Beruflich Dokumente
Kultur Dokumente
Maternal
Conference
Auran Rosanne B. Cortes, MD – MBA
September 28, 2018
VULVOVAGINAL HEMATOMA
WITH COMPLICATIONS
CASE REPORT: Brief History and Findings
General Data
• EA
• 40 y/o Gravida 3 Para 3 (3-0-0-3)
• Married
• Roman Catholic
• Las Piñas
CASE REPORT: Brief History and Findings
Chief Complaint
Routine postpartum follow up
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
> Wound
for trial of > Evacuation
dehiscence
labor of hematoma
> Rectovaginal
> Delivered and ligation fistula (?)
of bleeders
via NSD
> Blood
transfusion
(2u pRBC)
> Postpartum
Day 1
> Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
> Wound
for trial of dehiscence
labor 7 days prior > Evacuation > Rectovaginal
> Delivered “Labor pains”of hematoma fistula (?)
via NSD and ligation
Stable vital signs
of bleeders
Good fetal heart tones
IE: 7 cm, 70% effaced, (+) bag of water, cephalic,
station -3 85
Mode of delivery: Normal spontaneous delivery with
perineal support and repair of 2nd degree laceration
> Postpartum
Dayunder
1 local anesthesia
> Post-
Outcome: Baby Boy, 2935 grams
> Vulvovaginal AGA
evacuation
hematoma
Duration of labor: > 3 hours Day 1
Estimated blood loss: 400 ml > Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Voiding freely Day 7
> Wound
for trial of No subjective complaints dehiscence
labor > Evacuation > Rectovaginal
> Delivered
Stable
of hematoma
vital signs fistula (?)
via NSD Pelvic examination:
and ligation
of bleeders
Intact sutures
(+) 8 x 6 cm fluctuant,
tender mass between 85
the 6 & 7 o’clock position
of the perineum
> Postpartum extending to the right
Day 1
> Vulvovaginal
posterior vaginal wall
> Post-
hematoma evacuation
Cervix soft, admits 1 finger
Day 1
Uterus contracted> Hospital
Minimal, non-foul smelling lochial discharge
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted ASSESSMENT: Day 7
> Wound
for trial of dehiscence
labor > Evacuation3 Para 3 (3003) > Rectovaginal
> Delivered
Gravida
of hematoma fistula (?)
via NSD Status post
and ligation
of bleedersspontaneous delivery
Normal
with repair of
2nd degree laceration85
under local anesthesia,
Vulvovaginal hematoma
> Postpartum
Day 1
> Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted INTERVENTIONS: Day 7
> Wound
for trial of dehiscence
labor
> Delivered
•of> Evacuation
Hemostasis
hematoma
> Rectovaginal
fistula (?)
via NSD andInsertion
ligation of vaginal pack
• ofVenoclysis
bleeders as double line
for possible fluid
resuscitation 85
• Bladder catheterization
• Medications:
> Postpartum Antibiotic (Ampicillin 2g/IV)
Day 1 and anti-fibrinolytic> Post-
> Vulvovaginal
hematoma (Tranexamic acidevacuation
1g/IV)
• CBC: Hgb 91 | HctDay0.30
1 | WBC 14.2 | Platelet 351
• Stat evacuation>discharge
Hospital
of hematoma with ligation of
bleeders and repair under spinal anesthesia
CASE REPORT: Brief History and Findings
> Postpartum
TECHNIQUE OF REPAIR: Day 7
> Admitted
> Wound
for trial of > Evacuation dehiscence
labor of hematoma • Series of figure-of-eight stitches
> Rectovaginal
> Delivered and ligation of for the deepest layerfistula (?)
bleeders
via NSD > Blood
• Vaginal mucosa
transfusion reapproximated in 2 layers
(2u pRBC) • 1st layer: figure-of-eight
stitches using polyglactin 0
85suture
• 2nd layer: continuous
interlocking stitches using
> Postpartum chromic 2-0 suture
Day 1 • >Skin:
Post-
Inverted T stitches using
> Vulvovaginal chromic 2-0 suture
hematoma evacuation
• Repair
Day 1 followed by perineal
cleansing and Povidone Iodine
> Hospital
application
discharge
CASE REPORT: Brief History and Findings
> Postpartum
OPERATIVE FINDINGS:Day 7
> Admitted
> Wound
for trial of > Evacuation dehiscence
labor of hematoma • (+) 8 x 6 cm fluctuant, tender
> Rectovaginal
> Delivered and ligation of mass between the 6 fistula
& 7 o’clock
(?)
bleeders
via NSD > Blood
position of the perineum
transfusion extending to the right posterior
(2u pRBC) vaginal wall
• 300 ml blood clots were
85
evacuated
• 8 x 8 cm laceration between 6
and 7 o’clock position of the
> Postpartum perineum
Day 1 • >Smooth
Post-
and intact rectal
> Vulvovaginal mucosa with tight sphincteric
hematoma evacuation
tone
Day 1
> Hospital
• discharge
Estimated blood loss: 1 L
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
> Wound
for trial of PELVIC EXAMINATION FINDINGS:
DISCHARGE > Evacuation dehiscence
labor of hematoma > Rectovaginal
>External
Deliveredgenitalia: and ligation of fistula (?)
bleeders
via NSD
Intact sutures, no discoloration, no bleeding
> Blood
transfusion
Internal examination: (2u pRBC)
Intact sutures, no masses nor tenderness,
Cervix soft, admits 1 finger
Uterus well contracted
Minimal non-foul smelling lochial discharge
> Postpartum
Repeat CBC: Day 1
Hgb 102 | Hct 0.31> Vulvovaginal
| WBC 17.6 | Platelet 258 > Post-
hematoma evacuation
Day 1
Home medications: > Hospital
Co-amoxiclav, Ferrous sulfate, Mefenamic acid discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
Routine postpartum follow-up > Wound
for trial of > Evacuation dehiscence
No subjective complaints
labor of hematoma > Rectovaginal
>Stable
Delivered and ligation of
vital signs fistula (?)
bleeders
via NSD > Blood
PELVIC EXAMINATION FINDINGS: transfusion
(2u pRBC)
(+) Loose sutures with wound gaping at the site of laceration repair, 6
cm in length and 5 cm in depth
85
(+) Minimal yellow, non-foul smelling discharge, necrotic tissues, and
minimal bleeding at the site of laceration repair
(+) 2 cm defect within the right side of the wound dehiscence at the
middle third of the vagina that communicates with the rectal vault, with
> Postpartum
Day 1
fecaloid material upon probing with a cotton pledget > Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
Routine postpartum follow-up > Wound
for trial of > Evacuation dehiscence
No subjective complaints
labor of hematoma > Rectovaginal
>Stable
Delivered and ligation of
vital signs fistula (?)
bleeders
via NSD > Blood
PELVIC EXAMINATION FINDINGS: transfusion
(2u pRBC)
Cervix soft, admits 1 finger
Uterus enlarged to 12 to 14 week-size, well contracted
Minimal-foul smelling lochial discharge 85
No uterine or adnexal tenderness
> Postpartum
Day 1
> Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Brief History and Findings
> Postpartum
> Admitted Day 7
Routine postpartum follow-up > Wound
for trial of > Evacuation dehiscence
No subjective complaints
labor of hematoma > Rectovaginal
>Stable
Delivered and ligation of
vital signs fistula (?)
bleeders
via NSD > Blood
RECTAL EXAMINATION FINDINGS: transfusion
(2u pRBC)
Good sphincter tone
(+) 2 cm mucosal break at the rectal vault that communicates with the
85
right side of the wound dehiscence at the middle third of the vagina,
with fecaloid material
> Postpartum
Day 1
> Post-
> Vulvovaginal
hematoma evacuation
Day 1
> Hospital
discharge
CASE REPORT: Admitting Impression
DESCRIPTION: Beefy red in some areas DESCRIPTION: Beefy red appearance in most tissues admixed with minimal fibrin deposits
admixed with necrotic tissues and isolated areas of necrotic tissues
Fistula As described 2 cm defect within the right side of the 2 cm defect within the right side of the 1.5 to 2 cm defect within the right side of the
dehiscence connected to the anal canal dehiscence connected to the anal canal with dehiscence connected to the anal canal with
greenish fecaloid material greenish fecaloid material
Laboratory Findings Hgb 103 Hgb 116 Barium fistulogram:
Hct 0.34 Hct 0.37 Fistulous tract in the
WBC 11.5 WBC 11.2 episiotomy incision
Plt 499 Plt 435 showing influx of
contrast material into
the rectum
Additional Blood transfusion Dietary fiber 5g
Intervention (1u pRBC)
Discharged stable
IV Antibiotics completed for 10 days shifted to oral
Ciprofloxacin 500 mg/tab 1 tablet every 12 hours for 7 days
Daily wound flushing and scrubbing
Await for spontaneous closure of the fistula
Follow up after 1 week at the Urogynecology Service
CASE REPORT: Final Diagnosis
Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications
Key Points of
Discussion Perineal
wound
dehiscence
Perineal
lacerations
Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications
Perineal
wound
dehiscence
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Background
1Webb S, Sherburn M, and Ismail KM. (2014). Managing perineal trauma after childbirth. BMJ. 349:g6829.
2Cunningham FG et al. (2018). Williams Obstetrics 25th Ed. [E-reader version]. Retrieved from https://t.me/ebookers
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Risk Factors
1Webb S, Sherburn M, and Ismail KM. (2014). Managing perineal trauma after childbirth. BMJ. 349:g6829.
2Cunningham FG et al. (2018). Williams Obstetrics 25th Ed. [E-reader version]. Retrieved from https://t.me/ebookers
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Anatomy
Female pelvic muscles at the level of the pelvic floor Muscles of the female perineum
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Anatomy
LOCATION DESCRIPTION
Anterior perineal trauma Injury involving the labia, anterior
vagina, urethra or clitoris
Posterior perineal trauma Injury to the posterior vaginal
wall, perineal muscles or anal
sphincters and may extend
through the rectum
Female Perineum
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Classification
DEPTH DESCRIPTION
First-degree lacerations Injury to the skin and subcutaneous tissue of the perineum and vaginal epithelium only
Perineal muscles remain intact
Second-degree lacerations Extend into the fascia and musculature of the perineal body, which includes the deep and
superficial transverse perineal muscles and fibers of the pubococcygeus and
bulbocavernosus muscles
Anal sphincter muscles remain intact
Third-degree lacerations Extend through the fascia and musculature of the perineal body and involve some or all of
the fibers of the external anal sphincter (EAS) and/or the internal anal sphincter (IAS)
Subclassification:
•3a – <50 percent of EAS thickness is torn
•3b – >50 percent of EAS thickness is torn
•3c – Both EAS and IAS are torn
Fourth-degree lacerations Involve the perineal structures, EAS, IAS, and the rectal mucosa
American College of Obstetricians and Gynecologists. (2016). Summary: Prevention and Management of Obstetric Lacerations at Vaginal Delivery: Correction. Practice
Bulletin No. 165. Obstetrics & Gynecology. 128:411.
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Management
DEPTH TECHNIQUE
First-degree lacerations Do not always require repair, and sutures are placed to control bleeding or restore anatomy
Fine-gauge absorbable or delayed-absorbable suture or adhesive glue
Second-degree lacerations Most studies support a continuous suturing method
Blunt needles
2–0 polyglactin 910 (traditional vs rapidly absorbed) or chromic catgut
Third-degree lacerations EAS: End-to-end technique vs Overlapping technique
IAS: Interrupted sutures
Cunningham FG et al. (2018). Williams Obstetrics 25th Ed. [E-reader version]. Retrieved from https://t.me/ebookers
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PERINEAL LACERATIONS ASSOCIATED
WITH CHILDBIRTH: Management
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
Perineal
lacerations
Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications
Perineal
wound
dehiscence
PURPUERAL GENITAL HEMATOMA:
Background
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PURPUERAL GENITAL HEMATOMA:
Risk Factors
1Mawhinney S, and Holman R. (2007). Puerperal genital haematoma: a commonly missed diagnosis. The Obstetrician & Gynaecologist. 9:195 – 200.
2American College of Obstetricians and Gynecologists. (2017). Postpartum hemorrhage. Practice Bulletin No. 183. Obstetrics & Gynecology. 130:e168 – 86.
3Sultan AH, and Thakar R. (2014). Lower genital tract trauma in Baskett TF, Calder AA, and Arulkumaran S (12th ed.), Munro Kerr’s operative obstetrics (pp. 217 – 224).
1Mawhinney S, and Holman R. (2007). Puerperal genital haematoma: a commonly missed diagnosis. The Obstetrician & Gynaecologist. 9:195 – 200.
2American College of Obstetricians and Gynecologists. (2017). Postpartum hemorrhage. Practice Bulletin No. 183. Obstetrics & Gynecology. 130:e168 – 86.
3Sultan AH, and Thakar R. (2014). Lower genital tract trauma in Baskett TF, Calder AA, and Arulkumaran S (12th ed.), Munro Kerr’s operative obstetrics (pp. 217 – 224).
Upper 1/3
Cervico-vaginal branch of the uterine
artery
Middle 1/3
Inferior vesical artery
Lower 1/3
Middle rectal and internal pudendal
arteries
PURPUERAL GENITAL HEMATOMA:
Blood Supply: Vagina
Upper 1/3
Cervico-vaginal branch of the uterine
artery
Middle 1/3
Inferior vesical artery
Lower 1/3
CASE CORRELATION: Middle rectal and internal pudendal
(+) 8 x 6 cm fluctuant, tender arteries
mass between the 6 & 7
o’clock position of the
perineum extending to the
right posterior vaginal wall
PURPUERAL GENITAL HEMATOMA:
Blood Supply: Perineum
CASE CORRELATION:
(+) 8 x 6 cm fluctuant, tender
mass between the 6 & 7
o’clock position of the
perineum extending to the
right posterior vaginal wall
Arteries of the female perineum
PURPUERAL GENITAL HEMATOMA:
Anatomical and Blood Supply Correlation
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
Roman AS. (2017, December 14). Management of hematomas incurred as a result of obstetrical delivery. Retrieved from https://www.uptodate.com
PURPUERAL GENITAL HEMATOMA:
Diagnosis
• Clinical awareness
• Excessive perineal pain
• A change in vital signs disproportionate to the amount of
blood loss should prompt a gentle pelvic examination.
• Imaging may be helpful to confirm the diagnosis when there is
a high clinical suspicion for hematoma but the patient remains
hemodynamically stable.
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
PURPUERAL GENITAL HEMATOMA:
Management
• Early recognition
• Prompt resuscitation and search for the cause
• Complete blood count and coagulation screen
• Adequate anesthesia
• Conservative management for small, non-expanding
hematoma (< 3 cm)
• Surgical evacuation, primary closure, and compression for
large hematoma (≥ 3 cm)
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
Roman AS. (2017, December 14). Management of hematomas incurred as a result of obstetrical delivery. Retrieved from https://www.uptodate.com
PURPUERAL GENITAL HEMATOMA:
Management
Reyes, LD. (2014). Genital tract trauma in Philippine Obstetrical and Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric hemorrhage (pp. 115
– 157). Makati City, Metro Manila, Philippines: OVT-Graphic Line, Inc.
Roman AS. (2017, December 14). Management of hematomas incurred as a result of obstetrical delivery. Retrieved from https://www.uptodate.com
Perineal
lacerations
Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications
Perineal
wound
dehiscence
PERINEAL WOUND DEHISCENCE:
Background
• Wound breakdown
• Separation of sutured perineal skin,
vaginal mucosa or the underlying
perineal muscles
Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
PERINEAL WOUND DEHISCENCE:
Background
• Partial or Complete
• Peak time of separation is ~ 10 to 14
days following vaginal delivery
Berkowitz LR, and Foust-Wright, CE. (2018, May 24). Postpartum perineal care and management of complications. Retrieved from https://www.uptodate.com
PERINEAL WOUND DEHISCENCE:
Risk Factors
Dudley, L. (2014). Perineal re-suturing versus expectant management following vaginal delivery complicated by a dehisced wound ‘The PREVIEW Study’. Staffordshire
University, England, United Kingdom.
PERINEAL WOUND DEHISCENCE:
Risk Factors
Dudley, L. (2014). Perineal re-suturing versus expectant management following vaginal delivery complicated by a dehisced wound ‘The PREVIEW Study’. Staffordshire
University, England, United Kingdom.
PERINEAL WOUND DEHISCENCE:
Signs and Symptoms
SIGNS SYMPTOMS
Edema Pain
Erythema Fever
Exudate formation Difficulty or inability to void
Tenderness Stool and flatal incontinence
Dehiscence of the repair
Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
PERINEAL WOUND DEHISCENCE:
Management
✓ Baseline CBC
✓ Wound debridement
✓ Daily wound preparation and irrigation*
*Half strength Daikin’s solution, betadine impregnated brush, or a combination
of povidone iodine, hydrogen peroxide, and normal saline
✓ Early repair (within 3 – 14 days) once the wound is exudate-free and covered with
pink granulation tissue
✓ Repair by layered closure with either chromic catgut or polyglactin under regional
anesthesia
Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
PERINEAL WOUND DEHISCENCE:
Management
Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
PERINEAL WOUND DEHISCENCE:
Post operative Care
Esteban, LK. (2015). Episiotomy wound dehiscence in Philippine Infectious Diseases Society for Obstetrics and Gynecology, Inc. and Philippine Obstetrical and
Gynecological Society Foundation, Inc. Clinical practice guidelines on obstetric and gynecologic infectious diseases (pp. 18 – 26). Makati City, Metro Manila,
Philippines: OVT-Graphic Line, Inc.
Perineal
lacerations
Postpartum
Perineal Care
Rectovaginal Vulvovaginal
fistula
and hematoma
Management of
Complications
Perineal
wound
dehiscence
RECTOVAGINAL FISTULA:
Background
Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
RECTOVAGINAL FISTULA:
Classification
SIZE Measurement
Small < 0.5 cm
Medium 0.5 to 2.5 cm
Large > 2.5 cm
Das B and Synder M. (2016). Rectovaginal fistulae. Clin Colon Rectal Surg. 29:50–56.
RECTOVAGINAL FISTULA:
Risk Factors
• Obstetric complications
• Inflammatory bowel disease
• Infection
• Previous surgery in the anorectal area
• Pelvic radiation therapy
• Neoplasm
• Trauma
GOALS
• To restore the anatomy and function
• To improve the quality of life for
patients
RECTOVAGINAL FISTULA:
Management: Conservative
Basic Principles:
✓ Proper timing of the repair
✓ Wide mobilization of the adjacent tissue planes
✓ Complete excision of the fistula tract
✓ Multilayered closure (Tension-free approximation of all layers)
Lobo RA, Gershenson DM, Lentz GM, and Valea FA. (2017). Comprehensive gynecology 7th ed. China: McGraw – Hill.
RECTOVAGINAL FISTULA:
Management: Surgical
Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
RECTOVAGINAL FISTULA:
Management: Surgical
Techniques:
✓Transanal
✓Transvaginal
✓Perineal
✓Abdominal
Glowacki CA and Zitsman S. (2017). Rectovaginal fistula in Lippincott Continuing Medical Education Institute, Inc. Topics in obstetrics & gynecology. 37 (2):1 –6.
RECTOVAGINAL FISTULA:
Management: Surgical
LOCATION PROCEDURE
Obstetric related Transvaginal or transanal approach through episioproctotomy,
defects or Low fistula Fistulotomy with a tension-free layered closure without episioproctotomy, or
Fistulotomy with transvaginal purse-string method of repair without
episioproctotomy
Midlevel Transvaginally or transanally by a tension-free layered closure or an
endorectal advancement flap
Lobo RA, Gershenson DM, Lentz GM, and Valea FA. (2017). Comprehensive gynecology 7th ed. China: McGraw – Hill.
In hindsight,