Martius labial fat pad graft (use in rectovaginal fistula repair).

INTRODUCTION AND HYPOTHESIS: The objective is to demonstrate the utility of the Martius labial fat pad graft in pelvic fistula repair. METHODS: An incision is made over the labium majus from the level of the clitoral hood superiorly and extending inferiorly to the level of the labiocrural fold. The fibrofatty graft is then mobilized from the adjacent labium majus. The flap can be divided either at its anterior or at its posterior pedicle. A subepithelial defect is created through which the flap will be passed. The flap is sewn into place by attaching it to the underlying rectovaginal fascia without associated tensioning. Next, the posterior vaginal wall is closed over the graft with a series of everting subepithelial mattress sutures followed by a reinforcing layer of interrupted #1 Vicryl through the vaginal epithelium. CONCLUSIONS: The advantages of the Martius flap in fistula repair include low morbidity, lack of a cosmetic defect, and the need for only a single surgical field. Its prominent fibrous component makes it a stronger graft than adipose tissue from other areas and its abundant blood supply promotes rapid neovascularization and lends itself well to many surgical modifications that can be utilized in even the most difficult of fistula repairs.

Postoperative Opioid Prescribing Following Gynecologic Surgery for Pelvic Organ Prolapse.

OBJECTIVES: The aim of this study was to evaluate postoperative pain scores, quantity of prescribed opioids at hospital discharge, and need for additional opioid prescriptions among women undergoing surgical treatment of pelvic organ prolapse. METHODS: Institutional billing data were used to identify all patients undergoing pelvic reconstructive surgery between January 1, 2012, and May 30, 2017. Inpatient records were utilized to obtain prescription data (reported in oral morphine equivalents for standardization) and pain scores. The cohort was organized by surgical approach (open, endoscopic, vaginal), number of concomitant procedures, and patient age stratified by decade. These factors were then matched to postoperative pain scores, amount of opioid prescribed at discharge, and number of subsequent opioid refills. Pain scores and opioid use were also compared for correlation. RESULTS: One thousand eight hundred thirty patients underwent surgical treatment of pelvic organ prolapse and met criteria for study participation. A significant decrease in pain scores, mean oral morphine equivalents prescribed, and opioid refill rates was seen with increasing patient age by decade regardless of surgical approach. Pain scores were significantly different only between patients undergoing vaginal surgery with 0 concomitant procedures versus 1 or more concomitant procedures. Finally, pain scores were directly correlated to the amount of opioid prescribed. CONCLUSIONS: Pain scores, opioid prescription amounts, and refills varied by patient age and surgical approach but were unaffected by concomitant procedures. Further work in correlating pain scores to opioid utilization is needed to ensure appropriate prescribing patterns and reduce risks of opioid dependence and diversion.