STEP-BY-STEP TRANS-VAGINALVESICOVAGINAL FISTULA REPAIR - A SURGICAL TEACHING TOOL
F. G. GOULD 1, M. CAREY 2,S. AL-SALIHI3;
1Royal Women's Hosp.,Melbourne, Melbourne, Australia, 2Royal Womens Hosp.,Parkville, Victoria, Australia, 3Urogynaecology, The RoyalWomen's Hosp., Melbourne, Australia.
Objective of Video: To create avideo teaching tool for trainee surgeons, that clearly demonstratesthe surgical steps involved in the transvaginal repair ofvesicovaginal fistula using a multilayer technique.
Introductionand background: This video demonstrates a step-by-step approachto the transvaginal multi-layer repair of vesicovaginal fistula(VVF). Transvaginal repair of VVF is performed in lithotomy and insuch a way that there is often poor visual exposure for bothobservers and scrubbed assistants. Initial techniques and steps forVVF repair to often need to be learnt from texts or diagrammaticexplanation. By using video as a teaching tool, there is anopportunity for clear surgical demonstration of fistula repairtechnique in a stepwise fashion. Video provides the trainee withexcellent visualisation of the surgical field from an aspect usuallyonly afforded to the primary surgeon. Learning with the aid of videois further enhanced with the recorded verbal explanations of salientpoints and surgical steps.
VVF is defined as an abnormalconnection between the bladder and vagina. VVF accounts for more thanhalf of all fistulas in women. VVF may be iatrogenic in nature, forexample as a result of gynaecological surgery or pelvic radiation, ormay be obstetric in nature and attributed to obstetrical trauma. Theetiology differs significantly between developed and developingcountries, such that in developing countries, over 90% of VVF issecondary to obstetric trauma and over 75% of VVF in the developedworld is due to unrecognized injury during hysterectomy1.There are some differences in the management of these two etiologies,however the principles of management remain overall consistent andVVF will frequently require surgical repair.
To optimize surgicaloutcome, consideration must be given to the skill set and experienceof the surgeon in addition to the timing of repair, method of repair,and health of the patient. The first attempt at surgical repair ofthe fistula is the best opportunity for a successful repair2and the greater the experience of the surgeon, the greater the oddsare of success. It is imperative that surgeons who are performing VVFrepair are sufficiently experienced, and that trainees continue to betrained in the techniques of fistula repair, so as to ensure acontinued supply of fistula surgeons.
Method: Informedconsent for surgical video recording was obtained from the case studysubject, a 42 year old female. A vesicovaginal fistula occurredfollowing a laparoscopic total hysterectomy for fibroids. The patientwas noted to have insensible urinary loss approximately 10 dayspost-operative. She was referred to the closest Urogynaecologyservice and repair was undertaken 6 months post hysterectomy. Thesurgical video was recorded with a stationary video camera mounted ona tripod and positioned directly behind the surgeon. A monitor waspositioned over the patient’s abdomen to allow the surgeon todirectly monitor the video footage during surgery. Video was alsorecorded with the endoscopic camera at the time ofcystoscopy.
Results: This video demonstrates the techniqueof multi-layer closure of a transvaginal VVF fistula repair,including the used of cystoscopy to identify the communication withthe bladder. The video highlights the individual steps required toachieve repair with clear footage of an uncomplicated vesicovaginalfistula repair.
Conclusions: The use of video is a valuableteaching tool. It is especially useful when teaching surgicalacquisition of complex procedures, cases that are less frequentlyperformed and is ideal for teaching the initial steps of transvaginalVVF repair. By improving the early skill acquisition in the surgicalmanagement of VVF repair, the trainee is then able to maximize eachindividual hands on training opportunity when it does occur. Thisacceleration of skill acquisition can be achieved with dedicatedsurgical training videos such as this video.
Textbookof Female Urology and Urogynaecology 4th Edition,Volume 2 page1163. 2017 Boca Raton Florida. ISBN978-1-4987-9632-3
Am J Obstet Gynecol1994;170(4):1108-1118