Narrowing of the genital tract in african vesico-vaginal fistulae   is a major challenge in selecting  the best way of approach.

Supine positions as described by  TrendelenburgRobert Proust Picot and Couvelaire etc.  compel the surgeon to work most uncomfortably  " at the ceiling" . 

Prone positions , as described by Sims, Chassar Moir, Steg  etc. put the patient on one's knees and force the surgeon to work between the legs  while the compressed intestinal  tract pushes  the diaphragm upwards and bothers the anesthesist.

 I use to put the patient in the  " jockey position ".



Drawings by Rudi Pillen. See his web site.

The patient straddles  the extremity of  the operating table.  The three contact spots  i.e.   the  inner upper thighs  and the sternum  are protected by  paddings. The buttocks overstep the table.


The anesthesia cradle is fixed at the extremity of the table with its two poles stopping  the thighs  and its bar supporting the inverted vaginal valve as an  upwards retractor.

The shoulder locks are used to block  the thighs instead of  the shoulders


Through the  fistulous aperture one can see a ureteral meatus  ejaculating its urine.


Abdominal wall  and  lower thorax  do not touch the table,  which does  not  impede  respiration.

Although it might seem rather surprising at first sight,  this remains true in huge obesity  as  the gap between abdomen and table is commensurate with the three-dimensional size of the thighs.


Actually  the jockey position is best fit for accessing  to the cervix in  extreme obesity  and especially in  fistulae  after cesarean section.


Hooking  the inverted vaginal valve  to the  anesthesia canvas frees both hands of the surgeon and his assistant.  Owing  to that position  which lifts up  the intestines,   the rectum  slips backwards into the sacral concavity and  the vagina  can take its largest dimensions. Often the cervix  moves off  sight  and  should be pulled  back  by a previously stitched thread.

In an uninterrupted series of  65 post partum  african  fistulae , no  anesthetic, nervous or vascular troubles were recorded.

Surgical benefit of working  " on the floor "  instead of   " at the ceiling "  always overcame  the drawbacks of   inverting  twice the   position  on   the  operating  table. 

It must be emphasized  that  doing so  is unpracticable  whenever  no  endotracheal   intubation  is available.