Beruflich Dokumente
Kultur Dokumente
2014
Home / Site Map / Vulva and Introitus / Vagina and Urethra / Bladder and Ureter / Cervix / Uterus Fallopian Tubes and Ovaries / Colon / Small Bowel / Abdominal Wall / Malignant Disease: Special Procedures
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Occasionally, a fistula high inside a narrow vagina is difficult to expose. Therefore, a mediolateral episiotomy should be performed without hesitation to allow maximum exposure to the operating site. The mediolateral episiotomy should be extended up the vaginal mucosa to the margin of the fistula. If adequate exposure cannot be obtained completely from the vaginal approach, the abdominal route should be considered, particularly in those cases where the fistula is high in a deep vagina.
Extreme care should be taken that the bowel mucosa is adequately mobilized and that devitalized, scarred, or avascular portions of the mucosa have been excised. If the intestinal mucosa cannot be mobilized and it is apparent that the closure of the intestinal mucosa will be under tension, the surgeon should perform a laparotomy and totally mobilize the rectosigmoid colon from above. Many fistula repairs fail because this in not done. After adequate mobilization of the intestinal mucosa, the edges of the intestinal mucosa are closed in an inverting fashion with interrupted 3-0 Dexon suture with a Lembert stitch.
The perirectal fascia and even some levator ani muscle may be drawn into a second layer of closure using 0 Dexon.
If an outside blood supply is desirable, the margin of the excised fistula tract is connected with the incision of the episiotomy. The bulbocavernosus muscle is palpated under the labia majora, and a longitudinal incision is made down the labia majora through the fat pad until the bulbocavernosus muscle is located.
The bulbocavernosus muscle is dissected out and transected above its insertion into the perineal body, http://www.atlasofpelvicsurgery.com/2VaginalandUrethra/14RectovaginalFistulaRepair/chap2sec14.html
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Rectovaginal Fistula Repair transected above its insertion into the perineal body, leaving its blood supply from the branches of the The bulbocavernosus muscle is sutured over the pudendal artery intact. A tunnel approximately 3 cm perirectal fascia with interrupted 3-0 Dexon wide is created from inside the vaginal canal with a sutures. Kelly clamp, and the bulbocavernosus muscle is drawn through this tunnel underneath the labia
minora and hymenal ring.
The edges of the vaginal mucosa are then approximated with interrupted 2-0 Dexon sutures. The wound over the labia minora may be sutured by subcuticular 3-0 Dexon or interrupted 4-0 nylon sutures. Occasionally, there will be troublesome bleeding from the bed of the bulbocavernosus muscle. If this cannot be brought under adequate control by delicate clamping and suturing, it is often possible to pack this area with Avitene collagen hemostat. In this event, a small 1/4-inch closed suction drain can be brought out from the inferior edge of the labial incision. To have the entire wound completely dry and avoid hemostatic agents or drains is preferred, however. Care must be taken to ensure that the stool is completely soft and that there is no buildup of flatus above the sphincter. The latter can be accomplished by two techniques. One is to dilate the sphincter to 45 cm manually, thus temporarily paralyzing the rectal sphincter and leaving the patient fecally incontinent for approximately 1 week. The other is to incise the rectal sphincter at the 7 or 9 o'clock position in one plane only. Multiple radial incisions in the rectal sphincter may produce permanent fecal incontinence. It is highly recommended that the patient use a stool softener for 3-6 months following fistula repair.
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