VM87 - Repair of Low-grade Rectovaginal Fistula by Endoscopic Linear Stapler---- a Novel Technique of Repair on RVF

Purpose/Background: Rectovaginal fistula (RVF) results from an eclectic range of causes and presents with a variety of symptoms including the passage of air and/or stool per vaginam along with frequent urinary and vaginal sepsis. These distressing symptoms are accompanied by a significant psychosocial burden, and successful management remains a major surgical challenge. The outcome of these difficult cases isinfluenced by the underlying etiology, the local tissue quality, the fistula size and locale, and by a history of prior unsuccessful repairs. The most common cause of an RVF is obstetrical trauma resultant either from obstructed labor or because of third-and fourth-degree perineal lacerations.We present a novel approach toward RVF closure developed by our group utilizing a transvaginal deployment of the Echelon Flex 60 Endopath stapler.

Methods/Interventions: Clinical examinations, routine laboratory investigations, colonoscopy (assessing the state of rectum),MRI and anorectal manometry were performed in all the patient. Each patient received a preoperative cleansing enema with vaginal betadine lavage and intravenous antibiotics hour prior to surgery (ciprofloxacin and metronida-zole).Patients are operated upon in the lithotomy position with routine urethral catheterization and isolation of the operative field using a Lone Star Retractor System. After identification of the RVF, a Nelaton tube is inserted into the fistula with measurement of its diameter and the distance from the introitus to the distal fistula border . Inject diluted adrenaline in the plane of rectovaginal septum.Make the incision line around the orifice and dissect arround the fistula into the space of rectovaginal septum.The space around the fistula was fully dissected until it closes without tension.The fistula is then closed with the Echelon Flex 60 Endopath stapler employing the blue staple cartridge (3.5-mm staple length with 1.5-mm closed staple height.Repeat the air-leak test ensure that the fistula is closed throughly.Continuous sutures by absorbable unidirectional monofilament barbed Statafix embedding of seromuscular layer and closing muscosa of vagina.Place an anal decompression tube.Postoperative management,diet is commenced at least one week after the operation.

Results/Outcomes: Over a follow-up of 6 months , there were no recurrences with this case reporting normal continence.A total 20 cases underwent a transvaginal RVF repair and received follow-up. Of this group,it was observed that 85% of the patients achieved healing.

Conclusion/Discussion: Stapled transvaginal repair of RVF appears safe and effective.We recommend conducting larger prospective studies with longer-term follow-up to further validate these findings.