A 54-year-old female suffered from a rectovaginal fistula after an obstetric injury. She had already undergone a transanal and a transvaginal fistula repair; both failed. She currently had a complex rectovaginal fistula with also a fistula in the perineum that connects to the rectovaginal fistula (Fig. 9.1). On exam she had a sphincter defect that was confirmed on endoanal ultrasound. She also had preoperative manometry that demonstrated good resting and squeeze pressures.

The patient underwent preoperative bowel preparation and received preoperative antibiotics. A Foley was placed in the operating room. She was placed in a prone position and her buttocks were taped apart. A curvilinear incision was made in rectovaginal septum posterior to the perineal fistula. The lone star retractor was utilized for exposure (Fig. 9.2).

The sphincter complex was dissected bilaterally; again, a large anterior sphincter defect was identified. An Alice clamp grasped the right side of the sphincter complex to facilitate retract to allow for adequate mobilization of the sphincter muscles (Fig. 9.3).

The sphincter muscles were dissected and mobilized bilaterally, and the central scar was divided sharply. Both ends of the sphincter muscles are grasped with Alice clamps. The rectal side of the rectovaginal fistula has been closed in two layers with 3-0 Vicryl in an interrupted fashion (Fig. 9.4).

The gynecologist preferred the patient in lithotomy position and performed a vaginoplasty, excised the perineal and vaginal fistula, and then did a two-layered closure of the vagina and reconstructed the perineal body. Using the Alice clamps, the ends of the sphincter muscles are overlapped. This overlap provides a tissue barrier between the vaginal and rectal repair and provides bulk to the perineal body (Fig. 9.5).

The two overlapped sphincter muscles are then sutured together with interrupted 3-0 PDS in a mattress fashion (Fig. 9.6).

The completed overlapping sphincteroplasty is seen in Fig. 9.7. A small Hill-Ferguson retractor is placed in the anus to confirm that the repair is not too tight.

The skin is then closed with vertical mattress 3-0 Vicryl sutures (Fig. 9.8). The middle of the wound is left open with a Penrose drain placed and in this case is sutured to a 4 × 4 gauze to facilitate its removal. The patient also had vaginal packing placed by the gynecologist for their repair. The patient was admitted overnight and given oral pain medications and a regular diet. The following day, the vaginal packing and the Penrose were removed. After the removal of the packing, the patient’s Foley was removed and she was able to void and she was discharged to home.

Others have described surgical repair of obstetric injuries as an episioproctotomy or perineoproctectomy with layered closure. This surgical procedure, like the overlapping sphincteroplasty, offers a simultaneous repair of the sphincter complex. This procedure is more extensive than an advancement flap and requires the division of the perineal tissue. This procedure is indicated when there is a significant anterior sphincter defect, when there is a substantial injury to the perineal body, or when a large rectovaginal septum defect exists. Patients are placed in the Kraske position, and a probe is placed through the fistula. The tissue overlying the fistula is divided creating a fourth-degree perineal laceration. The sphincter edges are then dissected free. The rectal mucosa is closed, followed by an overlapping sphincter repair. Finally, the vaginal mucosa and the perineal skin are closed. The healing rates are equivalent to a rectal advancement flap and allow for improvement in continence [24]. Some surgeons feel that episioproctotomy should be considered first-line treatment in patients with a fistula and compromise of the anterior sphincter complex [25]. Just as with an overlapping sphincter repair, a diverting stoma should be considered in select cases with no data to support their use.

Simple fistulotomy is a surgical option in very low anovaginal fistulas. But extensive consideration needs to be given to the risk of incontinence. For any anovaginal fistula that is not superficial in nature, the risk of significant incontinence makes this procedure undesirable.

Other treatment options for simple rectovaginal fistulas include the use of a bioabsorbable fistula plugs and fibrin glue. These techniques are used to attempt to prevent radical surgery. With regard to fistula plugs based on experience, the outcomes are similar to advancement flap repair [26]. However, in cases of complex fistulas, the success rate is only moderate—44 % in one series [27]. Just as any other fistula repair procedure, a fistula plug is performed after local sepsis has been controlled. Currently, two different bioabsorbable plugs are commercially available. One is of xenogeneic origin (Cook Biodesign™) and the other is a synthetic absorbable plug which has a disc and 6 tails (Gore fistula plug™). For the procedure itself, the plug is placed through the fistula tract and excess plug is excised. The head or disc of the plug is then sutured in place with absorbable suture on the rectal side in figure-of-eight fashion, and the vaginal side is left open to allow for drainage. Similarly, the use of fibrin glue can be used. There are only a couple of small case series examining the use of fibrin glue, some of these demonstrating promising results, while others demonstrate low success rates [28, 29]. These local procedures tend to work best in fistula tracts that are long (which is usually not the case in rectovaginal fistula). However, given the low morbidity and the ease of the procedure, it is not an unreasonable first-line treatment for patients with rectovaginal fistulas.

Like the fistula plug, another procedure that was designed for anal fistulas and then trialed in patients with rectovaginal fistulas is the ligation of intersphincteric fistula tract (LIFT) procedure [6]. This procedure entails dissecting in the intersphincteric plane around the fistula, which is isolated and then ligated. The rectal opening is then closed, and the vaginal opening may be closed or left open to drain. No muscle is cut during this procedure, so there is little to no risk of incontinence. There are several studies on the use of this sphincter-sparing technique for anal fistulas but just case reports for rectovaginal fistulas, so there are no studies to compare the LIFT procedure to other surgical procedures in this disease process.

Sleeve advancement flap may be a useful treatment in patients with severe perianal Crohn’s disease. There is a small published case series from the Cleveland Clinic where they performed advancement sleeve flap in 13 Crohn’s patients for severe fistulas disease, several with rectovaginal fistulas. In these 13 patients, they achieved successful healing in eight of the patients [30]. Another series from the Cleveland Clinic on patients with recurrent rectovaginal fistulas performed several different types of repairs from local repairs to pull-through coloanal anastomoses. The rectal sleeve advancement flap was performed in three patients. They state that the procedure is suitable for patients with more extensive scarring or anal stenosis. For this procedure, the mucosa and the submucosa are mobilized circumferentially from the dentate line to several centimeters proximally. Then, the dissection becomes full thickness up to the levator space. This extensive mobilization allows for the rectum to be advanced past the fistula to the anal canal without undue tension [31]. Ileal pouch advancement is the equivalent procedure for those patients with ileal pouches and pouch vaginal fistulas. Diversion with a stoma should be considered in these cases given that this is an anastomosis and with that comes a risk of anastomotic leak complications. Diversion should be used selectively based on patient comorbidities and the quality of the tissue that is being approximated.

Turnbull-Cutait proctectomy with coloanal anastomosis is another option for repair of complex rectovaginal fistulas. This two-stage procedure includes a proctectomy, excision of fistula, mobilization of the abdominal colon, and pull-through of the colon through the anus during the first stage. Some suggest rotating the colon slightly when you are pulling it through the anus so that the mesentery lays over the vaginal defect. Before pulling the colon through the anus, sutures are placed to allow for the anastomosis to be completed at a later date (making sure to take a bite of the internal sphincter). A drain is left in the pelvis, a loop ileostomy is created, and the colon is left unanastomosed externally for 5 days. This delay allows for adherence between the colon and the anal canal. The patient is taken back to the operating room, the exteriorized colon excised, and cut end checked for viability. The coloanal anastomosis is completed with the already placed sutures. This procedure is preferred over an immediate anastomosis in patients with a reoperated, irradiated pelvis with chronic inflammation or infection, persistent rectovaginal or rectourethral fistula, and complex perianal fistula [32]. This is obviously an extensive procedure for the treatment of rectovaginal fistula, but in some patients is the only option available besides permanent diversion. Functional outcomes after this procedure are the same compared to other coloanal anastomoses.