J Gastrointest Surg DOI 10.1007/s11605-014-2719-6
HOW I DO IT
How I Do It: Martius Flap for Rectovaginal Fistulas Kevin Kniery & Eric K. Johnson & Scott R. Steele
Received: 17 September 2014 / Accepted: 27 November 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Rectovaginal fistulas present a difficult problem that is frustrating for patients and surgeons alike. Surgical options range from collagen plugs and endorectal advancement flaps to sphincter repairs or resection with coloanal reconstruction. For recurrent or complex rectovaginal fistulas, especially in the setting of prior radiation, Crohn’s disease, or large wounds, bringing in healthy tissue into the space provides an excellent opportunity for improved results. The bulbocavernosus muscle and its surrounding vascularized tissue pedicle, first described by Martius in 1928, is an excellent option for fistula closure. Surgeons caring for these patients should be aware of this technique and have it as one method in their operative armamentarium when faced with these challenging cases. Keywords Rectovaginal fistula . Martius flap . Bulbocavernosus flap
Introduction Rectovaginal fistulas (RVFs) are an abnormal communication between the rectum and vagina, and generally present with passage of air, stool, or even purulent discharge from the vagina. This not only may result in recurrent urinary tract or vaginal infections, but also creates a serious psychosocial burden for the patient.1 They are well known to dramatically lower a female’s self-esteem and impair successful intimate relationships. Unfortunately, they are also notoriously difficult to manage, despite the numerous surgical options presently described, and may even require fecal diversion in attempt to aid closure. When choosing the optimal method to surgically manage these fistulas, the available literature is limited, and there currently are no large K. Kniery : E. K. Johnson : S. R. Steele (*) Department of Surgery, Division of Colorectal Surgery, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA 98431, USA e-mail: [email protected]
prospective trials available to compare the numerous surgical options. While the paucity of data is driven in part by the relatively low incidence of RVFs and the complex anatomical differences between individual patients, it remains one of the more challenging conditions that surgeons caring for colorectal disease encounter. For more complex fistulas, it is imperative to ensure that healthy, well-vascularized tissue is available to optimize outcomes. One such technique involves rotating in the bulbocavernosus muscle and its associated fat pad from the adjacent labia to fill in the rectovaginal septum after debridement and closure of the fistula.
Martius Flap: How I Do It In 1928, Dr. Heinrich Martius, a professor of gynecology in Gottingen, described using the bulbocavernosus muscle and labial fat pad for vaginal wall defects due to its proximity which allows for a single operative field.2 The Martius flap was first used in cystovaginal and urethral-vaginal fistulas. Only later was it adapted to its present use in RVFs. In sum, it is ideally suited for RVF repair, providing a local well-vascularized pedicle of adipose/muscular tissue that is mobile and results in low morbidity. Yet, due to the technical nuances,
J Gastrointest Surg Fig. 1 Crypt probe through distal recurrent rectovaginal fistula (RVF), purple line marks planned incision in vaginal mucosa
many surgeons shy away from its use. Admittedly, it is most suited for complex, recurrent, or recalcitrant RVFs.3 The Martius flap is best able to treat low and mid-level fistulas up to ~5 cm proximal to the vaginal introitus, but in reality is only limited by the reach of the bulbocavernosus pedicle. We present the technique of “How I Do It: Martius Flap for Rectovaginal Fistula” in a 28-year-old woman with a recurrent low-lying RVF who had previously failed an initial fistula plug placement, a subsequent endorectal advancement flap, and was currently fecally diverted.
Fig. 2 Vaginal mucosa is elevating demonstrating the rectovaginal septum
Surgical Technique To optimize outcomes, it is important to ensure that any associated perineal sepsis has resolved completely before attempting a Martius flap. This should be achieved primarily by addressing the underlying cause of the fistula (e.g., medical therapy for Crohn’s disease, removal of a foreign body such as a staple, or drainage of an abscess). Once this has been addressed, adjunctive measures such as fecal diversion or a draining seton will help resolve the active inflammation and allow the tissues to be more amenable to operative repair.
J Gastrointest Surg
Fig. 5 Pedicled bulbocavernosus flap
Fig. 3 Labial incision to harvest bulbocavernosus flap
We prefer to give a full mechanical bowel preparation with oral antibiotics, along with a preoperative dose of a broad-spectrum intravenous antibiotic, prior to surgery. The patient is placed in the high lithotomy position using yellow-fin or “candy cane” stirrups ensuring all bony prominences are well padded. The perineum is prepped with povodine-iodine solution, and the vagina is prepped separately with placement of a Foley catheter. Initial inspection involves ensuring that there are no other potential sources or undrained sepsis that would prohibit proceeding with the repair. In many cases, a seton is already in place and the anatomy is well known. We prefer to confirm the anatomy of the fistula tract with a fistula probe to ensure that it is amenable to bulbocavernosus flap (Fig. 1). We then inject a mixture
Fig. 4 Subcutaneous tunnel connecting the labial incision with the rectovaginal septum
of epinephrine-based local anesthetic in the rectovaginal septum to help with hemostasis, visualization, and pain control. An incision is made just inside the vaginal introitus distal to the fistula opening to create a large broad-based vaginal flap to expose the rectovaginal septum (Fig. 2). With the vaginal flap elevated, dissection continues in the plane of the rectovaginal septum proximally until the fistula is easily within view. Once dissection is well above the fistula, the tract is then curetted on the rectal side and closed primarily with an absorbable 2-0 Vicryl suture in an interrupted figure-of-8 fashion. The vaginal portion of the fistula is excised off of the mobilized vaginal flap so that healthy vaginal tissue is all that remains. We place a small moistened gauze in the rectovaginal septum, and attention is then turned to the selected labia. In most instances, we choose the labia that is closest to the site of the pathology, although prior surgery or individual variations in anatomy may preclude this tenet. A vertical incision is then made in the labia majora to allow for mobilization of the labial fat pad and bulbocavernosus muscle (Fig. 3). In many instances, there is little to no muscle visible, and this should not deter its use. It is important to keep in mind that the blood supply for Martius flap will come from an inferior and posterior location from the posterior labial vessels. The dissection is performed in a lateralto-medial direction and a Penrose is used encircle the pedicled flap. Before transecting the flap superiorly, it is important to confirm that adequate length has been achieved (Fig. 4). We use a Rochester-Pean clamp to form the tunnel from the base of the labial incision into the rectovaginal septum. It is critical to avoid damage to the blood supply as well as the rectum in the process. It is also imperative to make the tunnel large enough to easily accommodate the entire bulbocavernosus flap
J Gastrointest Surg Fig. 6 Pedicled flap rotated through the subcutaneous tunnel
Fig. 7 Arrow points to fat pad in place in rectovaginal septum
Fig. 8 Vaginal cuff repair over the flap
J Gastrointest Surg
had recurrent RVFs after more conservative procedures. Three of these patients have had long-term resolution of their RVFs and have since the reestablished intestinal continuity. Dyspareunia has been reported in as many as 30 % of females at 6 weeks post operatively when they are allowed to resume vaginal intercourse, but it appears to improve with time. The only other more common complication reported in the literature are labial wound issues (
HOW I DO IT
How I Do It: Martius Flap for Rectovaginal Fistulas Kevin Kniery & Eric K. Johnson & Scott R. Steele
Received: 17 September 2014 / Accepted: 27 November 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Rectovaginal fistulas present a difficult problem that is frustrating for patients and surgeons alike. Surgical options range from collagen plugs and endorectal advancement flaps to sphincter repairs or resection with coloanal reconstruction. For recurrent or complex rectovaginal fistulas, especially in the setting of prior radiation, Crohn’s disease, or large wounds, bringing in healthy tissue into the space provides an excellent opportunity for improved results. The bulbocavernosus muscle and its surrounding vascularized tissue pedicle, first described by Martius in 1928, is an excellent option for fistula closure. Surgeons caring for these patients should be aware of this technique and have it as one method in their operative armamentarium when faced with these challenging cases. Keywords Rectovaginal fistula . Martius flap . Bulbocavernosus flap
Introduction Rectovaginal fistulas (RVFs) are an abnormal communication between the rectum and vagina, and generally present with passage of air, stool, or even purulent discharge from the vagina. This not only may result in recurrent urinary tract or vaginal infections, but also creates a serious psychosocial burden for the patient.1 They are well known to dramatically lower a female’s self-esteem and impair successful intimate relationships. Unfortunately, they are also notoriously difficult to manage, despite the numerous surgical options presently described, and may even require fecal diversion in attempt to aid closure. When choosing the optimal method to surgically manage these fistulas, the available literature is limited, and there currently are no large K. Kniery : E. K. Johnson : S. R. Steele (*) Department of Surgery, Division of Colorectal Surgery, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA 98431, USA e-mail: [email protected]
prospective trials available to compare the numerous surgical options. While the paucity of data is driven in part by the relatively low incidence of RVFs and the complex anatomical differences between individual patients, it remains one of the more challenging conditions that surgeons caring for colorectal disease encounter. For more complex fistulas, it is imperative to ensure that healthy, well-vascularized tissue is available to optimize outcomes. One such technique involves rotating in the bulbocavernosus muscle and its associated fat pad from the adjacent labia to fill in the rectovaginal septum after debridement and closure of the fistula.
Martius Flap: How I Do It In 1928, Dr. Heinrich Martius, a professor of gynecology in Gottingen, described using the bulbocavernosus muscle and labial fat pad for vaginal wall defects due to its proximity which allows for a single operative field.2 The Martius flap was first used in cystovaginal and urethral-vaginal fistulas. Only later was it adapted to its present use in RVFs. In sum, it is ideally suited for RVF repair, providing a local well-vascularized pedicle of adipose/muscular tissue that is mobile and results in low morbidity. Yet, due to the technical nuances,
J Gastrointest Surg Fig. 1 Crypt probe through distal recurrent rectovaginal fistula (RVF), purple line marks planned incision in vaginal mucosa
many surgeons shy away from its use. Admittedly, it is most suited for complex, recurrent, or recalcitrant RVFs.3 The Martius flap is best able to treat low and mid-level fistulas up to ~5 cm proximal to the vaginal introitus, but in reality is only limited by the reach of the bulbocavernosus pedicle. We present the technique of “How I Do It: Martius Flap for Rectovaginal Fistula” in a 28-year-old woman with a recurrent low-lying RVF who had previously failed an initial fistula plug placement, a subsequent endorectal advancement flap, and was currently fecally diverted.
Fig. 2 Vaginal mucosa is elevating demonstrating the rectovaginal septum
Surgical Technique To optimize outcomes, it is important to ensure that any associated perineal sepsis has resolved completely before attempting a Martius flap. This should be achieved primarily by addressing the underlying cause of the fistula (e.g., medical therapy for Crohn’s disease, removal of a foreign body such as a staple, or drainage of an abscess). Once this has been addressed, adjunctive measures such as fecal diversion or a draining seton will help resolve the active inflammation and allow the tissues to be more amenable to operative repair.
J Gastrointest Surg
Fig. 5 Pedicled bulbocavernosus flap
Fig. 3 Labial incision to harvest bulbocavernosus flap
We prefer to give a full mechanical bowel preparation with oral antibiotics, along with a preoperative dose of a broad-spectrum intravenous antibiotic, prior to surgery. The patient is placed in the high lithotomy position using yellow-fin or “candy cane” stirrups ensuring all bony prominences are well padded. The perineum is prepped with povodine-iodine solution, and the vagina is prepped separately with placement of a Foley catheter. Initial inspection involves ensuring that there are no other potential sources or undrained sepsis that would prohibit proceeding with the repair. In many cases, a seton is already in place and the anatomy is well known. We prefer to confirm the anatomy of the fistula tract with a fistula probe to ensure that it is amenable to bulbocavernosus flap (Fig. 1). We then inject a mixture
Fig. 4 Subcutaneous tunnel connecting the labial incision with the rectovaginal septum
of epinephrine-based local anesthetic in the rectovaginal septum to help with hemostasis, visualization, and pain control. An incision is made just inside the vaginal introitus distal to the fistula opening to create a large broad-based vaginal flap to expose the rectovaginal septum (Fig. 2). With the vaginal flap elevated, dissection continues in the plane of the rectovaginal septum proximally until the fistula is easily within view. Once dissection is well above the fistula, the tract is then curetted on the rectal side and closed primarily with an absorbable 2-0 Vicryl suture in an interrupted figure-of-8 fashion. The vaginal portion of the fistula is excised off of the mobilized vaginal flap so that healthy vaginal tissue is all that remains. We place a small moistened gauze in the rectovaginal septum, and attention is then turned to the selected labia. In most instances, we choose the labia that is closest to the site of the pathology, although prior surgery or individual variations in anatomy may preclude this tenet. A vertical incision is then made in the labia majora to allow for mobilization of the labial fat pad and bulbocavernosus muscle (Fig. 3). In many instances, there is little to no muscle visible, and this should not deter its use. It is important to keep in mind that the blood supply for Martius flap will come from an inferior and posterior location from the posterior labial vessels. The dissection is performed in a lateralto-medial direction and a Penrose is used encircle the pedicled flap. Before transecting the flap superiorly, it is important to confirm that adequate length has been achieved (Fig. 4). We use a Rochester-Pean clamp to form the tunnel from the base of the labial incision into the rectovaginal septum. It is critical to avoid damage to the blood supply as well as the rectum in the process. It is also imperative to make the tunnel large enough to easily accommodate the entire bulbocavernosus flap
J Gastrointest Surg Fig. 6 Pedicled flap rotated through the subcutaneous tunnel
Fig. 7 Arrow points to fat pad in place in rectovaginal septum
Fig. 8 Vaginal cuff repair over the flap
J Gastrointest Surg
had recurrent RVFs after more conservative procedures. Three of these patients have had long-term resolution of their RVFs and have since the reestablished intestinal continuity. Dyspareunia has been reported in as many as 30 % of females at 6 weeks post operatively when they are allowed to resume vaginal intercourse, but it appears to improve with time. The only other more common complication reported in the literature are labial wound issues (
