title: The Gonzalez hernia revisited: use of the ischiorectal fat pad to aid in the repair of rectovaginal and rectourethral fistulae.
abstract: BACKGROUND
  During the development of the posterior sagittal approach to anorectal malformations a vital technical challenge was a precise midline dissection, which if off, allowed for the ischiorectal fat pad to bulge into the wound. This occurrence became affectionately known as a "Gonzalez hernia", after a trainee of Dr Pena's (and a co-author of this paper). We describe here an innovative use of the ischiorectal fat pad to aid in the repair of acquired rectovaginal and rectourethral fistulae.
  
  
  METHODS
  Patients with recurrent vaginal or urethral fistulae were selected for review. The ischiorectal fat pad was deliberately mobilized (via a posterior sagittal or transanal approach) and used to buttress the repair of the posterior vagina or urethra.
  
  
  RESULTS
  The ischiorectal fat pad technique was used in 9 patients. All had an acquired fistula (6 rectovaginal fistula, 3 rectourethral fistulas). We used the posterior sagittal approach in 7 and in 2 the transanal approach. Six patients had had at least two prior attempts at fistula repair. Six patients had a stoma, and 3 did not. There were no recurrences in greater than six month follow-up.
  
  
  CONCLUSIONS
  The ischiorectal fat pad is easily visualized and mobilized, either via a posterior sagittal or transanal approach, providing excellent coverage with native, well-vascularized tissue, in an area that is difficult to heal. It is an excellent option for recurrent rectovaginal and rectovaginal fistulae and may have other additional creative applications.
authors.affiliation: Colorectal Center for Children, Cincinnati Children's Hospital, Cincinnati, OH, USA. Electronic address: Marc.levitt@cchmc.org.
authors.forename: M A
authors.initials: MA
authors.lastname: Levitt
authors.affiliation: Department of Paediatric and Neonatal Surgery, The Royal Children's Hospital, Melbourne, Australia.
authors.forename: S K
authors.initials: SK
authors.lastname: King
authors.affiliation: Colorectal Center for Children, Cincinnati Children's Hospital, Cincinnati, OH, USA.
authors.forename: A
authors.initials: A
authors.lastname: Bischoff
authors.affiliation: Division Pediatric Urology Cincinnati Children's Hospital, Cincinnati, OH, USA.
authors.forename: S
authors.initials: S
authors.lastname: Alam
authors.affiliation: Department of Pediatric Surgery, Primerode Octubre ISSSTE, Mexico City, Mexico.
authors.forename: G
authors.initials: G
authors.lastname: Gonzalez
authors.affiliation: Colorectal Center for Children, Cincinnati Children's Hospital, Cincinnati, OH, USA.
authors.forename: A
authors.initials: A
authors.lastname: Pena
mesh_terms: D000273:Adipose Tissue / Q000637:transplantation*; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010502:Perineum / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012006:Rectovaginal Fistula / Q000601:surgery*; D012008:Recurrence; D016896:Treatment Outcome; D014522:Urethral Diseases / Q000601:surgery*; D014548:Urinary Fistula / Q000601:surgery*; D014945:Wound Healing
keywords: Ischiorectal fat; Posterior sagittal approach; Rectourethral fistula; Rectovaginal fistula