Robert D. Moore, DO,John R. Miklos, MD, and Neeraj Kohli, MD

Home , Rectocele, Rectovaginal fistula

been reported.2We report the successnI1repair of a rectovaginal fistula using porcine dermal graft as an interposition material in 2 patients with rectovaginal fistulae. Robert D. Moore, DO,john R. Miklos, MD, and Neeraj Kohli, MD CASE 1 Atlanta UrogynecoWg)'A",()(;iates, Atlanta, Georgia,and Brigham and WomenJ Hospital, Haroard Me,licdl Sc/wol,Bmton, MtL!JamusettJ A 39-year-old multigravida presen~ed af~er being in- formed of the presence of a possible rectovaginal fistula. She stated that she had been passing gas vaginally and BACK~ROUND:Rectovaginal fistula repair is commonly per- fonned through a vaginal route. In many cases,healthy having brownish/green vaginal discharge for years since tissue such as an autologous fat pad may be interposed the vaginal birth of her first child in southeast Asia 10 between the suture lines and the vaginal epithelium to years prior. This was a vaginal delivery of a 8-lb, 8-oz facilitate healing and prevent reCUrrence.We present a child, complicated by what she recalled as being a very simple altemative to autologous flaps with the use of pOl"- large vaginal laceration. Physical examination, as well as cine dennal gI'aft8 in the repair of rectovaginal fistulae. barium enema, confirmed a rectovaginal fistula, approx- CASES:Two patients ar:epresented with rectovaginal fistu- ima~ely 5 mm in size, 3 cm inside of vaginal introitus in lae. In both casesthe patients were found to have insuffi- the lower third of the vagina. The anal sphincter was cient native tissue to achieve an adequate uaditional mul- intact, and there was no evidence of any other fistulous tilayered closure, and therefore an acellular: collagen tracts. The patient was placed on a clear liquid diet for 24 porcine dennal graft was used as an interposition gJOaft hours before surgery, completed a sodium phosphate between the rectum and the vaginal epithelium in the enema the night before surgery, and a laxative supposi- repair. tory the morning of surgery. Antibiotic prophylaxis was CONCLUSION:Pomne deI"Dlal gI'aft8 may be a viable altel"- given preoperatively. The patient opted for general an- native to uaditional autologous flaps or human dem1al esthesia and was placed in the dorsal lithotomy position, gf"afts for the repail" of rectovaginal fistula (Obstet Gy- and the rectovaginal fistula was identified. A vaginal necoI2004;104:1165-7. @2004 by The American College of Obstetricians and Gynecologists.) incision was made, circumscribing the fistula and ensur- ing healthy tissue margins around it. Vertical incisions Despite !:heuse of preoperative antibiotics and meticu- were then made cranially and caudally in the vaginal lous surgical techniques,rectovaginal fistula repair con- epithelium, extending away from the circular incision tinues to be a challengefor the gynecologicor colorectal and increasing access to the subepithelial plane. The surgeon. Repair can be accomplished!:hrough the va- vaginal epithelium was then mobilized in all directions from the underlying rectovaginal fascia. The fistulous gina,perineum, sphincter, rectum, or abdomen(wi!:h the abdomen usually the choice of approachfor high fistu- tract was then excised all the way down through the lae). Re~dless of approach,standard principles should rectum, incorporating the vaginal epithelium, fistulous be used to repair fistulae, including excision of !:heepi- \:fact, and rectal mucosa, as well as scar tissue surround- thelialized tract, completeclosure of !:he rectal opening ing the \:fact. Because necrotic tissue was encountered in with clean healthy tissuemar~, adequatetissue mobi- the dissec~ion and healthy viable tissue margins were lization, tension-freemultilayer closure, and hemosta- needed, a large defect (approximately 2 cm) was left to sis.1 Recurrept or complicated fistulae, such as those close. A 2-layer closure of the rectum was attemp~ed with associatedwi!:h irradiatiop, often require a more compli- interrupted 3/0 absorbable suture in a tension-free clo- cated operation, This may include interposing healthy sure. The second layer imbricated the first and was tissuebetween layers (suchas a pedicle graft from omen- placed in the same plane, but it was very difficult to tum, peritoneum, muscle,or fat pad) to facilitatehealing. obtain healthy tissue for the second layer because the patient was found to have very tenuous and poor quality Additiopally, patients found to have very poor tissue quality or lacking sufficientnative tissue to accomplish tissue. We felt she was at high risk of breakdown of the an adequatemultilayer repair may also bepefitfrom !:he repair. Therefore, before closing the vaginal epithelium, an acellular 3 X 3 cm porcine dermal graft was placed over the use of an interpositiongraft. The use of human dermal allograftsin this type of repair of rectovaginalfistula has incision line and anchored laterally ~o the rectovaginal septum with 2/0 absorbable suture. The vaginal epithelium Address reprint requeststo: RobertD. MOQre,DO, Atlanta Urogyne- was then closed over the graft with interrupted 2/0 absorb- cology Associates,3400-C Old Milton Parkway, Suite330, Alpharetta, able suture. The patient was discharged home in 24 hours GA 30005; [email protected]. and had an uncomp1ica~edpos~operative course. She was

VOL. 104, NO.5, PART 2, NOVEMBER 2004 @ 2004 by The American College of Obstetricians and Gynecologists. 0029- 7844/04/$30.00 1165 Published by Lippincott Williams & Wilkins. doi: 10.1097/01.AOG.0000128116.52051.!0 placedon a clearliquid diet for 3 days,followed by a low having overlying suture lines in the same direction on residue diet for 3 weeks and bowel regimen incluWng top ofcach other. Patients who are foQnd to have very softenersfor 6 weeks.Intercourse was discouragedfor 12 poor tissue quality or inadequate "native" tissue to weeks.The patienthas beenfollowed for 18 monthswith- achieve a multilayer closure may also be at risk of failure out recurrenceof the fistula or complicationfrom place- or recurrence. Various methods of interpositioning of ment of the porcine graft. Shehas resumedsexual inter- healthy tissue between the suture lines to help rcduce the courseand reportsno dyspareunia. risk of failure or recurrence have been described. The theory is that the use of a bulbocavernosus fat pad (Martius flap) or gracilis muscle Hap may result in en- CASE2 hanced blood supply to devasculariloedepi~heliQm, oblit- A 35-year-oldwoman presentedwith complaintsof fecal eration of dead space, and the interruption of suture lines incontinence approximately 3 months after a normal along the length of multilaycr closure. These tcchniqQes, spontaneousvaginal delivery complicated by a third- however, involvc additional SQrgcry, advanced sQrgical degreelaceration. Physical examination, including pelvic skills, and can be associated with increased morbidity. examination,was normal exceptfor a 3-mmrectovaginal We have previously described the use of a cadaveric fistula slightly to the right of midline and 1 cm proximal dermal allograft in the surgical repair of rectovaginal to the hymenal ring. The perineal body Wasshortened, fistula as a simplified alternative to aQtologous interposi- and rectal examinationrevealed decreased external anal tional flaps.2 This approach minimizes the need for sphinctertone. Dye instillation into the rectumexcluded additional surgery, is based on COmmonanatomical prin- coexistingfistula tracts.The patient underwent uncom- ciples well known to the gynecologic surgeon, and offers plicated fistula repair in a fashion similar to that de- the advantage of an interpositional graft betWeen the scribed in Case 1, with concurrent externalanal sphinc- suture lines to help prevent recurrence. This may be teroplasty. An interpositional porcine dermal graft was especially helpful in patients who are found ~ohave poor placed after very poor tissue quality was noted during tissue quality or an absence of healthy rectovaginal fascia dissection.There was essentiallyno rectovaginalfascia to use in a multilayer closure. Compared with traditional found that could be used for a second-layerclosure of the autologous Haps, a cadaveric allograft is readily avail- rectum, and attempts to go out laterally farther to the able, cost-effective, and associated with ltUnimaJ compli- side walls would have caused significant narrowing of cations or morbidity. Their use has also been recendy her introitus. Therefore, a porcine graft was placedas an described in complicated pelvic floor repairs,3.4as well in additional layer for the repair and to interrupt the suture augmenting rectocele repairs to help improve cure rates lines. She was dischargedon postoperativeday 1 with and achieve a more anatomical repair ,5 A very similar conservativebowel management.On postoperativefol- anatomic technique is used when placing the graft during low-up, there was complete resolution of the rectovagi- a fistula repair. nal fistula, with good wound healing. At the 6-month The use of porcine dermis in the repair of rectova~aI postoperativevisit, the examinationwas normal, and the fistulae has not been previously reported ~EDLINE patient is without complaints of fecal incontinence or and PubMed searches with the terms "rectova~al fis- c urgency. Shehas resumedsexual intercourse and denies tula," "dermal graft," and "allograft," for the years dyspareunia. 1940-2004, in all languages). Pelvicol (Bard Urology, CoVington, GA) porcine dcrmis is a natUral acellular, nonallergenic matrix that has emerged as an alternative COMMENT to cadaveric dermis for pelvic floor repairs. Porcine Surgical correction of the rectovaginal fistula can be a dermis offers the same advantages as cadaveric dermal complicated procedure, even for the advanced pelvic grafts in repairs, as well as these additional advantages: surgeon.Simple fistula of the mid and lower vagina are offers an essentially unlimited supply, is easily stored most often treated with transrectaladvancement flap or (does not require refrigeration), handlcs very easily, has transvaginallayered closure techniquesand are associ- excellent strength properties, is readily incorporatcd into ated with good surgicalresults. However, complicatedor host tissue, and has decreased risk of bacteria or viral recurrent fistulae often require additional procedures, transmission. Pelvicol has been used for permanent im- with meticulous surgical techniqueand tissuehandling. plantation in humans since 199B.It has been used cxten- The causeof recurrent fistulae is controversial, but su- sively in dermal grafting for burn victims and other areas ture line breakdown may be due to infection causedby of plastic, ear, nose, and throat, and general surgery. A contaminationfrom stool or vaginal bacteria,not haVing recent rcport described its usc in 60 ditTercnt surgical a tension-freeclosure with healthy tissue margins, or procedurcs in 140 patients,6 Thcre is limited data regard-

1166 Moore et al Fistula Repair With Porcine Dermal Graft OBSTETRICS& GYNECOLOGY ing porcine graft use in gynecologic surgery, but initial traditional autologousflaps, but initial resu]tsare encour' ~tudieshave reported its u~e in anteripr and posterior agIng. repair, as well as in pubovaginalslings (Graul ES, Hurst B. Porcine allograft in the repair of an~eriorand posterior vaginal defects[abst.r~c~]. m~ Urogynecolj Pelvic Floor REFERENCES Dysfunc~2002;13 suppl:S36).7,8Our initial experience 1. Wiskind AK, ThompsonJD. Fecal incontinence.In: Rock with porcine dermis in prolapserepair has beenencour- ]A, ThompsonJD, editors.Telinde's operativegynecology. aging,and the indicationsfor its usecontinue ~oincrease. 9ili ed. Philadelphia (PA): Lippincott Williams & Wilkins; We have found i~ ~obe an excellen~m~~erialfor pelvic 1997.p. 1223-36. Boor repairs and have had no significantintr~operative 2. Miklos JR, Kohli N. Rectovaginalfistula repair utilizing a or postoper~tive complications (Moore RD, Kohli N, cadaveric dermal allograft. Int Urogynecol] Pelvic Floor Miklos JR. Laparoscopicuterosacral colpoperineopexy Dysfunct 1999;10:405-6. u~i1iling dermal graft for v~ginal vaul~ prolapse [ab- 3. Moore RD, Miklos JR. Repair of a vaginal evisceration st.rac~].Int Urogynecolj Pelvic Floor Dysfunct 2002;13 following colpocleisisutilizing an a1logenicdermal graft. mt suppl:S39). UrogynecolJ Pelvic Floor Dysfunct 2001;12:215-7. The use of a porcine dermal graft in repair of recto- 4. MiklosJR, Kohli N, Moore RD. Levator plastyrelease and vaginal fistul~ is a method that offers a simplified ap- reconstructionof rectovaginal septumusing allogenicder- proach for placingan interpositional graft with minimal mal graft.lnt UrogynecolJ Pelvic Floor Dysfunct 2002;13: risk or morbidity, giving the surgeonthe advanl:agcsof 44-6. interruption of thc suture lincs withou~the extra surgical 5. Kohli N, MiklosJR. Dermal augmentedrectocele repair. W risks of bringing in an au~ologoustissue Bap. Consider- Urogynecol] Pelvic Floor Dysfunct 2003;14:146-9. ~tion of the use of a dermal graft in the repair of rec~o- 6. Harper C. permacol: clinical experiencewiili a new bioma- vaginal fistula should be givcn ~o patientswho have a terial. Hosp Med 2001;62:90-5. higher risk of failure, including patientsfound ~ohave 7. AruPkalaivanan AS, BarringtonJW. Randomized trial of poor tissuequ~ity that inhibits the surgeonin achieving porcine dermal sling (pelvicol implant) vs tensionfree vag- an adequa~emulti1ayerclosure. Their useshould alsobe inal tape(rvT} in surgicaltreatment of stressincontinence. considered in recurrent or complicatedfistulae or in a Int UrogynecolJPelvic Floor DysfQUct2003;14:17-23. patient where a previous autologous ~issueBap hasfailed.8. Gomelsky A, R~dy DC, DmochowskiRR. Porcine dermis A porcine dermal graf~ should be avoided in interposition graft for repair of high grade anteriorcompart- patients known ~o have a hypersensitivity to porcine ment defects wiili or wimo~t concomitant pelvic organ products or noted ~ohave an active infec~ion.A grea~er prolapse proced~res.] UrQI2004;171:1581-4. number of casesusing porcine dermal graftsin rectovaginal fistula repairs is needed before these grafts can be recommendedin primary repairs~o reduce risk of failure ~ceived October26, 2003.~ceived in revifedformFehruqry 5, 2004. or in more complicatedrepairs ~o avoid having to use 4cceptedFehruqry11, 2004.