Video Clips on DVD
- 4-1
Transanal Repair of Recurrent Rectovaginal Fistula with Rectal Advancement Flap
- 4-2
Rectal Sleeve Advancement Flap
- 4-3
Transperineal Repair of Recurrent Rectovaginal Fistula
- 4-4
Episioproctotomy
- 4-5
Rectovaginal Fistula Plug Repair
- 4-6
Martius Graft Interposition for Repair of Complex Rectovaginal Fistula
Introduction
An anorectovaginal fistula connects the distal rectum or anal canal with the posterior vagina, perineal body, or labia. Technically, a true rectovaginal fistula connects the upper rectum or sigmoid colon with the vagina. In the literature, however, the term rectovaginal fistula is applied to any fistula that connects the rectum or sigmoid with the vagina. For simplicity the designation RVF will be used. However, only fistulas from the distal rectum and anal canal to the distal vagina and related structures will be discussed.
The etiology of the fistula is important as it will affect preoperative testing and repair options. The most common causes are obstetrical injury, Crohn’s disease, cryptoglandular fistula, iatrogenic injury, radiation therapy, and cancer.
Preoperative Evaluation
All surgical considerations start with a thorough history and physical examination. Besides the usual issues in preoperative evaluation, there are specific questions related to RVF. These include exactly what symptoms the fistula is causing, fecal control, obstetrical history, stool patterns, previous anal surgery or attempts at repair, and why the woman wishes the fistula addressed now. Specifically, when looking at the etiology if obstetrical injury is the cause, the status of the anal sphincters is crucial in planning repair. For Crohn’s disease, the amount of intestinal involvement elsewhere in the bowel, the amount of disease in the rectum and anal canal, and the presence of large anal tags all affect the ability to close the fistula. For patients with cancer as the contributing factor, verification that the cancer has not recurred is paramount. Likewise for fistula caused by radiation therapy—verification of being cancer free and the status of the tissue of the rectum and perineum influence treatment choices. One frequent historical fact elicited from women (especially at a tertiary care center) is a problem with frequent Bartholin gland infections that cannot be resolved. This should always alert the caregiver to the possibility of a RVF, and a careful digital examination many times will point out the real problem.
Before the evaluation is completed, all previous records that pertain to the RVF should be reviewed. This includes previous surgical repairs, cancer treatments, and treatment and/or evaluations for Crohn’s disease.
The examination focuses on the perineal skin and tissue, anus, rectum, and vagina. Location of the fistula along with degree of inflammation and induration is assessed. Scars and rigidity of the anal skin and perineal body is noted. Performing a digital examination nearly always gives clues to the internal opening. It may be just a small ridge or bump anteriorly, so the examiner should be alert for this finding. The amount of inflammation and induration is again assessed. The rectovaginal septum is palpated with a finger in the anus and vagina to give an indication of undrained sepsis. Proctoscopy and flexible sigmoidoscopy allows for quantification of rectal disease and to assure that the rectum is distensible. Visual inspection of the vagina may demonstrate stool, but also drainage of pus may point to the external opening or additional unsuspected tracts with openings.
If the examination cannot be completed because of pain, an examination under anesthesia is done. Likewise any treatment starts with seton placement to drain any sepsis in the tract. It is unclear in the literature, but some studies have shown that a loosely tied seton for 3 to 4 weeks in the tract before the definitive repair will improve the chance of closure of the fistula. No surgical repair should be considered without verification that no undrained sepsis exists in the tract as this would doom the procedure to sure failure.
Additional specific preoperative testing is individualized based on the etiology of the RVF and the physical examination. If there is any suspicion of an anterior sphincter defect, anal endosonography is considered. Usually anal physiology is not needed. For patients with Crohn’s disease or radiation- or cancer-induced fistula, bowel evaluation with colonoscopy and radiology (small bowel studies and computed tomography [CT] scans) is done to rule out other disease.
After a full evaluation, a treatment plan is established. The goals of treatment include eradication of the fistula along with preservation of fecal continence. In some women with significant inflammation from radiation or Crohn’s disease, the degree of symptoms is closely weighed against the possibility of making the condition worse. When faced with the possibility of a permanent stoma versus flatus per vagina, repair may not be the best choice. Therefore realistic goals of therapy need to be established before embarking on definitive repair.
Surgical Repair
All surgical repair starts with exact delineation of the tract and verification of tissue “softness” and lack of sepsis. Following previous injury (such as childbirth) or failed repairs it may take 3 to 6 months of “patient” waiting before a repair is undertaken to allow for the tissue to become soft and supple. Seton drainage for 4 weeks is not mandatory, but has been shown to be a positive factor in ability to surgically close the fistula as stated previously. It should always be given serious consideration as it allows for all minute sepsis to be drained and further reduce inflammation and induration. The following is a description of a variety of procedures described for repair of anorectovaginal fistula. The decision on which procedure should be performed on a particular patient is dependent on the training of the surgeon, the location and size of the fistula, and the state of the surrounding tissue as well as concomitant pathology.
Advancement Flap Procedure
The advancement flap procedure is the advancement of tissue to close the fistula and can be done from the rectal or vaginal approach. The rectal approach has several variations.
Case 1
A 48-year-old woman with a history of anal Crohn’s disease presents with a recurrent rectovaginal fistula. The previous repair was a transvaginal repair with excision of the fistula tract and a layered closure of the defect. A transanal repair with rectal advancement flap is offered to the patient.
Rectal advancement flap is probably one of the most common approaches for RVF (especially for nongynecologic doctors). The anal canal and distal rectum must be soft and pliable. It is preferable that the anterior sphincter is intact. Patients can be placed in the prone position. Patients are asked to take a bowel preparation the day before and a Foley catheter is placed before positioning. Anal everting sutures consisting of 1 Vicryl sutures placed to evert the anus in four locations aids in exposure and seem to decrease the amount of stretch on the sphincter complex. (Some prefer the commercial products that evert the anus. The Lone Star retractor is one example.) A Hill-Ferguson retractor with a light attachment gives visualization of the anal canal. A curvilinear incision is made of approximately 50% circumference starting just distal to the internal opening. The mucosa is dissected off the internal sphincter and at the top of the anorectal ring, the plane is deepened to include full thickness rectum anteriorly. Mobilization is continued until the flap can be advanced down without tension to the distal cut margin of the anoderm. Hemostasis is obtained with the Bovie. At this stage the internal opening is closed and the flap is advanced down and sewn to the neodentate line. Closure of the internal opening varies between surgeons with some not closing it at all. I prefer to débride the area lightly to eliminate any epithelial cells that may have grown into the tract. Then using a 2-0 or 3-0 Vicryl suture (or any delayed absorbable suture) the hole is closed from the anal approach. Sometimes it is more appropriate to close the hole distal to caudad and other times side-to-side. It depends on the physical lay of the tissues. After the hole is closed, then the flap can be brought down. Note the vaginal side is left open for drainage. Just before placing the sutures at the neodentate line, the stay sutures are released and the distal edge of the flap is trimmed to remove the area of the flap that had the initial internal opening. Attempts to close dead space with the sutures is also done if feasible. Sometimes placing sutures from the undersurface of the rectum that is being advanced down to the denuded internal sphincter will pull the flap distally, address dead space, and decrease tension on the flap—neodentate line anastomosis. Vicryl suture with a UR-6 needle is helpful to optimize the technical aspect of placing sutures. (See Video 4-1 for a demonstration of transanal repair of recurrent rectovaginal fistula with rectal advancement flap. 
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Postoperative instructions vary and can include bedrest for 1 to 2 days to light activity and performing the procedure as an outpatient. I prefer IV antibiotics and attempting to keep patients in the hospital for 2 days with nil per mouth. When they are discharged antibiotics are continued for 5 more days (for a total of 7 days). I ask patients to take 29 mL (1 oz) of mineral oil each morning to avoid passing hard stools or straining for a month. Additionally I instruct the patient to use magnesium hydroxide (Milk of Magnesia) orally if there is any issue with difficulty passing stool or the patient feels constipated. Patients are permitted to shower, but sitz baths and regular baths are avoided for the first 2 to 3 weeks to avoid maceration of the tissue. There is almost no data to verify what postoperative instructions should be followed. Most rely on the experience the surgeon has acquired as to what seems to work. My above instructions fall into that category.
Rectal Sleeve Advancement Flap
For patients with significant scarring in the anal canal or a failed rectal advancement flap, a sleeve flap is considered. The position, bowel preparation, stay sutures, and Foley use are the same as described above for the rectal advancement flap. The difference is that a full 360-degree mucosectomy is done, and then at the top of the anorectal ring the plane is deepened to allow full thickness rectal wall as a tube to be advanced down. The plane of dissection is similar to the plane used to perform and Altemeier procedure. Hemostasis with the Bovie is critical. When the bowel is mobilized sufficiently to allow advancement without tension, the internal opening is closed with 2-0 or 3-0 Vicryl suture, and the sleeve edge is trimmed and advanced down to the cut edge of the neodentate line and sewn in place with interrupted 2-0 Vicryl sutures. The stay sutures are released just before the neodentate line is sutured. Again the UR-6 needle aids technical ability to place the sutures. An advantage of this procedure seems to be the minimal dead space that is formed. However the stretch to the sphincter muscles is greater than with an advancement flap. A diverting stoma is also nearly always used with the more extensive procedure. In rare instances, reach of the sleeve is not adequate, and patients must be turned onto their backs, placed in stirrups, and an abdominal approach with rectal mobilization is required. The possibility of needing abdominal mobilization when considering a sleeve is always a possibility and thus must be addressed in the informed consent and when planning the operation. The details of the abdominal component are described in the next section.
The postoperative instructions are the same for a sleeve as described earlier for the advancement rectal flap. (See Video 4-2 for a demonstration of rectal sleeve advancement flap. 
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Proctectomy with Coloanal Anastomosis
For complex fistula that have failed multiple repairs, an abdominal approach with a full mucosectomy of the anal canal, full rectal mobilization, and advancement out of the anus with the formation of a coloanal anastomosis is done. This approach is always done with a covering stoma that is usually an ileostomy to avoid compromise to the reach of the rectum that a colostomy may invoke. As stated above abdominal mobilization may be needed with a sleeve approach if there is insufficient reach to the anus from the cut edge of the sleeve of rectal tissue. The abdominal mobilization of the rectum is usually carried out in the presacral plane similar to the plane of mobilization for a total mesorectal excision. This provides excellent mobility and does not compromise the vascular supply. The mesorectum may be bulky as it comes through the anus, but this is usually not a problem in women who typically have shorter anal canals (than men) and anal sphincters that are not as robust (again versus men). Occasionally the splenic flexure must be mobilized and/or the inferior mesenteric vessels divided to allow for sufficient reach and avoid tension. Great care must be taken if either of these maneuvers are needed to avoid injury to the marginal vessel that provides the blood supply to the distal cut bowel. The opening of the fistula from the anal side is closed as described above, and the sutured anastomosis performed as described for the sleeve advancement. Care should be taken to avoid placing the anastomosis over the closed internal opening. Every attempt should be made to manipulate the tissues such that it is placed distal to the closed internal opening. Patients almost routinely receive a stoma with this procedure. Care is dictated according to the abdominal incisions mostly. Specific care of the anal area is as described above. The procedure has typically been done open, but a laparoscopic approach in selected appropriate women can be considered.
Transvaginal Repair of Rectovaginal Fistula
The transvaginal approach to repair of a RVF is preferred by many and is considered by many gynecologic-trained surgeons to be the approach of choice.
Case 2
A 35-year-old woman who developed a rectovaginal fistula after a vaginal delivery with what was thought to be a third-degree tear presents to the office. A small fistula occurred most likely because a defect in the rectal mucosa was missed at the time of the episiotomy repair. An initial attempt at a primary repair resulted in a breakdown and a recurrence of the fistula. A second transvaginal repair was performed with a complete excision of the fistulous tract and a multilayered closure.
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