Non-Oral Poster 33

Abstract

OBJECTIVES: To review our experience pertaining to the surgical repair of rectovaginal fistulae during a medical mission at Hospital Escuela in Tegucigalpa, Honduras. Included are the scope of the problem, surgical repair, and the opportunity for resident learning experience during the mission. MATERIALS AND METHODS: In May 2009, a MEDRETE (medical readiness mission) involving urogynecologic surgical care was undertaken for two weeks at the Hospital Escuela in Tegucigalpa, Honduras. Two attending urogynecologists, 2 OB/GYN senior residents, 4 aneshtesia providers, and OR staff were deployed to Tegucigalpa from Brooke Army Medical Center and Wilford Hall Medical Center in San Antonio, Texas. Seventy-two patients were evaluated for surgery with problems including pelvic organ prolapse, urinary incontinence, and rectovaginal fistula. Sixty-one surgical procedures were performed over 9 operating days. Eleven patients were identified as having rectovaginal or anovaginal fistulae. The average age of these patients was 26 years and average parity was 3. Nine of these patients sustained injury during childbirth which was not attended by physician or mid-wife or not properly repaired. The average time these patients waited for evaluation was 18 months. Hospital Escuela in Tegucigalpa, Honduras is the main teaching hospital and also provides free care to patients with little means. There are approximately 65 deliveries per day in this hospital with an average of 2 attending obstetricians and 2 residents each day. RESULTS: Eleven patients underwent surgical repair of rectovaginal or anovaginal fistulae. Eight of these underwent sphincteroplasty, and three underwent perineoplasty alone. Each spent one night in the hospital and were discharged the next day. Each case was staffed by an attending urogynecologist with a senior level OB/GYN resident. At the conclusion of the mission, the senior resident was acting as primary surgeon with attending assistance. Prior to the mission, each resident reported exposure to 2 4th degree repairs and no rectovaginal fistulae procedures. To date, there were no major complications reported with only one patient with a perineal skin separation. Ten of the eleven patients were seen in follow up by the Honduran Gynecologist. At the conclusion of the mission, there were approximately 50 patients with the similar condition waiting for evaluation. CONCLUSION: Recto-vaginal fistula is a devastating condition in 3rd world countries where it is a common complication of childbirth resulting from obstructed labor or either poorly or unrepaired obstetric lacerations. It is exceedingly rare in developed countries. Social, emotional and psychological consequences incurred by women with obstetric fistulas can lead to stigmatization, isolation and loss of social support and in some cases divorce or separation. In the United States, with diminishing use of episiotomy and fewer operative vaginal deliveries utilizing forceps, the opportunity to train Obstetric and Gynecology residents this important skill has decreased. Other than the obvious benefit of providing surgical care to the impoverished population of a Third World country, it provided a robust learning experience for OB/GYN residents.