I do not think the type of imposition flap ( whether peritoneum, ormentum, labial fat pads) really makes a difference. the most important are the quality of the appositions (vaginal and bladder tissue)- like vascularity, thickness, absence of tension etc. In my experience interposition flaps are rarely necessary even in the redos.

Thank you Sir.

I'm against omental flap and I'd never do it in all of my cases. Actually I have many cases done without interposed layer. and many others with peritoneal flap. the result was good in both. but I feel more comfortable when I put the flap, It could be the sticking to traditions.

have had to use the omentum occasionally in some very difficult redos. Are you aware of any study comparing the outcome using the different types interposition flap?

I dont ever use omentum,

regarding the study that you ask about, I 'll be thankful if you send me such a studies.

Hadi

I agree completely with Dr Tijani.

Dr Browning has demonstrated that the interposition of Martius fat grafts does not work.

Browning A. Lack of value of the Martius graft in obstetric fistula repair.

Int J Gynaecol Obstet 2006;93:33–7.

The most important factors for surgical success are the quality of the appositions (vaginal and bladder tissue). The critical factor is to ensure that the vagina is freed completely from the scar. Good hemostasis is critical. There must be total absence of tension when the vagina is approximated.

If after the dissections are complete, there is a gap between the two walls of the vagina, you will need a skin graft applied in the gap. Always make it about 20% larger. Lower abdominal wall is a good site, as that part has good elasticity . Take the fat off the skin, ensure the bed is not bleeding, then attach the skin to the bed and then suture to the walls of the vagina with interrupted sutures.

With large obstetric fistulas, you may need a Singapore Flap graft

See article in Pelviperineology (free online) and BJOG

Petros PEP Williams G Browning A Post Vesico-vaginal Fistula Repair Incontinence - a new hypotheses and classification potentially guide prevention and cure Pelviperineology Pelviperineology 2015; 34: 48-50

Browning A, Williams G , Petros P ,Prevention and cure of post vesico-vaginal fistula repair incontinence by insertion of skin graft in the bladder neck area of vagina- update on hypothesis and interim report; Pelviperineology 2017; 36: 9-11

Browning A, Williams G, Petros P. Skin flap vaginal augmentation helps prevent and cure post obstetric fistula repair urine leakage: a critical anatomical analysis. BJOG. 2017 Oct 11. doi: 10.1111/1471-0528.14953. [Epub ahead of print]

Thank you Sir for this informative answer, as usual you give an expert point of view.

do you have a figure regarding the failure rate of the VVF repair. and any comparative study between abdominal and vaginal repair, taking in consideration the cause, the site and the size of VVF.

I think that the type of flap make no difference the most important is the good dissection of the bladder from the vagina, removal of fibrous tissue. Tension free closure in layers and any type of intervening tissueif possible

thank you for this answer, in trigonal fistula, it is some times very difficult to perform proper dissection.

regards

Yes, but insertion of ureteric catheter before disaffection and vaginal approach may help

I totally agree with you..

I do not know of any comparative studies, abdominal vs vaginal. The statements made by our colleagues above all say the same thing , beautifully summarised by Dr el Din: "I think that the type of flap make no difference. The most important is the good dissection of the bladder from the vagina, removal of fibrous tissue. Tension free closure in layers and any type of intervening tissueif possible."

On this basis, no RCT could have any validity as no surgeon can be equally skilled in abdominal and vaginal fistula repair. Furthermore, the difficult Obstetric Fistulas just can't be adequately repaired abdominally as it would not be possible to make up any tissue deficit with a skin graft.

So the one should not blame the missed step of interposed layer if had a failed VVF repair.

The challenge with the big interuretric fistula, dissection may injure the ureter, would you suggest reimplantation of ureter to be done concomitantly

I do not hesitate in re implanting the ureters once i am convinced they will be at risk during the dissection. Indeed I have found re-implantation almost inevitable in the big interureteric fistulae . That has been my own personal experience.

I face this scenario 4 or 5 times, over the past 15 years, I feel more convenient, though it takes more operative time.

thank Sir @kehinde .

Peritoneal interposition is one of the viable options assuming that good dissection, removal of fibrous tissue, good vacularity of the margins and tension free closure are considered