What is Martius Flap Surgery.


There is no perfect life after mesh complications and something that was once considered rare, now happens more and more when women are badly damaged because of mesh (or tape) implants. The one thing I wanted to do with this blog is try to share other complications that women rarely talk about. This is because it is so very personal. For me it is very sad when women are at the prime of their lives but they live in constant pain because of various complications and subsequent surgeries. This should NEVER happen to any woman because she believed in her doctor and thought what she was having done would end with a good result and she could go on with a normal life. I keep writing blogs in hopes that when a woman is searching for answers BEFORE she has a hysterectomy, incontinence or prolapse surgery, she will understand what CAN happen BEFORE she makes any decision.

I know women who have had to have this surgery because of mesh. It is not an easy surgery on their bodies and definitely not on their mental wellbeing. Any surgery has success rates and failures, but there are many times when women don’t have a choice but to do something to help them get well. This should NEVER happen to anyone because of a mesh implant and I want women to know that all new slings on the market are no different than the ones that have already injured women. Don’t believe bull…. that doctors tell you because after it is done, they will turn you away and you are left to deal with physical and mental anguish.

This surgery was once considered rare and yet I know it is happening to more and more women because of the damage done. Regardless of all doctors write about how this surgery is done and the success rates, it isn’t happening to their bodies. They don’t deal with the aftermath of any surgery regardless of how well meaning they are. Women do! I found a link to a book that said this surgery is successful 91% of the time, but it would not let me copy it. So what happens when everything has been tried and has failed? The answer is simple. Women are left to deal with the pain and their physical life has totally changed forever.

I can share with women injured, procedures that can be done to try to fix them, but I can’t share in their emotional anguish because it didn’t happen to me. But I can share awareness of all that can change after a mesh implant. Loss of everything that a woman once took for granted. It is an emotional and often a financial devastation and this should NEVER happen to women at all, and yet doctors who use mesh are turning a blind eye to the results and turning their backs on women who live in pain. It is a very sad situation, and one that I will not turn MY back on.

First learn why this surgery is performed.

What is a vaginal fistula? A fistula is a passage or hole that has formed between:

  • Two organs in your body.
  • An organ in your body and your skin.

A fistula that has formed in the wall of the vagina is called a vaginal fistula.

  • A vaginal fistula that opens into the urinary tract is called a vesicovaginal fistula.
  • A vaginal fistula that opens into the rectum is called a rectovaginal fistula.
  • A vaginal fistula that opens into the colon is called a colovaginal fistula.
  • A vaginal fistula that opens into the small bowel is called a enterovaginal fistula.

What causes a vaginal fistula?

A vaginal fistula starts with some kind of tissue damage. After days to years of tissue breakdown, a fistula opens up. Vaginal fistulas are not a common problem in developed countries. But a fistula does sometimes happen after:

  • Surgery of the back wall of the vagina, the perineum, anus, or rectum. Open hysterectomy is linked to most vesicovaginal tract fistulas.
  • Radiation treatment for pelvic cancer.
  • A period of inflammatory bowel disease (including Crohn’s disease and ulcerative colitis) or diverticulitis.
  • A deep tear in the perineum or an infected episiotomy after childbirth.

In developing countries where women have no health care nearby, vaginal fistulas are much more common. After days of pushing a baby that does not fit through the birth canal, very young mothers can have severe vaginal, bladder, or rectal damage, sometimes causing fistulas. Yes we are becoming more like developing countries because of the overuse of mesh (tape) slings.

What are the symptoms?

A vaginal fistula is painless. But a fistula lets urine or feces pass into your vagina. This is called incontinence. And it can cause soiling problems that you cannot control.

  • If you have a vesicovaginal fistula, you most likely have fluid leaking or flowing out of your vagina.
  • If you have a rectovaginal, colovaginal, or enterovaginal fistula, you most likely have foul-smelling discharge or gas coming from your vagina.
  • Your genital area may get infected or sore.

How is a vaginal fistula diagnosed?

Your symptoms are the clearest signs of a vaginal fistula. Your doctor will want to talk about your symptoms and about any surgery, trauma, or disease that could have caused a fistula. For a physical exam, your doctor will use a speculum to look at the vaginal walls. You may have other tests, such as:

  • The use of dye in the vagina (and maybe the bladder or rectum) to find all signs of leakage.
  • Urinalysis to check for infection.
  • Blood test (complete blood count) to check for signs of infection in your body.

Your doctor may also use an X-ray, endoscope or MRI to get a clear look and check for all possible tissue damage. This is where I found this information

Now read more to learn about Martius flap surgery, which is done to fix the worse fistulas.

Rectovaginal fistulas (RVF) are rare but represent a challenge for both patients and surgeons. The most common cause of RVF is obstetric trauma, and treatment is based on fistula classification and localization of the fistula in relation to the vagina and rectum. Conventional therapy frequently fails, making surgery the most viable approach for fistula repair. One surgical procedure which offers adequate repair of lower and middle rectovaginal fistulas consists of interposition of a bulbocavernosus fat flap also called modified Martius flap. First described by Heinrich Martius in 1928, this approach has been continuously modified and adjusted over time and is used in the repair of various pelvic floor disorders. Overall success rates reported in the literature of the interposition of a Martius flap as an adjunct procedure in the surgical management of RVF are 65–100 %. We present a detailed description of the operation technique together with a discussion of the use of a dorsal-flapped modified Martius flap in the treatment of RVF.

What is the purpose of this surgery.
Principles of fistula repair using a modified Martius flap: healthy tissue provides neovascularization of the perineal space and divides the single sutures of the primary fistula repair (modified from Given et al. 34).

As a diverting colostomy is an appropriate method to prevent infectious complications in the perineal region which can impair wound healing, especially in the management of recurrent RVF, a temporary transversostomy is done during the same session in addition to RVF repair 17, 29.

Rectovaginal Fistula – Symptoms and Diagnosis While the diagnosis can often be easily confirmed by distal examination of the rectum, treatment, especially of recurrent fistula, makes this disorder very complex. Small fistula can be asymptomatic. The progress of RVF is accompanied by severe clinical manifestations: loss of gas and feces from the vagina, diarrhea, tenesmus, frequent urination, abdominal cramps, rectal bleeding, back pain or anorectal burning sensation 2. In about 90 % of cases, the patientʼs medical history together with a clinical examination including proctoscopy and vaginal exploration lead to the diagnosis of RVF 10. If the diagnosis remains unclear, no fistula is found, or malignant disease as the cause of fistula cannot be excluded, the next diagnostic step is imaging using magnetic resonance tomography (MR), computer tomography (CT), colon contrast study or endosonography (ES). MR and ES have the highest diagnostic value for colorectal fistula and additionally allow potential sphincter lesions to be evaluated 8, 11, 12. CT with rectal contrast filling is the second choice, although CT is very accurate in diagnosing abscess formations or malignancies as complicating comorbidities of RVF 13. The advantage of ES is its availability and the fact that it offers the option of evaluating sphincter lesions, which are important when choosing the surgical procedure.
I do warn you this article has some very graphic pictures but if you want to know more,
this is the link

So what about scar tissue.
So you may wonder about scar tissue from this surgery.
A “skin–on” Martius graft is especially helpful in patients with the “Tethered Vaginal Syndrome”, Figure 1. The “Tethered Vaginal Syndrome” is not a well recognized condition. It was first reported in 1990 [2]. It is an entirely iatrogenic condition that needs to be considered in patients with scarring after vaginal operations or after Burch colposuspension. The incontinence is severe. Urinary stress incontinence is very mild or absent. It is somewhat equivalent to ‘motor detrusor instability’ (MDI). The classical symptom is commencement of uncontrolled urine leakage as soon as the patient’s foot touches the floor, indeed, often commencing as the patient rolls over to get out of bed. The patient does not complain of bed–wetting during the night. The symptoms are caused by loss of elasticity in the bladder neck area of the vagina: the ‘zone of critical elasticity’ (ZCE). Because scar tissue contracts with time, it may present twenty years after vaginal repair or bladder neck elevation. This condition can be cured by plastic surgery, whose aim is to restore elasticity to the bladder neck area of the vagina.

Skin–on Martius flap surgery, Figure 1

The aim is to restore elasticity in the bladder neck area of the vagina, the ZCE, so that oppositely acting vectors can act independently of each other.

No matter what technique is used, it is essential to dissect the vagina from the bladder neck and urethra, and then to free all scar tissue from urethra, bladder neck (‘urethrolysis’), and pubic bones.

The surgical principle applied is that fresh vaginal tissue must be brought to the bladder neck area of vagina. If there is a severe shortage of tissue, the only solution is a skin graft. This can be a free graft, a Martius labium majus skin graft, or a split labium minus flap graft. A free graft can be problematic as up to one third may not ‘take’ or shrink excessively. Labium minus or Martius grafts are technically challenging, but bring their own blood supply. Cure rates reported with this operation exceed 80% [6].

ZCE and the urethral (U) and bladder neck (BN) closure mechanisms. ZCE extends from mid–urethra to the bladder neck area of the vagina. A scar at the ZCE tethers the PCM (pubococcygeus) muscle vector to the levator plate/longitudinal muscle of the anus (LP/LMA) vectors. As LP/LMA are more powerful, the posterior urethral wall is pulled open, from C to O, resulting in uncontrolled urine loss. C = closed urethra; O = open urethra; PUL = pubourethral ligament; PS = pubic symphysis. Read more here

I can’t change what has happened to women already, but I can raise awareness of what implants can do to a woman’s body. It is never enough to ease the suffering and pain that women experience, but I still do all I can to let the women of the world learn what can happen to their bodies after these surgeries. I will write and post all I can while I have a good mind and a willing spirit and I hope other women will follow suit and tell the world what has happened to them because of their surgery. Hush is not a good word when dealing with these injuries. Be quiet should never be a choice. Silence is not golden.

2 Comments

  1. Karen Lerner

    I have a left side colostomy and I have a vesicovaginal fistula, in looking to reverse the colostomy and have the fistula repaired, which one should I do first.

    Reply
    1. Linda (Post author)

      Karen I cannot answer that but I have sent you the email address of someone who can.

      Reply

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