RU2369337C1 - Method of surgical treatment of rectovaginal fistula - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely, to colorectal surgery, can be applied for treatment of rectovaginal fistulas of low and middle level with location of internal fistula opening in rectum at distance not more than 6 cm from anus edge. Rectovaginal fistula is excised. Anterior sphincterolevatoroplasty is performed. After excising fistulas cutting by section on back wall of vagina, complete layer segment of vaginas wall is separated and mobilised in caudal direction. Segment is thrown back. Then rectovaginal septum is split and sphincterolevatoroplasty is carried out. Further by formed flap carried out is plasty of anterior wall of anal canal and perineum, is formed sewing flap by separate sutures to skin, vagina is sutured in longitudinal direction.

EFFECT: allows to eliminate rectovaginal fistula, reduce risk of disease recurrence and development of post-operation complications by excluding retraction of brought down segment of rectum, to realise correction of anal sphincter insufficiency by carrying out adequate anterior sphincterolevatoroplasty, perineum creation.

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Description

The invention relates to medicine, namely to colorectal surgery, and can be used to treat rectovaginal fistulas of low and medium levels (the internal fistulous opening of the rectum is located no more than 6 cm from the edge of the anus).

The following methods of treating rectovaginal fistula are known.

1. Excision of the fistula with suturing defects of the wall of the rectum and vagina. This method allows you to eliminate rectovaginal fistula.

Its disadvantages are:

- A significant number of relapses of the disease, which is associated with the presence of subacute inflammatory changes in the rectovaginal septum.

- In 25% of patients due to traumatic injuries (ruptures in childbirth, previous operations), a prolonged current purulent process in the rectovaginal septum, there is insufficiency of the anal sphincter due to a defect in the anal sphincter in the anterior semicircle. In this group of patients, it is necessary not only to eliminate the fistula, but also to perform perineal plasty - anterior sphincteroleoplasty.

2. Excision of the fistula into the intestinal lumen allows eliminating the fistula, however, dissection of the muscles of the anal sphincter along the anterior semicircle leads to the development of insufficiency of the anal sphincter.

3. Excision of the fistula into the lumen of the intestine with sphincterolevatoroplasty. The disadvantages of this method are:

- With this method, given the inflammatory nature of the disease, the pronounced cicatricial process in the rectovaginal septum, the formation of the perineum is often difficult, which leads to a significant number of postoperative complications (diastasis of skin and / or muscle sutures, suppuration of a postoperative wound).

- In 25% of patients due to traumatic injuries (ruptures in childbirth, previous operations), a prolonged current purulent process in the rectovaginal septum, there is insufficiency of the anal sphincter due to a defect in the anal sphincter in the anterior semicircle. In this group of patients, it is necessary not only to eliminate the fistula, but also to perform perineal plasty - anterior sphincteroleoplasty.

4. Elimination of rectovaginal fistula with the reduction of the full-layer segment of the wall of the rectum along the anterior semicircle.

The disadvantages of this method are:

- While maintaining a normal passage of intestinal contents (without the formation of a preventive intestinal stoma), the risk of retraction of the reduced segment of the rectal wall along the anterior semicircle increases significantly and the disease recurs.

- Mobilization of the wall of the rectum along the anterior semicircle is often difficult due to pronounced cicatricial changes.

- In 25% of patients due to traumatic injuries (ruptures in childbirth, previous operations), a prolonged current purulent process in the rectovaginal septum, there is insufficiency of the anal sphincter due to a defect in the anal sphincter in the anterior semicircle. In this group of patients, it is necessary not only to eliminate the fistula, but also to perform perineal plasty - anterior sphincteroleoplasty.

The prototype of the proposed method for the treatment of rectocele is excision of the rectovaginal fistula, anterior sphincterolevatoroplasty.

The purpose of the invention:

- to improve the results of surgical treatment of rectovaginal fistula by reducing the risk of developing early and late postoperative complications, as well as anterior sphincteroleoplasty.

Technique of operation: A fistula is dissected into the intestinal lumen. Pathologically altered tissues, fistulous openings are excised. After this, the vaginal wall is cut. The selected full-layer segment of the posterior wall of the vagina is mobilized in the caudal direction.

The selected and mobilized segment of the vaginal wall leans back. After this, hydropreparation and cleavage of the rectovaginal conversion are performed. The front wall of the rectum, the front portions of the levator muscles and the ends of the anal sphincter stand out. The distinguished muscles of the levators are reduced by separate sutures with the capture of the front wall of the rectum. After this, the selected ends of the anal sphincter are reduced over the distal part of the anterior wall of the rectum and the selected and mobilized flap of the vaginal wall. Next, the plastic flap of the anterior wall of the anal canal is performed with the formed flap and the perineum is formed by hemming the flap with separate sutures to the skin. After that, the vagina is sutured in the longitudinal direction. The proposed technology allows to eliminate rectovaginal fistula, perform anterior sphincterolevatoroplasty, and form a perineum.

Clinical example

Patient D., 33 years old, IS No. 5434-07, was admitted with complaints of excrement of feces and gases from the vagina, incontinence of liquid feces and gases.

During vaginal examination, a fistulous opening up to 0.3 cm in size is located on the border of the vestibule and the lower third of the vagina.

During an external examination of the perianal region, there is no maceration. Anus is closed. With a digital study of the rectum, the sphincter tone, volitional efforts are weakened, the defect of the anal sphincter is determined from 11 to 2 hours. In the lower ampullar part of the rectum at 12 o’clock, at the upper edge of the anal canal, a funnel-shaped indentation is determined up to 0.5-0.6 cm in diameter with scarred edges. When examining with a button probe through the fistulous opening in the vagina, the end of the probe is removed through the fistulous opening in the rectum. The course of the fistula is located proximal to the external sphincter.

In a functional study of the obturator apparatus of the rectum, the electrophysiological indicators of the contractility of the muscles of the external sphincter are reduced due to a sphincter defect from 11 to 2 hours.

The patient was diagnosed with rectovaginal fistula. The insufficiency of the anal sphincter of 2 tbsp.

March 24, 2007 the patient underwent surgery by the proposed method. The postoperative period was uneventful. The postoperative wound in the perineum healed by primary intention. On day 11 was discharged.

The follow-up was 3 months. There is no data for the recurrence of the disease for the indicated period. The patient retains all components of the intestinal contents. In the control functional study of the obturator apparatus of the rectum, the electrophysiological indicators of the contractility of the muscles of the external sphincter are within the physiological norm.

The proposed method in comparison with the known methods of surgical treatment of rectovaginal fistulas of low and medium levels makes it possible:

- reduce the risk of relapse;

- adequately perform sphincterolevatoroplasty and form the perineum;

- improve the functional results of treatment of this category of patients.

Bibliography

1. Clinical surgical coloproctology (Edited by Fedorov VD, Vorobiev GI). M., 1994, p. 363-367.

2. Coloproctology and the pelvic floor (edited by M.M. Henry, M. Swosh).

3. Medscape Womens Health 1998 Jul; 3 (4): 4.

Pelvic prolapse: diagnosing and treating cystoceles, rectoceles and enteroceles. Cespedes RD, Cross CA, McGuire EJ.

4. Surgical management of anorectal and colonic diseases. Marc-Claude Marti, Jean-Claude Givel. 1998.

5. The basics of coloproctology. Edited by G. Vorobyov, M.: Medical Information Agency LLC, 2006, p.193-209.

Claims (1)

A method for the surgical treatment of low- and mid-level rectovaginal fistulas, including excision of the rectovaginal fistula and performing anterior sphincterolevatoroplasty, characterized in that after excision of the fistula, a full-layer segment of the vaginal wall is isolated and mobilized in the caudal direction and the rectovaginal segment is reclined, then the rectovaginal section is split sphincterolevoplasty is performed, then the plastic of the anterior wall of the anal canal is performed with the formed flap and ormiruyut crotch flap hemming separate sutures to the skin, the vagina is sutured longitudinally.