1. An introduction to Obstetric Fistula surgeryBrian HancockMD.FRCS.FRCOG

2. Obstructed LabourProlonged pressure of the babies headcrushes the base of the bladder againstthe back of the pubis 3. Causes of wetness post delivery Ischaemic necrosis to the bladder andvagina due to prolonged labour ( 90%) Accidental damage to the Bladder orUreter at Caesarean section orhysterectomy for ruptured uterus (10%) 4. The Vesico Vaginal Fistula1-2 million inAfricaWet for life.High skillLow tech surgeryDramatic results 5. The Cause. Unrelieved obstructed labourUrban poverty. Lack of Remote dwellings.Nofree medical care. Transport. No hospitals 6. Three stages of delay forCaesarean section. Delay deciding to get help Delay getting to hospital Delay in Hospital 7. ResultA hole between the Vagina and Bladder (VVF) 8. Effect of a VVFShe will be incontinent ofurine for lifeShe will become a socialoutcast unless she can find askilled surgeon 9. Vesico-Vaginal Fistula isMore than a hole in the bladder The whole body is damaged 10. The Obstetric Fistula Injury Complex Primary damageVagina, Uterus.Urethra, Bladder,Ureter.RectumNerve damagePelvic 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%intermediate50% difficult25%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. Results of VVF surgery1100 cases in Uganda in 10 years Inoperable Fail3%10% Stress 17% Dry70% 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. Many cases can be repaired underbasic conditions Lira. Uganda Kamuli. Uganda 16. Further progress is best made by apprenticeship with one of the master surgeons.Kees Waaldijk Dr MuluKatsinaAddis Ababa Nigeria Ethiopia 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. Diagnosis is made by, History taking Examination No special investigations required 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. 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. ExaminationInspection. For signs of wetness.Palpation by VE. ( dont 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. Examination in Left Lateral position 23. Dye test for a hidden fistulaThe last swab to be removed is blue 24. Two simple casesBoth 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 caseThis high fistula extends into an open cervical canal. 27. Equipment for fistula repairTilting tableGood quality scissorsforceps and needleholder. 28. Selection of cases for beginnersThe fistula must be small mobile and accessible. 29. Spinal anaesthesia 30. Principles of repairAdequate exposure sometimes withan episiotomyFlap splitting technique.Mobilise enough healthy bladder toclose without tension.Protection of uretersExcision of scar. 31. A simple juxta-urethral fistulaIt is small mobile and accessible; an ideal beginners case 32. The posterior margin The anterior vaginalhas 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 performa dye test with 50 ccs of dilute methylene blue 36. Vaginal pack andClosure of vagina with suture for catheterabsorbable sutures 37. Basic post operativecare for VVF patients. 38. The reality Nurses will be in short supply Post op care must be kept as simple aspossible. Patients and their carers must often takeresponsibility for their own care. 39. The essentials. The patient must beDryDrinkingDraining 40. Ensure free drainage at alltimes Options. Closed drainage into a bag. Free drainage into a basin or bucket 41. A practical method of drainageThe patient is nursed flatFor 24 hours post spinalAllow oral fluids freelyWatch the dripping into the bucket. 42. Closed drainageThis is a veryhigh techsystem. 43. Problems with closed drainageWhat happens to thisbag in the night? 44. A BLOCKED CATHETERis 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. Kinked Cathetersbig trouble ahead.The patient is lying on thecatheterThe catheter is kinkedThe urine is concentrated. 46. A blocked catheter 47. Drinking Drinking up to 4litres a day isessential to ensurea good output ofclear urine 48. Early mobilisationUp with a bucket on daytwo.Good for patient moraleAvoids Pressure soresand DVT risk.Low nursing care.Patients must continue toDrink ++++. 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 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. Some happy patients. 52. Further readingPractical Obstetric Fistula Surgery . Brian Hancock and Andrew BrowningStep 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)