Treatment of rectovaginal fistula

I believe some of my friends know the importance of the rectum and vagina. They are the main organs of the body, and their functions are closely related to health. Some friends are troubled by rectovaginal fistula, so how should it be prevented and treated? I will introduce its prevention and treatment methods to you below.

1. Fistula excision and layered suture: After the fistula is excised, it is sutured in layers and can be repaired through the vagina or rectum. The advantages are simple surgery and easy operation. The disadvantage is the high recurrence rate. Due to the tension during suturing, the rectal or vaginal tissue is separated unevenly, so the mucosal muscle flap must have sufficient blood supply.

(1) Surgical method: Free the posterior and both sides of the blind end of the rectum, and then separate the area around the rectovaginal fistula; after the free fistula is ligated and cut, use fine intestinal sutures to suture the rectovaginal septum intermittently; then fully free the rectum so that it is tension-free and sutured with the lower end of the mucosal muscularis.

(2) Postoperative care: Keep the wound clean and dry after surgery, and allow the wound to heal by primary intent. Anal dilation was started 2 weeks after surgery. Anal dilation should be continued for no less than 6 months to prevent anal stenosis from occurring again. This procedure is suitable for patients with low anal atresia, low rectovaginal fistula or recto-vestibular fistula. The older you are, the higher the success rate of surgery.

(3) Surgical consequences: The consequences are reported differently by different institutions. Lescher et al. reported that the postoperative recurrence rate was 84%, and Giver reported it was 30%. Hibband reported 14 cases of first-intention healing. Although some people do not advocate surgery for high rectovaginal fistula, Lawson reported 53 cases of high rectovaginal fistula, 42 of which were successful. He suggested opening the rectouterine pouch, which makes it easier to suture the fistula. The key points of this operation are that there should be no tension during suturing and no ischemia at the suture site.

2. Rectal mobile flap repair In 1902, Noble first used the rectal mobile flap repair to treat rectovaginal fistula. Recently, most scholars believe that this method should be the first choice for repairing low rectal fistula. After satisfactory anesthesia, the patient is placed in the prone position, the internal and external openings are first explored, a probe is inserted into the fistula, a U-shaped incision is used for the rectal mucosal flap, the length-to-width ratio of the flap cannot be greater than 2:1, and adequate blood supply is ensured. Submucosal injection of 1:20000 epinephrine to reduce bleeding. The internal sphincter was divided and sutured in the midline. The mucosal tissue with a width of about 0.3 cm is excised around the fistula to form a wound. Then the movable flap is pulled down to cover the internal wound. Intermittent sutures are performed with 2-0 or 3-0 intestinal sutures to restore the normal anatomical relationship between the mucosa and the skin. The vaginal wound is not sutured and is used for drainage. The effectiveness of this technique is over 77%.

3. Sacral perineal surgery Since the levator ani muscle of a newborn is only about 1.5 cm away from the anus, it is very easy to damage the puborectal ring when the perineum is separated from the rectum. The sacrococcygeal incision can clearly identify the puborectal ring, free the rectum, and easily separate and remove fistulas with higher openings. The surgery is suitable for infants over 6 months old. The longitudinal incision of the sacral skin is about 3 to 5 cm long, and the sacral cartilage is cut transversely to expose the blind end of the rectum; a longitudinal incision is made along the blind end of the rectum to find the fistula in the intestinal cavity, separate the fistula, cut it off and then suture it. The rectum is mobilized until it can relax and descend to the level of the anal fossa skin. Make an X-shaped incision in the skin of the anal fossa to expose the external sphincter, and slowly pull the rectum from the middle of the puborectal ring to the anus. Be careful not to twist the intestinal segment and avoid forceful expansion of the fingers inside the intestinal ring. The rectal wall and the subcutaneous tissue of the anus are sutured with several stitches of silk thread, and the full thickness of the rectum and the anal skin are sutured intermittently with 3-0 catgut or silk thread. Close the sacrococcygeal wounds one by one. In addition, high rectal atresia and rectovaginal fistula can also be treated with abdominoperineal anoplasty, rectovaginal fistula repair and colostomy in the neonatal period, but due to practical conditions and the high surgical mortality rate, it is not easily accepted by parents. The main surgical complications of all high-position fistulas are infection and fistula recurrence, and reoperation is more difficult. A treatment plan should be formulated for each specific case based on its condition and actual conditions, and an appropriate surgical method should be selected. For acquired rectovaginal fistula, treatment should be based on the cause. If caused by inflammation, enteritis should be actively treated and then the surgical procedures such as repair, intestinal resection and colostomy should be determined based on the condition. Rectovaginal fistula caused by obstetric surgery and trauma can be repaired through the rectum or vagina if the inflammation is under control. The edges of the rectum and vaginal walls were incised and separated, the rectal wall was closed by rolling it inward transversely, the vaginal submucosal tissue was matched longitudinally, and the vaginal mucosa was closed transversely. Local repair of radiation rectovaginal fistula is extremely difficult and often impossible, so a colostomy should be performed. For rectovaginal fistula caused by foreign bodies or electrocautery, a primary colostomy should be performed first, and a secondary fistula repair and intestinal anastomosis or pull-out should be performed if necessary. There are many surgical methods for rectovaginal fistula at present, but the best surgical method should be selected according to the specific case to achieve the best effect with minimal damage.

In the above article, we introduced the importance of rectovaginal fistula and the methods of treating rectovaginal fistula. If there is any problem in the body, it must be treated in time. I hope my friends take care of their health. Be happy every day.