Protect the anal sphincter: rectal-flap procedure called best for rectovaginal fistula.(Gynecology)

LAKE BUENA VISTA, FLA. -- The Noble-Mengert-Fish rectal-flap procedure should be considered first-line treatment for a chronic perineal laceration or a rectovaginal fistula in the lower half of the vagina, Dr. W. Glenn Hurt said at a conference on gynecologic surgery sponsored by the Cooper University Hospital.

"We prefer the Noble-Mengert-Fish procedure for chronic perineal lacerations and rectovaginal fistulas," said Dr. Hurt, professor of ob.gyn. at Virginia Commonwealth University, Richmond.

Dr. Hurt recommended the rectal-flap procedure because it provides adequate mobilization of tissues, produces very little blood loss, and offers tension-free closure along all suture lines.

Moreover, the single incision allows access to anal sphincter muscles and the perineal muscles for a perineoplasty, which improves support and thickness of the perineal body.

Perioperatively, Dr. Hurt's bowel preparation includes administering a low-residue diet and magnesium citrate. He does not use polyethylene glycol 3350 for oral solution because of the volume that must be consumed. He begins the patient on antibiotic therapy before surgery and continues it afterward.

The patient is placed in the lithotomy position. Dr. Hurt prefers delayed, absorbable 3-0 sutures for this procedure.

He offered a step-by-step description of the technique: Make a curvilinear incision about the junction of ...