Internal Pudendal Artery Perforator Island Flap for Management of Recurrent Benign Rectovaginal Fistula

Supplemental Digital Content is available in the text.

Summary:

The management of recurrent rectovaginal fistula after obstetric injury and cryptoglandular sepsis is considered a major surgical challenge. The fistula poses a significant negative psychosocial and sexual morbidity. In addition, the poor quality of local tissues due to previous attempts at surgical repair adds to this challenge. There are few data regarding the management of persistent or recurrent fistula in the literature; however, several studies reported high failure rates after 2 or more procedures. We present 4 cases managed successfully in a multidisciplinary approach involving fistulectomy and immediate reconstruction with an internal pudendal artery perforator island flap.

Recurrent benign rectovaginal fistula (RVF) represents a surgical dilemma and challenge. Fistula formation after obstetric injury and cryptoglandular anal sepsis is rare in developed countries, representing only 0.06% to 0.1% of presenting cases with recurrent cases being even rarer.¹ This problem poses a significant emotional, social, and sexual morbidity especially in healthy young women. In addition, the poor regional tissues’ quality, sparse vascularity, dense scar from previous attempts of surgical repair, and the disturbed anatomy contribute to this challenge. Repeated repairs after 1 attempt seem to have a reasonable success rate.² However, several studies reported higher failure rate after 2 or more procedures, so subsequent options should be chosen carefully.² The authors present a case series of 4 patients managed successfully with a multidisciplinary team approach by fistulectomy and immediate reconstruction utilizing the internal pudendal artery perforator (Ipap) island flap.

MATERIAL AND METHODS

Data were prospectively collected on 4 consecutive patients in the period between 2010 and 2015 and were reviewed. Their management entailed a multidisciplinary approach comprising the colorectal and reconstructive surgeons. All patients were subjected to routine clinical assessment, examination under anesthesia, and magnetic resonance imaging.

Data Collection

The demographic information, comorbidities, surgical history, and previous diagnostic workup were collected. The operative details identified the site, extent, length of fistulous tract, size of the resultant defect including the perineal skin deficiency, and size of Ipap flap. The postoperative follow-up period ranged from 8 to 30 months identifying the length of stay, complications, wound healing, and sexual activity.

Operative Consideration

The patients are catheterized and put in the lithotomy position. After identifying the fistula site with a probe, the perforators are marked using 8-MHz hand-held Doppler in the vascular triangle (ischial tuberosity, apex of coccyx, and vaginal orifice), approximately 3 and 6 cm lateral to the midline (Figs. 1–4). (See video, Supplemental Digital Content 1, which displays an intraoperative video demonstrating the surgical steps of the repair of a recurrent benign recto-vaginal fistula. This video is available in the “Related Videos” section of PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A243.) Free-style design of the skin paddle is performed starting in the medial thigh crease at the adductor longus origin and then caudally to a point medial to the identified perforator representing the flap height (11–15 cm). The skin pinch test technique will determine the width (4–7 cm) that allows primary closure, and subsequently the lateral border is marked joining the medial border cephalically.

Fig. 1.

Preoperative photograph showing scarred contracted deficient perineum previously due to cryptogenic infection and previous surgical attempt for repair of low RVF leading to cloacal deformity of the vaginal introitus.

Fig. 4.

Postoperative photograph 24 mo showing complete healing and restoration of the shape and volume of the perineum including the vaginal introitus.

Fig. 2.

Intraoperative picture showing the harvesting of the Ipap flap and the perineal defect after en bloc fistulectomy and excision of the perineal scar.

Fig. 3.

Intraoperative photograph showing 3-dimensional insetting of the flap to reconstruct the rectovaginal septum and restore the perineal deficiency with the cutaneous component with primary closure of the donor site.

Skin incision is performed including any previous perineal scar that is followed by dissection of the plane between the posterior vaginal and anterior anorectal wall to 2 to 3 cm cephalic to the fistulous opening. The low vaginal and midrectal openings of the fistulous tract were debrided to healthy tissue, which in turn increased the size of the defects further. One-layer closure of the defects was achieved using interrupted 3/0 PDS sutures (Ethicon, Cincinnati, Ohio).

Dissection of the flap is performed from cephalic to caudal in the suprafascial plane harvesting the superficial fascia. An intraoperative Doppler is used to reconfirm the perforator site within the thick fatty tissue of the ischiorectal fossa at the base of the flap. No attempt is made to skeletonize the perforators to avoid vascular injury as the vessels branch off deep in the fossa. Subsequently, the flap is tunneled deep to the labia majora and insetted into the rectovaginal septum with concomitant reconstruction of the perineal skin. This allows the determination of 3 zones (proximal, middle, and distal) of the flap. (See Supplemental Digital Content 2, which displays a diagram showing the insetting of the flap allow the determination of 3 zones, http://links.lww.com/PRSGO/A244.) Routine postoperative care is followed in all patients including careful structured ambulation.

RESULTS

The patient and operative characteristics are summarized in Table 1. All patients had history of classic step-up management of RVF because of recurrence with failed attempts of plug insertion, fibrin glue injection, local surgical treatment, and defunctioning stoma. The repeated surgery had led to extensive scar formation with contracted deficient perineal skin. All flaps survived with good cosmetic outcomes; all patients reported painless sexual intercourse within the follow-up period. Through the follow-up period, no recurrence was encountered after the reversal of their defunctioning stoma.

Table 1.

Patient and Operative Characteristics

DISCUSSION

The etiology, site, primary or recurrent, condition of the sphincters, comorbidities, and patient body habitus are recognized to have an impact on the outcome of RVF management.³ Despite the high failure rates reported whatever the surgical option chosen, few studies have reported to date an algorithm for the step-up management of RVF.⁴ This has ranged from simple seton drainage, fibrin glue, plug insertion, advancement mucosal flaps, sphincteroplasty, biomesh interposition to more complex procedures such as gracilis or Martius muscle interposition or abdominal procedures.^3–5 The value of the defunctioning stoma in the surgical management of RVF is still debatable; however, it has been reported to improve outcomes in patients who have had a number of failed repairs.⁶ In this series, all patients have been referred with a defunctioning stoma in an attempt to improve the healing rate. Nevertheless, recurrent fistulas involving the middle third of the vagina almost always require tissue interposition,³ which was encountered in all of the patients after debridement and fistulectomy.

The internal pudendal perforator thigh flap was first described by Wee and Joseph⁷ in 1989 and is also commonly known as the Lotus flap or Singapore flap. Hashimoto et al⁸ reported a large series of 71 Ipap flaps in 45 patients in which 9 of them were for total vaginal repair for malignant disease and included propeller, transposition, and advancement flaps. In our series, we present a 3-dimensional insetting of the island flap to reconstruct 2 components including the potential space in the rectovaginal septum after fistulectomy and the perineal skin deficiency simultaneously utilizing the multizone design which to authors’ knowledge would be the first to be reported within this context and design.

The armamentarium for reconstruction for perineal and vaginal reconstruction is diverse and includes musculocutaneous flaps as rectus and gracilis flaps, fasciocutaneous flaps including thigh flaps and deep inferior epigastric perforator flaps, bowel interposition, and omental flap.^8–10 These, however, are longer procedures, bulkier, and more distant options with different dermatomal supply and more donor-site morbidity.^8–10 Special attention to preservation of the local anatomy for a better cosmetic outcome and the preservation of the integrity of the intact anal sphincters is required for better outcomes. Anatomical considerations are paramount with the main aim directed to the restoration of the shape, volume, and function with the least morbidity. The Ipap flap provides these advantages with minimal local anatomical disruption and same urogenital dermatomal supply, low donor site morbidity with scars being concealed in the natural gluteal and thigh creases. The utilization of Ipap flap would not be suitable in previously damaged perianal skin because of either previous surgery or pathology. There are limitations for this study as this comes from a single-center experience with a small series; however, this is due to the relative rarity of these presentations for this selected group of patients.

CONCLUSIONS

The utilization of Ipap flap for recurrent RVF is a reliable, safe, easy-to-execute option, which has the same urogenital dermatomal supply and low donor-site morbidity. Its versatile nature allows reconstruction of concomitant perineal skin defect with minimal anatomical disturbance and hence should be considered as a valuable tool in the armamentarium of RVF management.

Video 1.

See video, Supplemental Digital Content 1, which displays an intraoperative video demonstrating the surgical steps of the repair of a recurrent benign recto-vaginal fistula. This includes the fistulectomy and primary closure of the vaginal and low rectal opening followed by immediate reconstruction of the rectovaginal septum and the concomitant deficient perineal skin simultaneously with internal arterty perforator flap (Ipap). This video is available in the “Related Videos” section of PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A243.

ACKNOWLEDGMENT

We thank Medial Illustration Team and Department, Heart of England NHS Foundation Trust.

Supplementary Material

gox-4-0e841-s001.pdf ^{(2.3MB, pdf)}