PMC6768818_01
TVM 1.5 cm in diameter protruded from the posterior vaginal wall just distal to the uterine cervix.
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TVM, which was 1.5 cm in diameter, protruded from the posterior vaginal wall at a 1 cm distal to the uterine cervix (Figure 1).
Two cm size of TVM protruded from the anterior rectal wall just proximal to the anal canal.
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The TVM, which was 2 cm in diameter, protruded from the anterior rectal wall just proximal to the anal canal (2.5 cm from the anal verge, Figure 2), with a concomitant rectovaginal fistula. The anterior arms of the TVM were palpated at the lateral sides of the vaginal wall to the obturator, and the posterior arms were palpated at the lateral sides of the rectum to sacrospinal ligaments through a digital examination of the vagina and the rectum.
Forceps were inserted from the rectal side of the fistula to the vagina under visualization by a Lone Star retractor and a retractor connected to an Octopus retractor holder during the removal of TVM.
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Visualization of the vagina was obtained using a Lone Star retractor and a retractor connected to an Octopus retractor holder (Figure 3). While grasping the TVM with forceps, the rectovaginal septum was bilaterally dissected with an additional transverse incision at the entrance of the vagina performed to fully visualize the TVM, though the severe adhesion of TVM to the surrounding tissues made the dissection difficult (Figure 3).
The vaginal wall was closed longitudinally followed by closure of the entrance of the vagina. Bilateral perianal wounds for division of the posterior arms of TVM can be seen.
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The fistula tract of the rectum and the vagina were trimmed, and the contaminated rectovaginal septum was curetted and irrigated with a 500 ml of saline. The rectal wall was transversely sutured and the vaginal wall was closed longitudinally followed by the drain placed at the rectovaginal septum (Figure 4).
TVM with anterior and posterior arms (9 x 5.5 cm in diameter) were removed.
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Finally, the TVM was removed with anterior and posterior arms (9 x 5.5 cm in diameter) (Figure 5), though some tips of anterior and posterior arms of TVM were left behind.