Fistula Operations: A Colour Atlas of Rectovaginal and Vesicovaginal Fistula (Volume 34) Narendra Malhotra, Arun Nagrath, Shipra Rajat Misra
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1Single Surgical Procedures in Obstetrics and Gynaecology–34: FISTULA OPERATIONS: A Colour Atlas of Rectovaginal and Vesicovaginal Fistula2
3Single Surgical Procedures in Obstetrics and Gynaecology–34: FISTULA OPERATIONS: A Colour Atlas of Rectovaginal and Vesicovaginal Fistula
Series Editors Arun NagrathMS MAMS FICOG Professor and Head Department of Obstetrics and Gynaecology Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India Erstwhile Professor and Head Department of Obstetrics and Gynaecology SN Medical College, Agra, Uttar Pradesh, India Senior Clinical Training Consultant Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO), Baltimore, USA Narendra MalhotraMD FICOG FICMCH President, FOGSI 2008 Dean, ICMU 2008–2009 Director, Ian Donald School of Ultrasound Consultant and Director Malhotra Nursing and Maternity Home (P) Ltd., Agra, Uttar Pradesh, India Apollo Pankaj Hospital (P) Ltd., Agra, Uttar Pradesh, India Associate Editor Shipra Rajat MisraMD Senior Resident Department of Obstetrics and Gynaecology Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India
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Single Surgical Procedures in Obstetrics and Gynaecology–34: A Colour Atlas of Rectovaginal and Vesicovaginal Fistula
First Edition: 2013
Printed at
… At the lotus feet of my master
Late Professor Nawal Kishore ms ficog facs
(Rockefeller Foundation Fellow)
In the loving memories of
Late Dr Nawal Kishore
MS FICOG FACS (Rockefeller Foundation Fellow)
To my parents
Late Dr SP Nagrath and Late Smt Indira Nagrath
Arun Nagrath
To my families
Mr Rajat Misra, Mr & Mrs KC Misra, Mr & Mrs Vinod Chaudhary
Mr Amit & Raj, my beloved Suyash & Aadhya
Dr Shipra Rajat Misra
Anything that simplified our medical education has always been welcomed. This book is organised into multiple volumes on all gynecological and obstetrical surgical procedures related to the female genital organs. Special sections are dedicated to patient positioning, type of incision, their closures along with proper use of drains, suture choices, etc.
We have followed the advice given to Alice when about to testify at the trial of the Knave of Hearts in Wonderland, “Begin at the beginning, keep on until you come to the end and then stop”.
In crafting the book, A Colour Atlas of Rectovaginal and Vesicovaginal Fistula, we have attempted to follow a logical sequence by dividing it into sections. Following the Introduction are three sections: the-preoperative, intraoperative and postoperative care.
Also included in this section are chapters describing in detail both the more traditional and newer surgical procedures, and discussing their place and outcomes. Where feasible, we have substantiated the choice of surgical manoeuvres with good science.
Acquired rectovaginal fistulas in the lower vagina are a result of trauma. Pelvic abscess may rupture either into the rectum or vagina or both, resulting in a high rectovaginal fistula. A complete perineal tear as a result of obstetrical trauma, fall on a sharp object, bull horn injury or rape in the prepubertal females requiring a primary repair followed by an inadequately healed complete perineal tear repair results in the formation of a rectovaginal fistula. Though, not very common, this produces incontinence of flatus and faeces which cause the sufferers to isolate themselves from society.
The incidence of pressure necrosis fistulas which are almost invariably the result of “bad midwifery” have reduced with the prevalence of hospital confinements and the thrust on National Health Programmes to promote hospital confinements.
The population which is still devoid of proper “at the doorstep” obstetrical services continue to bear the burden of domiciliary midwifery with its inherent complications, pressure necrosis fistulas as a result of obstructed labour being one of them and a very debilitating condition.
After the recognition of gynaecology as a separate subject and more and more women seeking help from gynaecologists for their operative problems, more and more hysterectomies are now being performed by gynaecologists. This has dramatically reduced the operative load of hysterectomies on the general surgeons who in the yester years were responsible for performing abdominal hysterectomies. Even today in the smaller townships where there continues a dearth of gynaecologists, hysterectomies are being performed by general surgeons and these are the pockets which continue to provide cases of posthysterectomy fistulas to the tertiary hospitals.
We hope that our efforts will provide a coherent, integrated account of the field we have attempted to cover which will be to the satisfaction of our readers. The book is enhanced by full colour illustrations and photographic reproductions. Special attention has been paid to the illustrations and photographs to make them more accessible and informative. The technical description is superb and to the point.
We as editors of this “Single Surgical Procedures in Obstetrics and Gynaecology” have set out to simplify surgery by creating a step-by-step procedural process, illustrated to emphasise those surgical steps which are critical to the individual procedure under consideration.
We have also provided important notes in an effort to aid the surgeon in reducing blood loss, minimising complication rates and improving their surgical skills.
We hope that our efforts will provide a coherent, integrated account of the field we have attempted to cover which will be to the satisfaction of our readers.
There is no doubt that readers will thoroughly enjoy this work as we have.
8Series Editor, Dr Arun Nagrath is one of the accomplished and renowned Obstetrics and gynaecology surgeon. He has gained excellence especially in non-descent vaginal hysterectomy. Based on his merits and rich expertise, John Hopkins University inducted him as a consultant.
In case, you want to give any suggestion or feedback you may contact him on the following address.
Present Address:
103 A, Varishtha Chikitsa Adhikari Awas
UPRIMS & R, Saifai, Etawah 206301 (UP), India
Contact Numbers: 09319112861, 09410666674
Arun Nagrath
Narendra Malhotra
Shipra Rajat Misra
I am grateful to Director, Brig T Prabhakar, who has a fixation for quality and continued progress, dedicated to his institution. He has always cajoled his staff to move forwards and do something that “makes a difference”. Though he is not heading the institution today, his infectious zeal of toil and excellence continues to inspire us.
My better half, Dr (Mrs) Manju Nagrath, Department of Radio-diagnosis, UP Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India, who has stood by me, tolerating my hours of frustration and its manifestations and constantly encouraging me to “keep up” my endeavours and see this work through completion. A gynaecologist herself, she has always been by my side helping me at every step through the completion of this volume.
I am grateful to Dr Shipra Rajat Misra for her dedication and commitment during the editorial process to enthusiastically and skillfully produce the manuscript.
The preparation of the book of this magnitude involves many individuals who play an important role in its creation. I am especially proud of the quality of the photographs and it would be in place to put on record the contribution of Mrs Geeta Jha, nursing sister in charge, who has shouldered the additional responsibility of helping me in the photography apart from providing facilities in the “State of Art” operation theatre in the Department of Obstetrics and Gynaecology, UP Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India.
I would also thank you, the readers for your constant quest for knowledge to enhance the goal of improved surgical care.
It is my fervent hope that this work will benefit all the postgraduates. I hope that these individual Single Surgical Procedures volumes will stimulate the reader to a greater understanding and thereafter a healthy appetite for more surgical knowledge.
Arun Nagrath10
11All Volumes in the Series “Single Surgical Procedures in Obstetrics and Gynaecology”
This book is one of the titles in the series of Single Surgical Procedures in Obstetrics and Gynaecology, a series which will eventually have 36 volumes.
If you wish to be kept informed of new additions to the series and receive details of our other titles, please write to Jaypee Brothers Medical Publishers (P) Ltd at
We list below a few of the other titles in print and in preparation in the Single Surgical Procedures series. Titles already published are marked (*); those titles to be published during the coming months are marked (#).
Bartholin's gland excision
Marsupilisation of Bartholin cyst
Release of labial fusion
Hymenectomy (Imperforate hymen)
Simple vulvectomy
Anterior colporrhaphy and Kelly's plication
Posterior colpoperineorrhaphy
Vaginal repair of enterocoel
Abdominal repair of enterocoel
Complete perineal tear repair
Fenton's operation
Schuchardt's operation
Biopsy of cervix
Cervical conisation
Endocervical curettage at colposcopy
Conisation of cervix by LEEP
Electrocauterisation of cervix
Cervical cryocauterisation
Abdominal excision of cervical stump
Correction of incompetent cervix by Shirodkar's technique
Correction of incompetent cervix by McDonald's operation
Correction of incompetent cervix by Lash operation
Total abdominal hysterectomy
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Nagrath's minilap hysterectomy
Abdominal subtotal hysterectomy
Obstetrical hysterectomy
NDVH - Conventional approach
NDVH - With salpingo-oophorectomy
NDVH - Debulking by uterine bisection
NDVH - Debulking by wedge excision
NDVH - Debulking by myomectomy
NDVH - Debulking by morcellation
NDVH - Debulking by Coring
NDVH - Debulking by spiral incision
NDVH - Debulking by cervical amputation
NDVH - Debulking by cervical wedge
Ward Mayo's hysterectomy
Modified Ward Mayo's hysterectomy—Dr Nagrath's modification
Clampless vaginal hysterectomy
Dilatation and curettage
Suction curettage for abortion
Dilatation and endometrial biopsy
Fractional curettage
Upper segment caesarean section
Lower segment caesarean section
Cervicopexy (Purandare's)
Supravaginal cervical amputation (Nadkarni's)
Manchester's operation
Fothergill's repair
Shirodkar's anterior sling
Shirodkar's posterior sling
LeFort's operation
Gilliam's operation
Modified Gilliam's operation
William Richardson's operation
Ventral suspension of vaginal vault
Abdominal sacro-colpopexy
Myomectomy for Fundal fibroid, Hood's operation
Myomectomy for anterior wall fibroid
Myomectomy for isthmic fibroid
Myomectomy for anterior cervical fibroid
Myomectomy for posterior wall fibroid
Myomectomy for intracavitary fibroid
Myomectomy for fibroid polyp
Myomectomy for broad ligament fibroid
Myomectomy for round ligament fibroid
Myomectomy for multiple fibroids
Wedge resection of ovary
Ovarian cystectomy
Enucleation of broad ligament cyst
Ectopic pregnancy
Cornual reimplantation
Tuboplasty—Microresection and anastomosis
Laparoscopic sterilisation by silastic bands
Sterilisation by minilaparotomy technique
Sterilisation by Pomeroy's operation
Sterilisation by modified Pomeroy's operation
Sterilisation by Irving's method
Sterilisation by Uchida's method
Sterilisation by Madlener's method
Sterilisation by Parkland's method
Sterilisation by Aldridge method
Sterilisation by Kroener's method
Sterilisation by Oxford's method
Sterilisation by Shirodkar's method
Infra-umbilical midline laparotomy
Paramedian abdominal incision
Pfannenstiel's incision
Kustner's incision
Maylard's incision
Cherney's incision
Abdominal closure
Single layer abdominal closure
Skin closure methods
Use of drains
Incisional hernia repair
Retropubic urethropexy
Kelly's operation
Marshall Marchetti Krantz operation
Burch suspension operation
Strassmenn's utriculoplasty
Jone's utriculoplasty
Tompkin's utriculoplasty
Excision of transverse vaginal septum
Excision of longitudinal vaginal septum
Mc Indoe's vaginoplasty
Modified McIndoe's vaginoplasty
William's vulvo-vaginoplasty
Ileal neovagina
Layer method of RVF
Sim's Moir saucerisation
Latzko's operation
Urethral reconstruction
Vesicovaginal fistula
Vesicocervical fistula
Ureterivaginal fistula
Intestinal loop urinary diversion
Urinary diversion cutaneous ureterostomy
Urinary diversion uretero-sigmodostomy
Ureterovesicle anastomosis (psoas hitch)
Posterior colpotomy
Insertion of suprapubic catheter
Demonstration of tubal patency via laparoscopy
Demonstration of tubal patency by HSG