Published in:
01-08-2013 | The Last Image
Martius flap for ano-vaginal fistula: a photographic step by step guide
Published in: Techniques in Coloproctology | Issue 4/2013
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A 24-year-old developed an ano-vaginal fistula following a normal vaginal delivery. Direct repair of the fistula with separation of the vaginal and rectal wall failed. A Martius flap was raised and tunnelled through to the vaginal side and sutured over the rectal defect. The vaginal defect was excised, and the vaginal mucosa closed without tension. The labial skin incision was closed with a small bore closed suction drain. Only one dose of perioperative antibiotic prophylaxis was administered. The patient made an uneventful recovery (Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9).
Fig. 1
The site of the vaginal opening of the fistula can be clearly seen
Fig. 2
The vaginal flap is raised, and the recto-vaginal septum separated by careful dissection and the fistulous opening excised
Fig. 3
An incision is made over the labia majora and deepened to the subcutaneous fat layer
Fig. 4
The labial fat pad is raised, and the blood supply protected. The blood supply arises from both the superior and the inferior ends of this fat pad and can be clearly seen during dissection
Fig. 5
Once an adequate length of flap is obtained, the fat pad can be divided at either end depending on whether the flap should be superiorly or inferiorly based. Here, the flap is divided superiorly
Fig. 6
The Martius flap is then tunnelled subcutaneously to the vaginal side without torsion
Fig. 7
The rectal defect is sutured with an absorbable 2/0 suture, and the flap is then sutured down to the rectal wall around the rectal defect
Fig. 8
The vaginal mucosa is then approximated and sutured with an absorbable 2/0 suture without tension
Fig. 9
The skin incision is closed after a small bore closed suction drain is inserted
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