The Gonzalez hernia revisited: Use of the ischiorectal fat pad to aid in the repair of rectovaginal and rectourethral fistulae

doi:10.1016/j.jpedsurg.2013.10.020

Journal of Pediatric Surgery

Volume 49, Issue 8, August 2014, Pages 1308-1310

https://doi.org/10.1016/j.jpedsurg.2013.10.020 Get rights and content

Abstract

Introduction

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.

Discussion

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.

Section snippets

Background/purpose

Acquired rectovaginal fistulae are difficult problems in colorectal surgery. They may occur following repair of an anorectal malformation, in the setting of HIV disease, as a consequence of birth trauma, or as a manifestation of Crohn’s disease. Rectourethal fistulae may be persistent, acquired or recurrent in patients with an anorectal malformation and re-do posterior sagittal anorectoplasty (PSARP) is an ideal approach for their repair [1].

During the development of the PSARP [2], as Pena was

Methods

Patients with recurrent vaginal or urethral fistulae were selected for review. IRB approval was obtained.

Results

The ischiorectal fat pad was used in 9 patients (age range, 2–10 years). Nine had an acquired fistula (6 rectovaginal, 3 rectourethral). The posterior sagittal approach was used in eight patients and the transanal approach in two patients. Six patients had had at least two prior attempts at repair, which had all been performed via a perineal approach. In six patients a covering stoma was already present, and in three patients no stoma was used. In all 9 cases the repairs were successful, with no

Discussion

Acquired rectovaginal and rectourethral fistulae are relatively common in adult patients but not routinely encountered in pediatric surgical practice. Rectovaginal fistulae most commonly occur as a result of obstetric complications. This is particularly the case in the developing world, where obstructed labor significantly increases the risk of rectovesical and rectovaginal fistulae [4], [5], [6]. Second only to obstetric trauma as a cause of rectovaginal fistulae in adult women is Crohn’s

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Cited by (20)

Posterior Sagittal Approach Provides Optimal Exposure for Urethral Reconstruction in Children With a History of Anorectal Malformations
2024, Urology
To present a unique series of children with previously repaired anorectal malformations (ARM) with subsequent urethral pathology repaired via a posterior sagittal exposure and highlight the associated technical advantages.
Using a retrospective review of all procedures performed in our pediatric colorectal and pelvic reconstruction program from January 2020 through December 2022, we compiled a case series of patients with a history of ARM and prior posterior sagittal anorectoplasty (PSARP) who had urethral pathology and concurrent indication for redo-PSARP. Clinical features, operative details, and postoperative outcomes were collected.
Six male patients presented at a median age of 4.3 years, all born with an ARM of recto-urinary fistula type, of which 3 were recto-prostatic, 1 recto-bladder-neck, and 2 unknown type. In addition to redo-PSARP, 2 underwent remnant of the original fistula excision and 4 had urethral stricture repair. One required post-operative Heineke-Mikulicz anoplasty. Patients underwent cystoscopy 4-6 weeks post-reconstruction, and none showed urethral stricture requiring treatment. Post-procedurally, 5 patients were able to void urethrally and 1 required additional bladder augmentation/Mitrofanoff.
Redo-PSARP completely mobilizes the rectum, thereby providing excellent exposure to the posterior urethra for repair. This approach also allows the option of a rectal flap for augmented urethroplasty as well as harvest of an ischiorectal fat pad for interposition.
How we select our surgical approach for cloacal reconstruction
2023, Journal of Pediatric Urology
During cloacal reconstruction, we consider both common channel (CC) and urethral length when deciding between total urogenital mobilization (TUM) and a urogenital separation (UGS). Our concern about TUM in the case of a short urethra is resultant bladder neck incompetence, while conversion to UGS after completing the TUM dissection may result in urethral injury. Use of an interposition flap harvested from the ischiorectal fossa is another measure we use to prevent potential complications.
Assessing the previously repaired patient with an anorectal malformation who is not doing well
2020, Seminars in Pediatric Surgery
Citation Excerpt :
Various techniques to repair a rectovaginal fistula have been described including the use of a bulbocavernosus graft (Martius procedure)51 Gracilis flaps.52 The ischiorectal fat pad has been described in the repair of the rectovaginal and rectourethral fistulae50 and is demonstrated in Fig. 23. The next two cases highlight the importance of screening the patient with an ARM for intraspinal and paraspinal abnormalities, regardless of the “type” of ARM lesion.
In this review, the care of children with a previously repaired anorectal malformation is explored. We know that the surgical care of children with anorectal malformations is complex; however, despite an increased understanding of the congenital anomaly and significant technical advances in the operative repair, many of these children continue to have poor functional outcomes. In this article we focus on the common surgical complications, discuss typical presentations, consider appropriate investigations, and review the risks and benefits of revisional surgery in those patients that are ‘not doing well’ following their primary reconstruction.
Recurrent rectourethral fistula repair: A novel technique of gracilis muscle interposition
2020, Journal of Pediatric Surgery
Citation Excerpt :
Three children with RUF at the age of 5, 13 and 15 years, who underwent multiple [3–5,and] failed fistulas repairs were referred to our clinic. In all cases, these were iatrogenic fistulas that occurred after operations for Hirschsprung's disease [2] or anorectal malformation [1], and subsequent dilatation of the anus. Two patients with Hirschsprung's disease had undergone redo abdominoperineal pull-through procedures, with subsequent failed attempts to close the fistula through the perineal approach and gracilis muscle interposition.
A perineal approach with gracilis muscle interposition (GMI) remains the most common in recurrent rectourethral fistulas (RUFs). The closure failures in10%–20% cases and urinary incontinence in 10%–80% cases referred to the disadvantages of the perineal approach owing to neurovascular damage. This article shows that the retraction of a survived muscle gracilis flap is one of the causes of fistula recurrence, and a simpler technique of the flap interposition is presented, requiring a less invasive perineal access.
Three consecutive patients with RUF at the age of 5, 13 and 15 years who underwent multiple (3, 4 and 5) unsuccessful reconstructive attempts were referred to our clinic. The last procedure was performed with GMI. In all cases, these were acquired iatrogenic fistulas that occurred after operations for Hirschsprung's disease (2) or anorectal malformation (1), and subsequent dilatation of the anus. All patients had a colostomy several years ago. Reinterposition and distant anchoring of the survived graсilis flap were performed through the perineal approach, avoiding lateral and anterolateral dissection.
The early postoperative period was uneventful. In one patient, a stricture of the posterior urethra formed. Urethrotomy was performed in 3 months, with complete restoration of micturition. The colostomy was closed in all patients after 3–4 months. In the long term follow up within 4–8 years, no fistula recurrence was noted.
The suggested traction technique of GMI allowed: to minimize the perineal access size, hence minimizing the injury and the operating time; to place the anchoring suture outside of the inflammation zone, ensuring secure attachment; to provide precise flap positioning and intimate contact between the flap and the urethra.
Level V.
Diagnosis and management of a remnant of the original fistula (ROOF) in males following surgery for anorectal malformations
2019, Journal of Pediatric Surgery
Citation Excerpt :
The ROOF was found in the bulbar-urethra in 4 patients (28.6%), prostatic in 9 patients (64.3%), and at the bladder neck in 1 (7.1%). The urethroplasty was performed in two layers (urethra and then closure of periurethral tissue), 7 patients (50%) had a fat pad placed between the urethral repair and the rectum [11], and 1 (7%) had an SIS (porcine derived small intestinal submucosa) patch placed in addition to the fat-pad. Of the 3 patients who presented with daytime dribbling, all 3 experienced complete resolution of their dribbling.
A complication of the surgical management of anorectal malformations (ARMs) is a retained remnant of the original fistula (ROOF) formerly called a posterior urethral diverticulum (PUD). A ROOF may have multiple presentations or may be incidentally discovered during the work-up of ARM after previous surgery. We sought to define the entity and the surgical indications for excision of a ROOF when found.
We performed a retrospective cohort study of all male patients who presented to our center following previous repair for ARM at another institution, who came for evaluation of problems with urinary and/or fecal continence, from 2014 to 2017. Charts were reviewed for symptoms, original type of malformation, preoperative imaging, treatment, and postoperative follow-up.
Of 180 referred male patients, 16 had a ROOF. 14 underwent surgical repair to address this and for other redo indications, and 2 did not require intervention. 13 patients had an additional reason for a redo such as anal mislocation or rectal prolapse. Indications for ROOF excision were urinary symptoms (e.g. UTI, dribbling, passage of mucous via urethra, stone formation), to make a smoother posterior urethra for intermittent catheterization, or for prophylactic reasons. Patients were repaired at an average age of 4.2 years, using a PSARP only approach with excision of the ROOF for all except one patient who needed a laparotomy due to abdominal extension of the ROOF. No patient needed a colostomy. The original ARM repairs of the patients were PSARP (9), laparoscopic assisted (4) and abdominoperineal pullthrough (3). Preoperative evaluation included pelvic MRI, VCUG, and cystoscopy. The ROOF was visualized on 14 of 16 MRIs, 10 of 14 VCUGs, and 14 of 15 cystoscopies. Urinary symptoms associated with a ROOF and ease of catheterization were improved in all repaired cases.
Patients not doing well from a urinary or bowel standpoint post ARM pull-through need a complete evaluation which should include a check for a ROOF. Both modalities MRI and cystoscopy are needed as a ROOF can be missed on either alone. A VCUG was not reliable in identifying a ROOF.
Excision is needed in patients to improve urinary symptoms associated with these lesions and to minimize the small but theoretical oncologic risk present in a ROOF.
Level III.
Gynecologic anatomic abnormalities following anorectal malformations repair
2018, Journal of Pediatric Surgery
Patients may present with gynecologic concerns after previous posterior sagittal anorectoplasty (PSARP) for repair of an anorectal malformation (ARM). Common findings include an inadequate or shortened perineal body, as well as introital stenosis, retained vaginal septum, and remnant rectovestibular fistula. An inadequate or shortened perineal body may impact fecal continence, sexual function and recommendations regarding obstetrical mode of delivery. We describe our experience with female patients referred to our center for evaluation of their previously repaired ARM, with a specific focus on perineal body anatomy and concomitant gynecologic abnormalities. We outline our collaborative evaluation process and findings as well as subsequent repair and outcomes.
A single site retrospective chart review from May 2014 to May 2016 was performed. Female patients with a history of prior ARM repair who required subsequent reoperative surgical repair with perineoplasty were included. The decision for reoperation was made collaboratively after a multidisciplinary evaluation by colorectal surgery, urology, and gynecology which included examination under anesthesia (EUA) with cystoscopy, vaginoscopy, rectal examination, and electrical stimulation of anal sphincters. The type of original malformation, indication for reoperative perineoplasty, findings leading to additional procedures performed at time of perineoplasty, postoperative complications, and the length of follow up were recorded.
During the study period 28 patients were referred for evaluation after primary ARM repair elsewhere and 15 patients (60%) met inclusion criteria. Thirteen patients (86.6%) originally had a rectovestibular fistula with prior PSARP and 2 patients (13.4%) originally had a cloacal malformation with prior posterior sagittal anorectovaginourethroplasty. The mean age at the time of the subsequent perineoplasty was 4.6 years (0.5–12). Patients had an inadequate perineal body requiring reoperative perineoplasty due to: anterior mislocation of the anus (n = 11, 73.3%), prior perineal wound dehiscence with perineal body breakdown (n = 2, 13.4%), acquired rectovaginal fistula (n = 1, 6.6%), and posterior mislocated introitus with invasion of the perineal body (n = 1, 6.6%). During the preoperative evaluation, additional gynecologic abnormalities were identified that required concomitant surgical intervention including: introital stenosis (n = 4, 26.6%), retained vaginal septum (n = 3, 20%) and remnant recto vestibular fistula (n = 2, 13.3%).
Patients with a previously repaired ARM may present with gynecologic concerns that require subsequent surgical intervention. The most common finding was an inadequate perineal body, but other findings included introital stenosis, retained vaginal septum and remnant recto vestibular fistula. Multidisciplinary evaluation to assess and identify abnormalities and coordinate timing and surgical approach is crucial to assure optimal patient outcomes.
Case series with no comparison group.
IV.

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Original ArticleThe Gonzalez hernia revisited: Use of the ischiorectal fat pad to aid in the repair of rectovaginal and rectourethral fistulae

Abstract

Introduction

Methods

Results

Discussion

Section snippets

Background/purpose

Methods

Results

Discussion

J Pediatr Surg

Int J Gynecol Obstet

J Pediatr Surg

J Pediatr Surg

Semin Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Am Coll Surg

J Urol

Reoperative surgery for anorectal malformations

Personal Communication

Original Article
The Gonzalez hernia revisited: Use of the ischiorectal fat pad to aid in the repair of rectovaginal and rectourethral fistulae