An introduction to Obstetric       Fistula surgery      Brian Hancock        MD.FRCS.FRCOG
Obstructed LabourProlonged pressure of the babies headcrushes the base of the bladder againstthe back of the pubis
Causes of wetness post delivery• Ischaemic necrosis to the bladder and  vagina due to prolonged labour ( 90%)• Accidental ...
The Vesico Vaginal Fistula1-2 million in  AfricaWet for life.High skillLow tech surgeryDramatic results
The Cause.         Unrelieved obstructed labourUrban poverty. Lack of   Remote dwellings.Nofree medical care.       Transp...
Three stages of delay for    Caesarean section.• Delay deciding to get help• Delay getting to hospital• Delay in Hospital
ResultA hole between the Vagina and Bladder (VVF)
Effect of a VVFShe will be incontinent ofurine for lifeShe will become a socialoutcast unless she can find askilled surgeon
Vesico-Vaginal Fistula isMore than a hole in the bladder The whole body is damaged
The Obstetric Fistula Injury Complex Primary damage      Vagina, Uterus.      Urethra, Bladder,Ureter.      Rectum      Ne...
The Obstetric Fistula Injury complex.   Secondary damage         Social outcast. Depression. Suicide.         Malnutrition...
Can all patients with VVF be cured?                                   easy                                   25%    interm...
Results of VVF surgery1100 cases in Uganda in 10 years       Inoperable   Fail          3%        10%                     ...
Why are so few repairs done?Surgery thought to be difficult               but 25% are quite easyResults thought to be poor...
Many cases can be repaired under        basic conditions   Lira. Uganda     Kamuli. Uganda
Further progress is best made by apprenticeship       with one of the master surgeons.  Kees Waaldijk                     ...
Understanding the nature of VVFThe commonest site for ischaemicinjury is the junction of the bladder andurethra. In severe...
Diagnosis is made by,• History taking• Examination• No special investigations required
History takingWet all the time?Leaking faeces as well? ( 5-10%)How long wet?Which delivery caused the problem?Did the baby...
Some demographic facts from 1000 cases in               Uganda• Mean age was 26 years• Mean duration of fistula was 6 year...
ExaminationInspection.     For signs of wetness.Palpation by VE. ( don’t forget abdo exam first)Is there any vaginal steno...
Examination in Left Lateral position
Dye test for a hidden fistula  The last swab to be removed is blue
Two simple casesBoth fistulae are about three cm from the external urethral orifice
Difficult fistulas. Not for a beginner This high juxta cervical fistula has a ureteric opening on its margin
Another troublesome caseThis high fistula extends into an open cervical canal.
Equipment for fistula repairTilting table        Good quality scissors                      forceps and needle            ...
Selection of cases for beginnersThe fistula must be small mobile and accessible.
Spinal anaesthesia
Principles of repairAdequate exposure sometimes withan episiotomyFlap splitting technique.Mobilise enough healthy bladder ...
A simple juxta-urethral fistula  It is small mobile and accessible; an           ideal beginners case
The posterior margin   The anterior vaginalhas been mobilised     flap has been elevated
A small rim of scar is                         Suture started at the margins. excised around the   fistula margin
Single layer closure with 2 zero catgut, dexon or vycril
After the bladder has been closed performa dye test with 50 ccs of dilute methylene blue
Vaginal pack andClosure of vagina with                         suture for catheter  absorbable sutures
Basic post operativecare for VVF patients.
The reality• Nurses will be in short supply• Post op care must be kept as simple as  possible.• Patients and their carers ...
The essentials. The patient must be  Dry  Drinking  Draining
Ensure free drainage at all              times• Options.     • Closed drainage into a bag.     • Free drainage into a basi...
A practical method of drainageThe patient is nursed flatFor 24 hours post spinalAllow oral fluids freelyWatch the dripping...
Closed drainageThis is a very  high tech  system.
Problems with closed drainageWhat happens to thisbag in the night?
A BLOCKED CATHETER        is an emergencySigns         Urine flow stops.         Patients feels a full bladder         Wet...
Kinked Catheters                    big trouble ahead.The patient is lying on thecatheterThe catheter is kinkedThe urine i...
A blocked catheter
Drinking• Drinking up to 4  litres a day is  essential to ensure  a good output of  clear urine
Early mobilisationUp with a bucket on day  two.Good for patient moraleAvoids Pressure sores  and DVT risk.Low nursing care...
Other aspects of post op care.  Daily perineal washing is essential.  At first by the nurse then by the patient or carer.
After day two, the patient can be largely self caring untilthe catheter comes out. The patient stays in bed if the areuret...
Some happy patients.
Further reading•Practical Obstetric Fistula Surgery .       Brian Hancock and Andrew Browning•Step by Step Surgery of Vesi...
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Introduction to vvf for glowm

  1. 1. An introduction to Obstetric Fistula surgery Brian Hancock MD.FRCS.FRCOG
  2. 2. Obstructed LabourProlonged pressure of the babies headcrushes the base of the bladder againstthe back of the pubis
  3. 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. 4. The Vesico Vaginal Fistula1-2 million in AfricaWet for life.High skillLow tech surgeryDramatic results
  5. 5. The Cause. Unrelieved obstructed labourUrban poverty. Lack of Remote dwellings.Nofree medical care. Transport. No hospitals
  6. 6. Three stages of delay for Caesarean section.• Delay deciding to get help• Delay getting to hospital• Delay in Hospital
  7. 7. ResultA hole between the Vagina and Bladder (VVF)
  8. 8. Effect of a VVFShe will be incontinent ofurine for lifeShe will become a socialoutcast unless she can find askilled surgeon
  9. 9. Vesico-Vaginal Fistula isMore than a hole in the bladder The whole body is damaged
  10. 10. The Obstetric Fistula Injury Complex Primary damage Vagina, Uterus. Urethra, Bladder,Ureter. Rectum Nerve damage Pelvic Floor Muscle damage
  11. 11. The Obstetric Fistula Injury complex. Secondary damage Social outcast. Depression. Suicide. Malnutrition Foot Drop. Contractures. Deformity Bladder stones. Renal damage Dermatitis. Infertility.
  12. 12. Can all patients with VVF be cured? easy 25% intermediate 50% difficult 25%One quarter are easy with near 100% successOne half are intermediate in difficultly, 80% success foran expertOne quarter are very difficult, 50% success rate for anexpert.
  13. 13. Results of VVF surgery1100 cases in Uganda in 10 years Inoperable Fail 3% 10% Stress 17% Dry70%
  14. 14. Why are so few repairs done?Surgery thought to be difficult but 25% are quite easyResults thought to be poor. but 100% success for easy casesNo teaching in post graduate curriculum but simple books are availableLack of special instruments but they are not needed for easy casesNo specialist nursing care but nursing care is very easy
  15. 15. Many cases can be repaired under basic conditions Lira. Uganda Kamuli. Uganda
  16. 16. Further progress is best made by apprenticeship with one of the master surgeons. Kees Waaldijk Dr Mulu Katsina Addis Ababa Nigeria Ethiopia
  17. 17. Understanding the nature of VVFThe commonest site for ischaemicinjury is the junction of the bladder andurethra. In severe cases the whole ofthe anterior vaginal wall and bladderbase are lost and the urethra isseparated from the bladder.
  18. 18. Diagnosis is made by,• History taking• Examination• No special investigations required
  19. 19. History takingWet 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. 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 acaesarean section.• 12% of women who developed a fistula after LSCS had a live babyIn contrast to 4% in those delivering vaginally.• 13% had already had at least one attempt at repair.
  21. 21. ExaminationInspection. 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.? Ifso, what is its site, size and mobility.Can the cervix be felt? Is the vagina shortened?If in doubt expose the anterior wall with aspeculum.
  22. 22. Examination in Left Lateral position
  23. 23. Dye test for a hidden fistula The last swab to be removed is blue
  24. 24. Two simple casesBoth fistulae are about three cm from the external urethral orifice
  25. 25. Difficult fistulas. Not for a beginner This high juxta cervical fistula has a ureteric opening on its margin
  26. 26. Another troublesome caseThis high fistula extends into an open cervical canal.
  27. 27. Equipment for fistula repairTilting table Good quality scissors forceps and needle holder.
  28. 28. Selection of cases for beginnersThe fistula must be small mobile and accessible.
  29. 29. Spinal anaesthesia
  30. 30. Principles of repairAdequate exposure sometimes withan episiotomyFlap splitting technique.Mobilise enough healthy bladder toclose without tension.Protection of uretersExcision of scar.
  31. 31. A simple juxta-urethral fistula It is small mobile and accessible; an ideal beginners case
  32. 32. The posterior margin The anterior vaginalhas been mobilised flap has been elevated
  33. 33. A small rim of scar is Suture started at the margins. excised around the fistula margin
  34. 34. Single layer closure with 2 zero catgut, dexon or vycril
  35. 35. After the bladder has been closed performa dye test with 50 ccs of dilute methylene blue
  36. 36. Vaginal pack andClosure of vagina with suture for catheter absorbable sutures
  37. 37. Basic post operativecare for VVF patients.
  38. 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. 39. The essentials. The patient must be Dry Drinking Draining
  40. 40. Ensure free drainage at all times• Options. • Closed drainage into a bag. • Free drainage into a basin or bucket
  41. 41. A practical method of drainageThe patient is nursed flatFor 24 hours post spinalAllow oral fluids freelyWatch the dripping into the bucket.
  42. 42. Closed drainageThis is a very high tech system.
  43. 43. Problems with closed drainageWhat happens to thisbag in the night?
  44. 44. A BLOCKED CATHETER is an emergencySigns Urine flow stops. Patients feels a full bladder Wet Bed due to leak through the urethra or repairAction Look to exclude kinked catheter Irrigate to clear obstruction Change Catheter.
  45. 45. Kinked Catheters big trouble ahead.The patient is lying on thecatheterThe catheter is kinkedThe urine is concentrated.
  46. 46. A blocked catheter
  47. 47. Drinking• Drinking up to 4 litres a day is essential to ensure a good output of clear urine
  48. 48. Early mobilisationUp with a bucket on day two.Good for patient moraleAvoids Pressure sores and DVT risk.Low nursing care.Patients must continue to Drink ++++.
  49. 49. Other aspects of post op care. Daily perineal washing is essential. At first by the nurse then by the patient or carer.
  50. 50. After day two, the patient can be largely self caring untilthe catheter comes out. The patient stays in bed if the areureteric catheters but these rarely need to be retained formore than 48 hours.
  51. 51. Some happy patients.
  52. 52. Further reading•Practical Obstetric Fistula Surgery . Brian Hancock and Andrew Browning•Step by Step Surgery of Vesico Vaginal Fistula. Kees WaaldijkBoth obtainable from Teaching Aids at Low Cost. (TALC)Box 49,St Albans, Herts, AL1 5TX, UK. (info@talcuk.org)
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