Mukwege Denis, Mukanire Ntakwinja, Himpens Jacques, Cadière Guy-Bernard
Gynaecology and General Surgery, Panzi General Referral Hospital, Bukavu, South Kivu, Democratic Republic of the Congo.
Gastrointestinal Surgery, Saint-Pierre University Hospital, 322, rue Haute, 1000, Brussels, Belgium.
Surg Endosc. 2016 Jan;30(1):379-87. doi: 10.1007/s00464-015-4192-z. Epub 2015 Apr 7.
We propose a new minimally invasive technique by laparoscopic approach which minimizes parietal damage and allows precise location of the fistula, hence reduces blind dissection.
Ten consecutive patients suffering from a HRVF benefited from the described technique. Location and time frame were east of the Democratic Republic of Congo and September 2012 through January 2014. By laparoscopy, dissection of the mesorectum in the "holy plane" is taken posteriorly as distally on the sacrum as possible. Dissection subsequently continues laterally beyond the fistula in an effort to maximally circumvene the fistulous area where no plane of cleavage can be found. If the cleavage plane beyond the fistula addresses a healthy rectum, a suture of vaginal and rectal defect is performed. If the cleavage plane beyond the fistula involves significant laceration of the rectum, while leaving at least 2 cm of healthy rectum above the sphincter, rectal resection and colorectal anastomosis are performed. If the rectal laceration involves the distal 2 cm but halts short of the sphincter (large fistula), the pull-through technique is performed.
Of ten participants, four had large HRVF and two presented significant fibrosis. Three underwent simple suture of rectal and vaginal defect, one rectal resection and six a "pull-through" technique. The median procedure time was 1h50 (1h00-3h30). There was no morbidity. None of the patients required protective ileostomy or colostomy. Nine patients were declared clinically cured with a median follow-up of 14.3 months (11-36). The Cleveland Clinic Incontinence Score was 20 in all patients before the treatment and was significantly (p = 0.004) reduced to 2.6 [0-20] after the treatment.
This minimally invasive technique allowed us to treat HRVF, including complex ones in ten patients without significant morbidity. Clinical success with a median follow-up of 14.3 months was 90%.
我们提出了一种新的腹腔镜微创技术，该技术可将壁层损伤降至最低，并能精确确定瘘管位置，从而减少盲目解剖。
连续10例患有高位直肠阴道瘘（HRVF）的患者受益于所述技术。地点和时间范围为刚果民主共和国东部以及2012年9月至2014年1月。通过腹腔镜检查，在“神圣平面”尽可能向骶骨远端后方进行直肠系膜解剖。随后，在瘘管外侧继续解剖，以最大程度避开找不到分离平面的瘘管区域。如果瘘管外侧的分离平面通向健康直肠，则对阴道和直肠缺损进行缝合。如果瘘管外侧的分离平面涉及直肠严重撕裂，同时在括约肌上方至少保留2厘米健康直肠，则进行直肠切除和结直肠吻合术。如果直肠撕裂累及远端2厘米但未累及括约肌（大瘘管），则采用拖出术。
10名参与者中，4例患有大的HRVF，2例有明显纤维化。3例进行了直肠和阴道缺损的简单缝合，1例进行了直肠切除，6例采用了“拖出”技术。中位手术时间为1小时50分钟（1小时 - 3小时30分钟）。无并发症发生。所有患者均无需保护性回肠造口术或结肠造口术。9例患者经临床判定治愈，中位随访时间为14.3个月（11 - 36个月）。所有患者治疗前克利夫兰诊所失禁评分为20分，治疗后显著降低（p = 0.004）至2.6分[0 - 20分]。
这种微创技术使我们能够治疗HRVF，包括10例复杂病例，且无明显并发症。中位随访14.3个月的临床成功率为90%。
