title: Minimally invasive treatment of traumatic high rectovaginal fistulas.
abstract: BACKGROUND
  We propose a new minimally invasive technique by laparoscopic approach which minimizes parietal damage and allows precise location of the fistula, hence reduces blind dissection.
  
  
  METHODS
  Ten consecutive patients suffering from a HRVF benefited from the described technique. Location and time frame were east of the Democratic Republic of Congo and September 2012 through January 2014. By laparoscopy, dissection of the mesorectum in the "holy plane" is taken posteriorly as distally on the sacrum as possible. Dissection subsequently continues laterally beyond the fistula in an effort to maximally circumvene the fistulous area where no plane of cleavage can be found. If the cleavage plane beyond the fistula addresses a healthy rectum, a suture of vaginal and rectal defect is performed. If the cleavage plane beyond the fistula involves significant laceration of the rectum, while leaving at least 2 cm of healthy rectum above the sphincter, rectal resection and colorectal anastomosis are performed. If the rectal laceration involves the distal 2 cm but halts short of the sphincter (large fistula), the pull-through technique is performed.
  
  
  RESULTS
  Of ten participants, four had large HRVF and two presented significant fibrosis. Three underwent simple suture of rectal and vaginal defect, one rectal resection and six a "pull-through" technique. The median procedure time was 1h50 (1h00-3h30). There was no morbidity. None of the patients required protective ileostomy or colostomy. Nine patients were declared clinically cured with a median follow-up of 14.3 months (11-36). The Cleveland Clinic Incontinence Score was 20 in all patients before the treatment and was significantly (p = 0.004) reduced to 2.6 [0-20] after the treatment.
  
  
  CONCLUSIONS
  This minimally invasive technique allowed us to treat HRVF, including complex ones in ten patients without significant morbidity. Clinical success with a median follow-up of 14.3 months was 90%.
authors.affiliation: Gynaecology and General Surgery, Panzi General Referral Hospital, Bukavu, South Kivu, Democratic Republic of the Congo.
authors.forename: Denis
authors.initials: D
authors.lastname: Mukwege
authors.affiliation: Gynaecology and General Surgery, Panzi General Referral Hospital, Bukavu, South Kivu, Democratic Republic of the Congo.
authors.forename: Ntakwinja
authors.initials: N
authors.lastname: Mukanire
authors.affiliation: Gastrointestinal Surgery, Saint-Pierre University Hospital, 322, rue Haute, 1000, Brussels, Belgium.
authors.forename: Jacques
authors.initials: J
authors.lastname: Himpens
authors.affiliation: Gastrointestinal Surgery, Saint-Pierre University Hospital, 322, rue Haute, 1000, Brussels, Belgium. coelio@resulb.ulb.ac.be.
authors.forename: Guy-Bernard
authors.initials: GB
authors.lastname: Cadière
mesh_terms: D000328:Adult; D005242:Fecal Incontinence / Q000209:etiology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D007744:Obstetric Labor Complications / Q000601:surgery; D011247:Pregnancy; D011446:Prospective Studies; D011902:Rape; D012006:Rectovaginal Fistula / Q000601:surgery*; D012007:Rectum / Q000601:surgery; D012720:Severity of Illness Index
keywords: Fistula; High rectovaginal fistula; Laparoscopy; Obstetrical fistula; Rectovaginal fistula
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