (Zenltralblatt fiir Chirurgic, P. 604, i9IO) reported ten such cases of sacral Alikulicz "vorlagerunig" for carciniomiia of the rectosigmoid with one death. 244 Volume 104 Nuzzkiber 2 VAGINAL FISTULAE approximated. There was no leakage, and, at the end of three weeks, a firm hlealilng ha(l al)parently taken place. During this time there was no tension on the plastic repair because the open sacral colostomy, directly opposite, allowed free escape of feces and( flatuis. On November 14, under spinal anesthesia, the sacrococcygeal colostomy was close(l. A circular incision at mucocutaneous margin freed the intestinal wall liberally, so that the lozenge-shaped longitudinal opening of mobilized posterior rectal wall could be sewe(d ibp in a transverse directioni. The skin margins were then approximated, except at onle point just below end of sacrum where a vaseline gauze. drain was inserted. This draini was removed at the end of the third day and the posterior wound gradually healed withl- out leakage. The rectovaginal repair, however, leaked a little for 13 days an(l thell closed spontaneously. Six weeks later the patienlt reported that there ha(d been no further leakage; regular normal bowel movements, an(l a gain of tenl po(iunds in weight.*

Exposed area of unopened (mobilized) posterior rectal wall

To pofsaec

Line of eventual incision for obtaining direct access to anterior rectal wall Posterior Precoccygel StageI(b) rectal wall fasci cut

StageI (a) FIcG ia.--Begiolinig the exposure of the l)os- FIG. ib.-Rectum has been mobilized suiffi- tenior rectal wall after remiioval of coccyx aid cieuitly to lermit a lougitutdilal area of the los- divoio,iuii of precoccygeal fascia. terior W'all to heal in place, level with the skin sturface. This experience suggeste(l tlhat, in the repair of persistent higlh rectovaginal or rectovesical fistulae, where muclh cicatricial deposit mighlt ren(ler molilization anid exposure (lifficult in following previotisly emplloye(d iletllo(ls, the following sacrococcygeal, transrectal approach might be considere(l anl performed in the appended three stages. Operative Technic.-I. Exposure of the posterior rectal wall throuiglh a nde(lian incision, extending from over the lower end of sacrum to withini one inch of the posterior anal margin, removal of coccyx (Fig. ia), mobiliza- tion of rectum,t sufficiently to permit delivery of the unopened posterior * Patient was presented before New York Surgical Society, January 8, 1936. A previous case operated upon according to this method was presented before the Surgical section of the New York Academy of Medicine, January 6, I928 (Gerster, J. C. A.: Carcinoma of Rectum. American Journal Surgery, vol. 4, No. 4, April, I928, PP. 444- 445), and later before New York Surgical Society, January I4, 1931 (ANNALS OF SURGERY, June, I93I, VOl. 93, PP. 1252-1253). She is living and well eight years after operation, January 8, I936. t The technic is the same as that described for mobilizing the rectum (for carcinoma), Text-Book of Operative Surgery, by Dr. Theodore Kocher, Third English Edition, trans- lated by Harold J. Stiles. The Macmillan Company, I9II, vol. ii, pp. 651-652, Figs. 385, 386, 387. 245 Annals of Slr,e" JOHN C. A. GERSTER August, 1936 rectal wall, so that it lies exposed in the wound at the skin level and in contact with the cut margins of the gaping skin wound (Figs. ib and 2). A vaseline gauze dressing covers the operated area for a week or ten days to permit healing, thereby avoiding infection of the subcutaneous tissues.

'llMobilized unopened crior rectal wall Pecto-vaginal fistula StageI (b) FIG. 2.-Sagittal section of the pelvis. Showing greater accessibility by sacrococcygeal attack than by perineal or vaginal routes. 2. The long oval of exposed bowel wall (Fig. ib) can now be opened longitudinally with scissors, actual cautery or electric cutting knife. (This obviates the necessity of a preliminary abdominal colostomy.) With proper retraction, the fistulous opening in the anterior rectal wall lies in view directly Dissection of muco-cutaneous margin begun fula opening in nee closed terioti rectal wall

Cut edge 1 of posterior \ I. 'I rectal wall Stagem Stage 31 Plastic closure of posterior rectal wall FIG. 3a.-Posterior rectal wall opened ex- FIG. 3b.-Plastic closure of the posterior posing fistula on anterior rectal wall. After rectal wall, only after healing of the rectovaginal transrectal plastic closure of fistula, posterior fistula is assured. rectal wall remains open until complete healing of fistula is assured. opposite, accessible for repair (Fig. 3a). If the fistula fails to close completely, a second attempt at closure is, of course, feasible. During this period of healing, the presence of the colostomy opening directly opposite, permits free escape of feces and flatus, and thus avoids strain on the suture lines of the plastic repair. 246 5'olume 104 Number 2' VAGINAL FISTULAE 3. Eventually, having satisfied oneself that the fistula is firmly and soundly healed, the sacral colostomy is closed as in final stage of any Mikulicz "vorlagerung" (Fig. 3b). The advantages of this method are: simplicity, accessibility of the region to be repaired, less risk from infection or of failure than by either the perineal or abdominal route, and lastly, less cosmetic deformity than after other methods of attack. In traumatic surgery with perforation of the bladder and rectunm, it is suggested that, as an emergency measure, an immediate sacrococcygeal de- compression of the rectum, as just described, be combined with a suprapubic cystostomy, to prevent infiltration of the pelvic cellular tissue with urine and feces. The method also may be used to approach certain rectovesical fistulae in the male.

SUMMARY Recently in the course of cutting through the spur of a double-l)arrele(l colostomy after a AMikulicz "vorlagerung" for a low rectosigmoidal carcinoma through a sacrococcygeal opening, a high rectovaginal fistula was inci(lenltally produced. Repair of this fistula was so easily accomplished through the sacrococcygeal opening, that it is suggested that a deliberate attack by this route for the repair of certain suitable, selected cases of high rectovaginal or rectovesical fistulae is feasible.

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