Repair of an obstetric VVF fistula.

Imagine you are faced with the task of repairing a hole in someone’s skin that connects with an inner cavity, the whole of which is within another deep cavity.

You first cut a circle around the hole with a very sharp small knife and extend it out on either side to give you access to the inner hole. You then carefully separate the outer skin and soft inner one, without damaging the latter. They are usually stuck together with very hard scar tissue.

You then close watertight the inner hole, with stitches at the correct tension placed at 3 millimetre intervals, and at last you stitch the outer layer.

Additional challenges:
If your inner line of sutures is at all unsatisfactory you have to reinforce it with a second line that inverts the first.

The ureters (urinary pipes from the kidney) are often involved in the hole and have to be identified and preserved at all costs, and the uterine opening (cervix) has also to be preserved.

There is usually mild to severe narrowing of the front passage

Scars of bone-like consistency that require special shears to cut through

Non existence of the water outlet pipe which has to be repaired, using nearby paper thin tissues

A hole into the back passage that has to be repaired separately.

Dave has been watching and taking notes of a world class expert this week doing extreme cases. I have also done a simpler case myself each day, growing slowly in confidence in the basic handling skills that will hopefully enable me to do the difficult cases later.

‘A fistula surgeon must never be hurried’

PS Gory photo was removed by request.

Please write : dave.lyth@mercyships.org, or helen.lyth@mercyships.org