2012 Annual Meeting-Rectovaginal Fistula Repair Using A Disposable Biopsy Punch

Video Transcription

In this video, we are demonstrating a novel approach to rectovaginal fistula repair using a biopsy punch to excise the fistula tract.  The patient is a 24-year-old woman who developed a rectovaginal fistula after a forceps delivery with a fourth-degree laceration. She had a previous attempt at repair which failed.  Undiluted methylene blue is used to stain the tract.  A lacrimal duct probe is placed through a rolled up moistened sponge and placed into the rectum and up through the fistula tract.  The fistula tract measured approximately 2-3 mm in diameter and was 3 cm from the introitus.  After local anesthetic is injected around the fistula tract, a 6 mm Miltex biopsy punch is placed over the lacrimal probe.  There is a passage through the biopsy punch that the lacrimal probe must traverse. The sponge in the rectum prevents the biopsy punch from injuring the rest of the rectum.  You can see that the punch biopsy does an excellent job of removing the entire epithelial tract which is critical to the success of the fistula repair.  An incision is made inferiorly and superiorly in order to gain better access for the repair.  The lacrimal probe and sponge are removed and a Leucite probe is placed in the rectum to help delineate the defect.  The full thickness rectal mucosa is then closed vertically with a running continuous stitch of 3-O-Vicryl.  Metzenbaum scissors are used to free up the rectovaginal fascia from the epithelium and a second layer of horizontal figure-of-eight stitches of 3-O-Vicryl are placed.  A third vertical layer is placed in the submucosa again using 3-O-Vicryl.  Generous normal saline irrigation is performed at each layer.  Finally, the epithelium is repaired with 2-O-Vicryl. The patient was discharged the following day on a low residue diet and stool softeners.  The biopsy punch is a simple-to-perform technique that ensures that the epithelial fistula tract is removed in its entirety which may translate to improved success for this repair.  The biopsy punch is a simple-to-perform technique that ensures that the epithelial fistula tract is removed in its entirety which may translate to improved success for this repair.

Video Summary

This video demonstrates a novel approach to repairing a rectovaginal fistula using a biopsy punch to remove the fistula tract. The patient is a 24-year-old woman who developed the fistula after a forceps delivery. Previous attempts at repair had failed. The procedure involves using methylene blue to stain the tract, inserting a lacrimal duct probe through a moistened sponge into the rectum and the fistula tract, and using a 6 mm Miltex biopsy punch to remove the tract. Incisions are made for better access, and the rectal mucosa is closed vertically with stitches. The success of the repair is attributed to the use of the biopsy punch technique. The patient was discharged on a specialized diet. No credits were given for this video.

Keywords

rectovaginal fistula repair

biopsy punch technique

forceps delivery complications

methylene blue staining

rectal mucosa closure