www.glowm.com - Audio test -The Global Libary of womens medicine - An introduction to Obstetric Fistula surgery

1. An introduction to Obstetric
Fistula surgery
Brian Hancock
MD.FRCS.FRCOG

2. Obstructed Labour
Prolonged pressure of the babies head
crushes the base of the bladder against
the back of the pubis

3. Causes of wetness post delivery
• Ischaemic necrosis to the bladder and
vagina due to prolonged labour ( 90%)
• Accidental damage to the Bladder or
Ureter at Caesarean section or
hysterectomy for ruptured uterus (10%)

4. The Vesico Vaginal Fistula
1-2 million in
Africa
Wet for life.
High skill
Low tech surgery
Dramatic results

5. The Cause.
Unrelieved obstructed labour
Urban poverty. Lack of Remote dwellings.No
free medical care. Transport. No hospitals

6. Three stages of delay for
Caesarean section.
• Delay deciding to get help
• Delay getting to hospital
• Delay in Hospital

7. Result
A hole between the Vagina and Bladder (VVF)

8. Effect of a VVF
She will be incontinent of
urine for life
She will become a social
outcast unless she can find a
skilled surgeon

9. Vesico-Vaginal Fistula is
More than a hole in the bladder
The whole body is damaged

10. The Obstetric Fistula Injury Complex
Primary damage
Vagina, Uterus.
Urethra, Bladder,Ureter.
Rectum
Nerve damage
Pelvic Floor Muscle damage

11. The Obstetric Fistula Injury complex.
Secondary damage
Social outcast. Depression. Suicide.
Malnutrition
Foot Drop. Contractures. Deformity
Bladder stones. Renal damage
Dermatitis.
Infertility.

12. Can all patients with VVF be cured?
easy
25%
intermediate
50%
difficult
25%
One quarter are easy with near 100% success
One half are intermediate in difficultly, 80% success for
an expert
One quarter are very difficult, 50% success rate for an
expert.

13. Results of VVF surgery
1100 cases in Uganda in 10 years
Inoperable Fail
3% 10%
Stress
17%
Dry
70%

14. Why are so few repairs done?
Surgery thought to be difficult
but 25% are quite easy
Results thought to be poor.
but 100% success for easy cases
No teaching in post graduate curriculum
but simple books are available
Lack of special instruments
but they are not needed for easy cases
No specialist nursing care
but nursing care is very easy

15. Many cases can be repaired under
basic conditions
Lira. Uganda Kamuli. Uganda

16. Further progress is best made by apprenticeship
with one of the master surgeons.
Kees Waaldijk Dr Mulu
Katsina Addis Ababa
Nigeria Ethiopia

17. Understanding the nature of VVF
The commonest site for ischaemic
injury is the junction of the bladder and
urethra. In severe cases the whole of
the anterior vaginal wall and bladder
base are lost and the urethra is
separated from the bladder.

18. Diagnosis is made by,
• History taking
• Examination
• No special investigations required

19. History taking
Wet all the time?
Leaking faeces as well? ( 5-10%)
How long wet?
Which delivery caused the problem?
Did the baby survive?
How born? CS or Vaginal Delivery?
Has repair been attempted before?
Social history.

20. Some demographic facts from 1000 cases in
Uganda
• Mean age was 26 years
• Mean duration of fistula was 6 years
• 50% were primiparous
• Only 33% of patients with a fistula delivered vaginally, the rest had a
caesarean section.
• 12% of women who developed a fistula after LSCS had a live baby
In contrast to 4% in those delivering vaginally.
• 13% had already had at least one attempt at repair.

21. Examination
Inspection. For signs of wetness.
Palpation by VE. ( don’t forget abdo exam first)
Is there any vaginal stenosis?
Can a defect be felt in the anterior vaginal wall.? If
so, what is its site, size and mobility.
Can the cervix be felt? Is the vagina shortened?
If in doubt expose the anterior wall with a
speculum.

22. Examination in Left Lateral position

23. Dye test for a hidden fistula
The last swab to be removed is blue

24. Two simple cases
Both fistulae are about three cm from the external urethral orifice

25. Difficult fistulas. Not for a beginner
This high juxta cervical fistula has a
ureteric opening on its margin

26. Another troublesome case
This high fistula extends into an open cervical canal.

27. Equipment for fistula repair
Tilting table Good quality scissors
forceps and needle
holder.

28. Selection of cases for beginners
The fistula must be small mobile and accessible.

29. Spinal anaesthesia

30. Principles of repair
Adequate exposure sometimes with
an episiotomy
Flap splitting technique.
Mobilise enough healthy bladder to
close without tension.
Protection of ureters
Excision of scar.

31. A simple juxta-urethral fistula
It is small mobile and accessible; an
ideal beginners case

32. The posterior margin The anterior vaginal
has been mobilised flap has been elevated

33. A small rim of scar is
Suture started at the margins.
excised around the
fistula margin

34. Single layer closure with 2 zero catgut, dexon or vycril

35. After the bladder has been closed perform
a dye test with 50 ccs of dilute methylene blue

36. Vaginal pack and
Closure of vagina with
suture for catheter
absorbable sutures

37. Basic post operative
care for VVF patients.

38. The reality
• Nurses will be in short supply
• Post op care must be kept as simple as
possible.
• Patients and their carers must often take
responsibility for their own care.

39. The essentials.
The patient must be
Dry
Drinking
Draining

40. Ensure free drainage at all
times
• Options.
• Closed drainage into a bag.
• Free drainage into a basin or bucket

41. A practical method of drainage
The patient is nursed flat
For 24 hours post spinal
Allow oral fluids freely
Watch the dripping into the bucket.

42. Closed drainage
This is a very
high tech
system.

43. Problems with closed drainage
What happens to this
bag in the night?

44. A BLOCKED CATHETER
is an emergency
Signs
Urine flow stops.
Patients feels a full bladder
Wet Bed due to leak through the urethra or repair
Action
Look to exclude kinked catheter
Irrigate to clear obstruction
Change Catheter.

45. Kinked Catheters
big trouble ahead.
The patient is lying on the
catheter
The catheter is kinked
The urine is concentrated.

46. A blocked catheter

47. Drinking
• Drinking up to 4
litres a day is
essential to ensure
a good output of
clear urine

48. Early mobilisation
Up with a bucket on day
two.
Good for patient morale
Avoids Pressure sores
and DVT risk.
Low nursing care.
Patients must continue to
Drink ++++.

49. Other aspects of post op care.
Daily perineal washing is essential.
At first by the nurse then by the patient or carer.

50. After day two, the patient can be largely self caring until
the catheter comes out. The patient stays in bed if the are
ureteric catheters but these rarely need to be retained for
more than 48 hours.

51. Some happy patients.

52. Further reading
•Practical Obstetric Fistula Surgery .
Brian Hancock and Andrew Browning
•Step by Step Surgery of Vesico Vaginal Fistula.
Kees Waaldijk
Both obtainable from Teaching Aids at Low Cost. (TALC)
Box 49,St Albans, Herts, AL1 5TX, UK. (info@talcuk.org)