Martius Labial Fat Pad Graft (use in RVF Repair)

Abstract

Video Objective To demonstrate the utility of the Martius Labial Fat Pad Graft in pelvic fistula repair. Setting We present a minimally invasive surgical approach for a patient with recurrent rectovaginal fistula. Interventions An incision is made over the labium majus exposing the yellow fibrofatty graft. This graft is first retracted medially where a natural tissue plane facilitates dissection from the adjacent labium majus. It is then retracted laterally where a plane between it and the bulbocavernosus muscle is developed. To avoid devascularization of adjacent skin, a thin fatty layer is left attached at its undersurface. The division of the flap is begun in this case, at its anterior pedicle. It is important to develop a flap that easily covers the defect with a good degree of overlap. Once the flap has been sufficiently mobilized, a shellcross is used to create the subepithelial defect to enable passage of the flap through the levator plate. This defect is widened enough to prevent compression on the pedicled blood supply. After appropriate positioning, the flap is sewn into place by attaching it to the adjacent, underlying rectovaginal fascia with interrupted 2-0 Vicryl suture. It is important to note that no tensioning of the flap is required to approximate it to the adjacent tissue. The posterior vaginal wall is next closed over the graft in two layers followed by closure of the labial defect. Conclusion The Martius flap has multiple minimally invasive advantages in fistula repair to include low morbidity, lack of a cosmetic defect and the need for only a single surgical field. Its’ abundant blood supply promotes rapid neovascularization of the transplanted graft and lends itself well to a variety of surgical modifications that can be utilized in the repair of even the most difficult of fistulas.