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AUGS/IUGA Scientific Meeting 2019
Martius Labial Fat Pad Graft (Use in RVF Repair)
Martius Labial Fat Pad Graft (Use in RVF Repair)
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Video Transcription
We present today the use of the Mardius graft to repair a multi-recurrent rectovaginal fistula. This video focuses on development and placement of the flap and begins after the rectal defect has been closed in two layers, followed by a third overlying layer of rectovaginal fascia. We begin here briefly outlining the labial fat pad and adjacent fold prior to incision. An incision is then made with a 15 blade over the middle and fattiest portion of the labium magus starting at the level of the clitoral hood superiorly and extending inferiorly to the level of the labial crural fold. Small rakes are placed bilaterally to facilitate further exposure and the yellow fibro fatty graft is then grasped and retracted first medially where the presence of a natural tissue plane facilitates dissection from the surrounding labium magus. First described in 1928, Mardius noted needing a flap as thick as a thumb and as long as a finger for his repairs. This incision could, however, be extended superiorly if the need for a longer graft is anticipated. Extension onto the mons to achieve a length capable of reaching the vaginal apex has been described. The graft is now retracted laterally and a plane between the graft and the bubocavernosus muscle is developed. To avoid devascularization of adjacent skin, it is best to leave a fatty layer attached at its undersurface. Pelvic fistulas are some of the most challenging conditions the reconstructive pelvic surgeon will need to correct. While nothing can replace primary excision, wide tissue mobilization, and multilayered tension-free closure, flaps are nevertheless an important adjunct to fistula repair and may be ideally suited for relatively large defects, radiation-induced fistulas, and for previously failed repairs. The Mardius flap is a relatively simple technique with low associated morbidity and favorable cosmetic outcomes. Once the desired width and length have been obtained, division of the flap, in this case, has begun at its anterior pedicle. Vessels are necessarily encountered and divided with any Mardius flap development, as can be seen here. It is important to develop a flap that easily covers the defect with a good degree of overlap. It is best to avoid covering the defect with just the tip of the graft. Here, the mobile cavernosus muscle is being pointed out by the surgeon. Care should be taken to remain lateral to this structure during the dissection to avoid unnecessary bleeding and devascularization. Once the flap has been sufficiently mobilized, a shell cross is used to facilitate creation of the subepithelial defect through which the flap will be passed. This defect is widened sufficiently enough to prevent compression on the pedicle blood supply. In this case, a defect approximately two centimeters in diameter, as seen here, is sufficient. The flap is then brought through the levator plate, being sure to avoid rotation at its base that would, again, risk its blood supply. A topical hemostatic agent and or drain may be utilized at the discretion of the surgeon. The flap has now been positioned and will be sewn into place by attaching it to the adjacent underlying rectal vaginal fascia with interrupted 2-O-vicral suture. We begin by attaching the lateral most extent of the graft to ensure adequate defect coverage, followed by counterclockwise graft attachment, progressing from more difficult to progressively easier points of visualization. It is important to note that no tensioning or pulling of the flap is required to approximate it to the adjacent tissue. In this way, the dead space over the fistula repair is obliterated and a new blood supply is brought into the devascularized dissected area. Anatomical dissection of this graft on a cadaver by Elkins in 1990 delineated an abundant vascular supply from several directions. The posterior labial branches of the internal pudendal artery and vein supply the graft posteriorly and inferiorly. Anteriorly and superiorly, it is supplied by a branch of the external pudendal vessels as they come off the femoral. Laterally, it is supplied by branches of the obturator vessels. Finally, a rich capillary network throughout the graft and continuous with the subcutaneous capillary blood supply of the monospubous is described. It is this blood supply that provides exceptional diversity to the use of this graft. It can be safely detached either at its superior or inferior end without vascular compromise. Detachment at the inferior pedicle may be more useful for vesicle vaginal or urethral vaginal fistulas. Martius himself describes a modification of his original procedure, mobilizing solely the fibroadipose graft on its superior pedicle. Finally, the vascularity is sufficient to maintain the viability of a variety of attached cutaneous grafts or islands that can be rotatated in to facilitate tension-free closure of larger defects. The posterior vaginal wall, which has already been mobilized at the start of the procedure, is now closed over the graft with a series of everting mattress sutures of number one vicral placed through the subepithelium, the first of which is seen thrown here. Some authors also describe the use of monofilament sutures for this portion of the repair. In this case, a series of five mattress sutures were placed and tagged. They were then tied in such a way as to reduce and evenly disperse tension on the overlying skin closure. A second reinforcing layer is now completed with interrupted number one vicral through the vaginal epithelium. This begins with bilateral suture placement as shown here. Traction on these facilitates visualization and closure of the remaining defect in an interrupted fashion. The labial defect is closed first by re-approximating the subcutaneous layer, again with interrupted two ovicral, the first of which is seen here. The skin is subsequently re-approximated in standard subcuticular fashion. In summary, the Martius flap has multiple advantages in fistula repair to include low morbidity, a lack of a cosmetic defect, and the need for only a single surgical field. Its prominent fibrous component makes it a much stronger graft than adipose tissue in other areas, and most importantly, its abundant blood supply promotes rapid neovascularization of the transplanted graft and lends itself well to the treatment of the graft. The Martius flap is a very common and common feature of the Martius flap. It is a very common feature of the Martius flap. It is a very common feature of the Martius flap. It is a very common feature of the Martius flap. It is a very common feature of the Martius flap. It is a very common feature of the Martius flap. It is a very common feature of the Martius flap. It is a very common feature of the Martius flap. It is a very common feature of the Martius flap. It is a very common feature of the Martius flap.
Video Summary
In this video, the use of the Mardius graft to repair a multi-recurrent rectovaginal fistula is demonstrated. The video focuses on the development and placement of the flap. The Mardius flap is a technique that involves creating a flap from the labium magus and using it to cover the fistula defect. The flap is mobilized, passed through the levator plate, and sewn into place. The abundant blood supply of the flap promotes rapid neovascularization and favorable cosmetic outcomes. The video highlights the advantages of the Martius flap, such as low morbidity and the ability to treat relatively large defects and radiation-induced fistulas.
Asset Caption
Douglas Allan Leach, MD
Keywords
Mardius graft
rectovaginal fistula
flap development
flap placement
Martius flap
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