VM105 - How I Do It: Martius Flap

Saturday, June 1, 2024

10:00 AM – 1:30 PM ET, USA

Location: Baltimore Convention Center, Hall BCD

Video Presentation(s)

Alicia Adams, MD (she/her/hers)

Fellow
University Hospitals
University Hospitals
Cleveland, OH, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Author(s)

RP

Rachel Pope, MD, MPH

Associate Professor
UH Hospitals
Cleveland, Ohio, United States

Disclosure information not submitted.
Emily Steinhagen, MD (she/her/hers)

Associate Professor
University Hospitals Cleveland Medical Center
University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine

All relevant financial disclosures have been managed and will be listed below.
This individual has no financial relationships with ineligible companies.
RC

Ronald Charles, M.D.

Colorectal surgeon, Assistant Professor of Surgery
University Hospitals Cleveland Medical Center / Case Western Reserve University
Cleveland, Ohio, United States

Disclosure information not submitted.
David Dietz, MD, MHCDS, FASCRS

Vice President System Surgery Value and Transformation
University Hospitals
Cleveland, Ohio, United States

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This individual has no financial relationships with ineligible companies.

Senior Author(s)

Jennifer L. Miller-Ocuin, MD

Assistant Professor of Surgery
Case Western Reserve - University Hospitals
University Hospitals - Case Western
Cleveland, OH, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Purpose/Background: Crohn's disease can present with stricturing or fistulizing disease. Rectal fistulas in this population can be complex and challenging to treat and usually require advanced repair. The Martius flap, which uses a muscle-adipose flap from the bulbocavernosus muscle to create a neo-rectovaginal septum, is seldom seen in training. Here we present the technique to repair a low rectovaginal fistula in a woman with Crohn's disease who also had an ileocolic anastomotic stricture.

Methods/Interventions: The patient was placed in lithotomy position and underwent a laparoscopic resection of her anastomotic stricture. The rectovaginal fistula is excised and skin flaps are created. The fistula on the rectum is closed in two layers. The Martius flap is created from the anterior labia majora being careful to perserve the posterior blood supply, A tunnel is created toward the vagina through which the Martius flap is passed. The Martius flap is laid on the rectal fistula repair and a serves as a new rectovaginal septum. The vaginal mucosa is closed and the soft tissue of the labia majora is reapproximated.

Results/Outcomes: The patient recovered uneventfully on the regular nursing floor and was discharged home once she had appropriate ileostomy output.

Conclusion/Discussion: Rectal fistulas in Crohn's disease can be difficult to manage and usually require a complex repair. At our institution we take a multidisciplinary approach to the repair of rectovaginal fistulas using the Martius flap technique with our Urogynecology colleagues. Patients are routinely diverted with a loop ileostomy in order to facilitate healing of the repair. While the Martius flap is seldom seen in training, it provides a durable repair of rectovaginal fistulas and should be a component of every Colorectal Surgeon's armamentarium.