pedicled omentum repair for vesicovaginal fistula

Repairing vaginal fistula with pedicled omentum is one of the most common and effective omental operations. The basic procedure is to separate a tunnel between the bladder wall and the vaginal wall at the pupil, and fill the pedicle with a large omentum. Animal experiments have shown that the omental blood supply is abundant, the lymphatic reflux is good, and the inflammatory exudate covering the tissue can be absorbed. After the adipose tissue of the omentum is fibrotic, it can be closely attached to the pupil wall to promote the healing of the pupil. Therefore, clinically, the pedicled omentum is filled between the bladder wall and the vaginal wall of the vaginal and vaginal pupil, and satisfactory results can be obtained. The main advantages of this operation are: 1 only need to expose the pupil, separate the tunnel and insert the omentum during operation, the operation is simple and safe. 2 When repairing, it is not necessary to remove the edge of the bladder and the bladder wall of the suture, so it will not cause the bladder capacity to shrink after surgery. 3 If the bladder contracture is combined, the pedicled omentum can provide a tissue source for bladder angioplasty. The main disadvantage of this operation is that the operation needs to open the abdominal cavity and cut the omentum, and the omentum is introduced into the pelvic floor and fixed. Therefore, intestinal obstruction (intestinal fistula), intestinal adhesion and abdominal infection may occur after operation. In addition, complications such as urinary fistula, urinary incontinence and urinary retention may occur after surgery. Treatment of diseases: postmenopausal cervical cancer pelvic inflammatory disease Indication 1. Huge vaginal fistula. 2. Bladder vaginal fistula failed after multiple repairs. 3. Tuberculosis or radiation therapy after bladder spasm condensation and vaginal fistula. Contraindications 1. Bladder vaginal fistula that can be repaired extraperitoneally, this operation should not be used to avoid abdominal complications after surgery. 2. The bladder vaginal fistula caused by birth injury is less than 3 months. Because the necrotic tissue in the pupil has not completely fallen off, the inflammation has not subsided, or the scar has not softened, the surgery is very easy to fail. 3. Bladder vaginal fistula occurred after radiation therapy of cervical cancer, such as cystoscopy, it is still found that the bladder mucosa is obviously congested, edema or suspected of being a cancer. 4. Tuberculous vesicovaginal fistula, such as cystoscopy found that there are still tuberculous changes in bladder mucosa, systemic tuberculosis and genitourinary tuberculosis failed to control. 5. The urinary tract infection has not been controlled, or the obstruction has not been relieved. Bladder stones have not been removed. 6. Pelvic inflammatory disease, vulvar dermatitis or erosion and vaginitis failed to control. 7. Pregnancy and menstrual period. Preoperative preparation 1. Detailed gynecological examination pay attention to vulvar dermatitis, pupil size, vaginal scar stenosis, urethral defect atresia, cervical tear and mobility, uterine size and mobility, and signs of pelvic inflammatory disease. 2. Correct anemia, improve systemic nutritional status, control urinary tract infections, relieve urinary tract obstruction and stones, strengthen anti-tuberculosis treatment or treat tumors (cervical cancer) and other primary diseases. 3. Elderly menopause, long-term lactation amenorrhea or other ovarian insufficiency, taking diethylstilbestrol (1 ~ 2mg / d) 1 week before surgery until the removal of the suprapubic bladder fistula, urinating. Improve blood supply to the vagina and promote healing of the vaginal incision. 4. From 1 week before surgery, use 1:5000 potassium permanganate solution (warm) to sit in the bath twice a day; 500ppm iodophor solution or 1:2000 Xinjieer solution to wash the vagina once a day. 5. Use effective antibiotics and anti-urinary tract infections from 3 days before surgery. 6. Patients with rectal injury may occur during the operation and should be prepared for the bowel. 7. In the evening before the operation and the morning of the day, enema with soapy water. Surgical procedure Incision Incision through the vagina and abdomen. 2. Separate the pupil (1) Insert the vaginal device into the vagina and disinfect the walls of the vagina again, including around the cervix and pupil. Disinfect the cervix with a cotton swab dipped in iodine and ethanol. (2) Sewing the labia minora on both sides of the labia majora with silk thread to facilitate exposure of the surgical field. Insert the vaginal hook into the vagina and pull the posterior wall of the vagina. Under direct vision, explore the location and size of the pupil, urethral defect and atresia, and vaginal scars. Use the tissue forceps to pull the vaginal wall or the anterior lip of the cervix at the lower edge of the pupil to make the pupil well. (3) Using the tissue forceps to pull the vaginal mucosa around the pupil, make an annular incision 0.5 to 1 cm from the edge of the pupil, and use a scalpel (or scissors) to separate from the periphery to the pupil center until it approaches the pupillary margin. In order to reduce the tension of the vaginal mucosa suture, the vaginal mucosa of the outer edge of the pupil incision can be lifted by surgery, and the scalpel can be separated by 1.5 to 2 cm with a scalpel (or scissors). 3. Cut the bladder Take the median incision of the pubis and enter the bladder area. The anterior wall of the bladder was cut longitudinally to examine the above-mentioned transvaginal separation of the pupil. If necessary, continue to separate the edge of the pupil in the bladder, up to 1.5 ~ 2cm is appropriate. If the ureteral orifice is located at the edge of the pupil or in the pupil, the ureter should be cut near the bladder wall, and the ureteral bladder anastomosis should be performed in the bladder away from the pupil. 4. Tunnel formation The extraperitoneal space along the posterior wall of the bladder is bluntly separated directly to the pupil, and the pupil is bluntly separated from the surrounding tissue to form a tunnel that can accommodate 2 to 3 horizontal fingers. 5. Cutting the omentum Extend the abdominal wall incision up to the xiphoid process, open the abdominal cavity, expose the omentum, and cut the omentum. The cut pedicled omentum was pulled out of the abdominal cavity to test whether it could reach the pupil without tension. Another 4-0 absorbable line was used to suture the vaginal wall through the vaginal longitudinal line. 6. Large omentum filling pupil The pedicled omentum was dragged into the bladder through the posterior wall tunnel of the bladder, covered on the sutured vaginal incision, folded into 3 to 4 layers, and the omental suture was fixed in the pupil incision with a 4-0 absorbable line. The edge of the bladder mucosa (Figure 7.10.12-7). Then, the edge of the bladder mucosa of the pupil incision is sutured intermittently with a 4-0 absorbable line above the omentum (if there is tension, it may not be sutured). In this way, the pedicled omentum can be satisfactorily packed between the bladder wall and the vaginal wall. 7. Fixed omentum The abdominal cavity of the pedicled omentum was sutured on the peritoneum of the anterior abdominal wall to prevent postoperative internal hemorrhoids. 8. Close the abdominal cavity Conventional sutured peritoneum combined with suprapubic bladder ostomy. 9. Place the drainage and close the incision A rubber drain strip is placed behind the pubis. Conventional suture of the abdominal wall incision. At the end of the procedure, a piece of sterile gauze was inserted into the vagina. complication Vaginal leakage In the early postoperative period, vaginal leakage occurred, which was caused by leakage of urine in the urethral orifice and/or vaginal fistula repair. If the urethral orifice overflows the urine, the supra-abdominal bladder stoma can be flushed with isotonic saline, or its position can be adjusted to keep its drainage smooth. If the vaginal mouth is repaired, the urine leaks, because the suture is not fast, the tension is too large or the blood supply is poor. The local tissue necrosis and suture opening are caused by the 7d after the operation. At this time, do not use a vaginal vaginal examination to avoid enlargement of the pupil due to the operation of the instrument. The pubic urethral resection tube should be adjusted or replaced, and the paralyzed patient should take the appropriate position (lateral position, prone position) to keep the urine circulation in the bladder. If necessary, the urine can be drained through the suprapubic bladder ostomy tube using a negative pressure bottle. 2. Urinary recurrence Seen in cases of premature sexual intercourse, re-pregnancy and bladder urethra stones. Therefore, avoid sexual life within 3 months after surgery and should emphasize contraception. In order to prevent the formation of postoperative stones, patients should develop the habit of drinking more water, and regular urinary system examination. Once the urinary fistula recurs, the treatment is very tricky. If the pupil is smaller, there is a possibility of self-healing; if the pupil is larger, it is still necessary to elective surgery again. 3. Incontinence Postoperative stress urinary incontinence may occur. After acupuncture therapy and urogenital muscle training, the function of controlling urination can be restored within 3 months. 4. Urinary retention after extubation It is more common in cases where the pupil is involved in the bladder neck or edema at the pupil of the pedicled omentum to affect the opening or patency of the bladder neck. Treatment: F12 ~ 24 metal urethral probe for urethral dilatation; continuous suprapubic bladder ostomy tube drainage, and urethroscopic examination to understand the bladder neck patency (if there is lip proliferative protrusion, can be cut); Repaired or caused by edema of the omental filling, after anti-infection, physiotherapy and bladder drainage, after local edema subsided within 2 months, it can restore smooth urination.

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