Martius fat pad flap procedure for management of obstetric rectovaginal fistula: A case report

Abstract

Obstetric trauma is a risk factor for rectovaginal fistula, and it is a challenge for both patients and surgeons. In this case report, we describe the surgical technique of the Martius fat pad flap for repair of a rectovaginal fistula. The patient was a 30-year-old woman, para 1, with a previous spontaneous vertex vaginal delivery of a 2500-g male baby at 37 weeks of gestation. There was a history of arrest of descent, and the patient had a third-degree perineal laceration that was repaired in the operating room. Twelve days after delivery, the patient complained about fecal vaginal discharge and was diagnosed with a rectovaginal fistula. Physical examination revealed a rectovaginal fistula with a 2 cm diameter and located 1 cm from the hymen. The tone of the external anal sphincter was within normal limits, which was confirmed with transperineal ultrasound scan. The repair was done 3 months after the previous repair in order to allow for the restoration of tissue integrity and the complete healing of the previous wound. The rectovaginal fistula was repaired with a Martius fat pad flap in a transperineal approach. After 60 days of follow-up, the wound involving the labia majora and the fistula were healed completely.

Keywords: Martius fat pad flap; Obstetric rectovaginal fistula; Transperineal repair.

Fig. 1

(A) Rectovaginal fistula examination. (B) Fat pad dissection from the right labia majora. (C) Labia majora and perineum after repair. (D) Rectovaginal fistula and wound evaluation 60 days after repair.

Fig. 2

(A) Transverse incision made in the perineum above the sphincter. (B) Dissection between the anterior rectal wall and the posterior vaginal wall. (C) The rectal mucosal defect was closed in two layers. (D) Incision at the right labia majora and dissection to mobilize the fat pad. (E) A broad fat pad base was transferred from the tunnel and placed over the second layer. (F) Closing the vaginal epithelium, perineal, and labia majora.