Fig. 10.1
A thin and soft silastic seton to allow the inflammation to subside before the final repair
The principles of proper wound healing should always be followed in order to decrease any chances of failure. Diabetic patients require optimization of their blood sugar. Because most repairs are scheduled well in advance, a window of opportunity exists during the preoperative period that allows for close monitoring of blood sugars and glycated hemoglobin (A1C). Euglycemia is crucial during the perioperative period, although achieving it might be difficult in patients with advanced diabetes. In these instances, glucose levels of 140–200 mg/dL are set as a preoperative goal, with fasting levels at <140 mg/dL and random checks of <180 mg/dL [9].
Smoking is also associated with impaired wound healing, through a multifactorial mechanism that includes vasoconstriction, leading to decreased perfusion, relative ischemia of dissected tissues, reduction of inflammatory response, impaired bactericidal mechanisms, and alterations of collagen metabolism [10]. This is especially important when tissue flaps are considered during reconstructive procedures [11, 12]. In certain cases, in order to provide an optimal environment for healing, complete abstinence from smoking can be monitored by measuring cotinine levels in body fluids. Non-compliant patients should have their cases postponed.
On occasion, the patient will present with a more complex fistula associated with a side branch or a secondary primary opening on the rectal side. The surgeon should always maintain a high index of suspicion for that possibility, particularly during re-operative approaches and recurrent fistulas. Consideration should also be given to performing a real-time endorectal ultrasound during EUA or a preoperative MRI [13, 14].
The recurrence rate might also be due to other causes, including hematoma, infection, poor tissue quality, inflammation, foreign body including staples (Fig. 10.2), mesh and non-absorbable sutures, plugs, inflammatory bowel disease (IBD), malignancy, radiation vasculitis, obliterative endarteritis, ischemia, dead space, obstructed defecation syndrome, or steroids. Thus, in the surgical treatment of RVF, many things can go wrong. It also helps to explain why it is often difficult for RVFs to heal after multiple operations, especially considering that the rate of success diminishes after each subsequent procedure [4].
Fig. 10.2
A staple (foreign body) found to be a reason for failure after second rectal advancement flap repair for fistula from PPH (procedure for prolapsed hemorrhoids)
Because of its transmural nature, patients with Crohn’s disease often develop fistulas. The anorectum is the most common anatomic area for fistula formation in these patients and the close proximity of the posterior vaginal wall also enables the formation of RVF. These fistulas often involve severe inflammation and stricture and are especially prone to recurrence following repair [7]. It is not uncommon for patients to undergo multiple procedures such as incision and drainage, placement of seton, plug, and sealant and flap procedures, and for all of them to fail. In fact, because of the frustrating results of treatment, many patients choose to forego further treatment and opt to live with the fistula. Likewise, surgeons who are concerned with inflamed rectal mucosa, prefer to approach Crohn’s related RVFs transanally and under the protection of diverting stoma [15].
Treatment with biologics, such as adalimumab (Humira, AbbVie) and infliximab (Remicade, Janssen Biotech), can often reduce inflammation and contribute to the closure of some fistulas. However, the long-term closure of fistulas, documented by MRI, is less certain. In the ACCENT II study of Crohn’s disease, Sands and colleagues studied 25 patients (18%) with RVFs [16]. Of these, 60% of fistulas closed in 10 weeks and 44.8% closed in 14 weeks using Infliximab infusion. Additionally, fistula closure lasted longer (46 weeks) with 5 mg/kg Infliximab infusion for maintenance vs. the placebo group (33 weeks). None of the patients received surgical intervention.
Fecal diversion, although helpful in reducing inflammation and infection, has not been shown to be effective in closing RVFs [17]. One of the benefits of fecal diversion, however, is the improvement in quality of life which might encourage patients to ultimately consider a proctocolectomy. Scott and colleagues reported that 13 of 38 patients with perianal Crohn’s disease, without RVF, needed stoma or proctectomy; while 18 of 29 patients with Crohn’s RVF ultimately needed stoma or proctectomy, and the differences were statistically significant [18].
In patients with cancer, RVFs may develop. Brachytherapy can lead to RVFs in patients with cervical cancer, while external beam radiation can lead to RVFs in patients with rectal cancer. In an anteriorly located rectal cancer invading the vagina, radiation-induced necrosis can sometimes result in RVF. Similarly, low RVF can be seen following chemoradiation in the treatment of advanced anal cancer. If the cause of RVF is cervical cancer therapy, the patient must have EUA and biopsies of both the vaginal and rectal sides of the fistula in order to exclude residual malignancy. If no cancer is diagnosed, a very low anterior resection (VLAR) and low colorectal or coloanal anastomosis can be attempted. The omentum can then be mobilized and interposed between the vagina and the colorectal anastomosis [19].
Bleeding
Bleeding is a possible complication of almost any surgical procedure. Operations involving the anorectum, rectovaginal septum, and vaginal wall are inherently associated with a higher risk of bleeding. The main reason for this is hypervascularity of the vaginal wall, perivaginal venous plexus, mainly in the lateral aspects and extending onto the posterior wall, and the prominent vasculature of the rectal wall, particularly the lower region where the hemorrhoidal plexus is located. Of importance is the possibility of direct communication between the rectal and vaginal venous plexus [20].
Bleeding can occur intraoperatively, which can lead to significant blood loss but is rarely life threatening. The main consequence of bleeding during RVF repair is the loss of helpful anatomical landmarks and excessive thermal tissue trauma from bleeding control using cautery. The risk for intraoperative bleeding is increased if the dissection veers off the proper, avascular (or the least vascular) tissue plane. The risk of this happening is higher when the anatomy is distorted either by previous surgeries or acquired conditions (e.g., large rectocele with thinned-out rectovaginal septum). In these cases, the use of fine suture ligatures is recommended, instead of high wattage cautery, to control the bleeding from the persistent vaginal venous plexus. Metallic clips should also be avoided to control bleeding in this area, due to the risk of foreign body retention in a potentially contaminated field. Persistent intraoperative bleeding also has a psychological effect on the surgical team by bringing morale down, creating an atmosphere of impatience, and limiting control over the operating field, all of which predispose to errors. The best way to avoid or stop any bleeding is by providing an adequate and stable exposure of the operating field, using self-retaining retractors, and following the avascular anatomical planes.
It is the practice of many surgical teams to inject the local anesthetic with epinephrine solution into the dissected tissues preemptively. This is done primarily to prevent intraoperative bleeding but also to decrease postoperative pain. This technique has been used successfully for many decades, although it is important to note that it can lead to distortion of the tissue planes as well as creation of hematoma, if the blood vessel is injured by the needle. In such cases, not only are the tissues changed by edema but they are also stained by hematoma. It is the authors’ experience that this infiltration technique be used only in cases of unexpected hypervascularity of the operating field. Conversely, local anesthetic with or without epinephrine is commonly used for anesthetic purposes once the tissues have been dissected.
Hematomas often form postoperatively and are frequently related to a bloody operative field. They can be of arterial nature (vaginal or rectal wall, levators) or have venous character (paravaginal venous plexus). They can also have a mixed character when originating from the hemorrhoidal plexus. Hematomas will likely occur more often in the potential dead space such as the dissected rectovaginal septum. Physical exercise and straining during constipation or diarrhea can lead to increased abdominal and pelvic pressure, which can then cause the hematoma. During sphincteroplasty it is possible to close the sphincter too tight, which can lead to obstructed defecation and abnormally high pelvic pressure during evacuation. The same scenario can happen in patients with obstructed defecation symptoms from other causes or hypertonic sphincters. Fiber bulking therapy has been found to be helpful in evacuation and should be recommended for most patients following repair.
Bleeding can also occur early in the postoperative period and should be considered a technical error. Passage of fresh blood or clots through the anal canal or vagina soon after surgery (within the first 24 h), mandates a return to the operating room, EUA, and control of the bleeding. Delayed bleeding, occurring many days postoperatively, is usually caused by a low-grade infection or disruption of the suture line and is associated with early failure of RVF repair. The patient must be taken back to the operating room for EUA, however, re-repair at this time typically fails and it is best to debride and clean the wound, leaving open to heal by secondary intention. Plans for re-repair should be postponed for 3–4 months.
Sepsis
Sepsis should be considered the primary reason for failure of RVF repair. If a small amount of drainage is noted in the perineum, the patient can be placed on more frequent wound cleansing, low residue diet, and a short course of antibiotics, in the hopes of preventing a full-blown infection or abscess [21]. However, if frank purulent discharge or evidence of abscess with pain, swelling, erythema, and fever is encountered, the only option is to return to the operating room for a EUA and lay the abscess open for debridement and drainage of the infection, without attempting a simultaneous re-repair.
Continuous fecal contamination, particularly in patients with diarrhea-predominate IBS, might also be at fault. Some surgeons advocate bowel confinement for 3–5 days following RVF repair. One has to consider the deleterious effect of passage of rock hard stool a few days later. It is unclear why repair of RVF undertaken after proximal diversion gets infected but it is safe to say that fecal diversion is not the final answer in the prevention of wound infection [22].
Dead space in RVF repairs is often the primary site of infection or abscess and can obscure sepsis for days (Fig. 10.3). It is therefore imperative to obliterate all dead spaces during the primary operation. If this is not possible, the vaginal side of the repair should be left open slightly in order to allow drainage and prevent fluid collection between the repaired rectal and vaginal walls. Similarly, if postoperative infection or abscess needs surgical drainage, the vaginal side of the repair should be opened sufficiently to allow for proper dependent drainage.
Fig. 10.3
Large amount of dead space after transperineal approach
Liquid stool found in the colon during RVF repair should not be taken lightly due to higher risk of repair failure. It is most often the result of incomplete bowel preparation in patients who have tendency for severe constipation or severe diverticulosis. This results in a large load of liquid fecal matter. In this instance, it is recommended that a colonoscopy be attempted before the formal repair in order to suction out all the liquid material. If this cannot be done, the procedure should be rescheduled. On occasion, diarrhea in the postoperative period can also be a harbinger of repair failure, due to inflammatory reaction in the lower rectum resulting from regional sepsis.
Recently, Alverdy at el. studied the influence of colonic microbiome on the failure of lower rectal repairs [23]. Their investigation focused primarily on the low and ultralow anastomosis performed in rectal cancer resections, which can likely be transposed to RVF repair. The early result of their research indicates that certain species of intestinal flora demonstrate higher tissue destructive potential. For this reason, oral antibiotics meant to sterilize the gut flora, in addition to mechanical bowel preparation, can often help in preventing fistula repair failure [24].
GI Complications
Constipation early in the postoperative period is frequently related to low oral intake of food and water, use of narcotic analgesics, and apprehension in having a bowel movement. This must be dealt with by counseling the patient, increasing oral fluid intake, and providing stool softeners and non-narcotic analgesics. If the patient is unable to defecate after a few days, particularly if there are obvious signs of fecal impaction, increased pelvic pressure, dysuria, or frequent return to the bathroom with only a small passage of liquids, a EUA is indicated in order to disimpact the stool and irrigate the rectum. If the repair becomes partially or completely disrupted during disimpaction, it must be left open and managed conservatively rather than attempting to perform a re-repair. If the wound needs to lay open, all foreign bodies must be removed, including sutures, plug, mesh, and staples.
Incontinence following RVF repair is strictly related to the preoperative status of the patient’s continence. Preoperative endoanal ultrasound, anorectal manometry, and pudendal nerve terminal motor latency studies will all provide information to enable the surgeon to have a detailed and meaningful discussion with the patient and the family during the informed consent process. This is critical because, in the United States, postoperative fecal incontinence is the most common reason for litigation in anorectal surgery [25].
If the patient’s RVF is the result of obstetric injury, a preoperative workup might reveal a source neurologic injury (prolonged pudendal nerve latency) which can result in persistent incontinence, despite an excellent anatomic repair [26]. Alternatively, if the endoanal ultrasound shows significant concomitant injuries to the internal and external sphincter, a simultaneous or delayed sphincter repair might be indicated and this possibility should also be included in the informed consent discussion.
Diarrhea in the early postoperative period may be related to preoperative bowel preparation (incomplete prep), irritable bowel syndrome (D predominant), rising prevalence of Clostridium difficile colitis, as well as early signs of fistula repair failure. Underlying Crohn’s disease and radiation-induced diarrhea should also be ruled out, preferably before the repair.
Genitourinary Complication
Urinary retention after any anorectal operation, especially hemorrhoidectomy and complex restorative procedures under spinal or epidural anesthesia, is common and can occur in up to 10% of patients [27]. Following a complex RVF repair, a Foley catheter can be inserted for 24–48 h if urinary retention occurs. If the patient is unable to void after removal of the catheter, it is best to reinsert the Foley catheter and send the patient home with the catheter in place for 4–5 additional days. Daily administration of oral Flomax® (0.4 mg) prior to removal of the catheter will obviate the need for further catheterization. This policy is preferred over repeated catheterization in emergency rooms, which can increase the risk of urinary tract infection and, even worse, can result in disruption of the repair. Judicious use of narcotic analgesics, which can contribute to urinary retention, is also important [28]. If urinary tract infection does develop, urine cultures and sensitivities and antibiotics are indicated according to standard practice protocols.
Following RVF repair, women should be instructed to refrain from having sexual intercourse for 6–12 weeks. Dyspareunia is not uncommon and usually subsides with time. It can, however, be particularly bothersome in young, sexually active women who have had extensive repair such as levatorplasty, which can contribute to narrowing of the introitus [29]. Physical therapy and use of vaginal dilators are rarely needed.
Surgeons should counsel the patient that subsequent vaginal delivery can put the repair at risk and lead to higher failure rates of repeated repairs. This allows the patient to make an informed decision as to whether to defer the RVF repair until after subsequent vaginal deliveries, particularly if she is experiencing minimal symptoms. Conversely, she may choose to have the RVF repair and undergo elective Caesarian section for subsequent deliveries. This information and recommendations should be provided in writing to the patient and her obstetrician to prevent subsequent claims of negligence.
Complications Related to Particular Repairs
Transanal Approaches
Rectal Advancement Flap
Rectal advancement flap (RAF) is a relatively simple technique with a high success rate. While rates vary, reports have them at 80% in most cases [7, 30–33]. Despite its popularity, however, the technique has many variations and modifications, as can be seen in the major surgical textbooks. In the authors’ experience, the procedure involves mobilization of a well-vascularized full thickness segment of the rectal wall, which is then used to cover the repaired fistula defect. Although the technique can be used in the mid and lower rectum, it is most often used for anovaginal fistulas. In such cases, the creation of a flap is begun just distal to the fistula. Initially, the flap involves only the anoderm, but at the level of the anorectal junction the dissection is moved deeper to involve the full thickness of the rectal wall. Of note, the internal and external sphincter muscles are not incorporated into the flap and can be used for the fistula repair. Since the repair frequently involves a two-layer closure (muscle layer and the anorectal wall layer), the vaginal opening can be left open for drainage. This approach allows for more muscle bulk to be used for the repair. The anoderm should be detached from the internal sphincter in a relatively narrow (around 1–1.5 cm) segment, as compared to the width of the flap mobilized in the rectum. A resulting thick flap is then used to cover the repair in the exposed muscle.
One of the major complications of RAF is necrosis of the flap due to ischemia, which inevitably leads to fistula recurrence. This can often be avoided by following the principle that the base of the flap should be at least twice the size of its apex. In reality, the base of the flap (in the rectum) stretches widely between the levators (antero-lateral aspects of the lower rectum adjacent to the levators). Additionally, since the dissection is performed in the anterior aspect of the rectum, the prone position is often the most preferred position. Some surgeons claim that the submucosal flap or partial thickness flaps are sufficient for reconstruction, however, the full thickness flap naturally has the best perfusion, and therefore should be the preferred method. It is possible, although rare, to create vasoconstriction of the flap, which can then cause hypoperfusion by injection of epinephrine solution given preemptively for anesthetic and hemostatic purposes. Smoking has also been found to impair blood flow of the rectal mucosa [12, 34].
Another complication of RAF is retraction of the flap. In general, when dissected from the surroundings, most tissues have tendency to retract and shrink. For this reason, the mobilized RAF always shrinks and retracts if not secured properly to the donor site. Therefore, tension on the distal suture line should be avoided when the flap is sutured in place. In order to achieve this, the most proximal sutures securing the flap are placed more distally on the recipient rectal wall than on the flap side. This will result in flap advancement relative to the donor site and eliminate tension on the distal suture line. Flap retraction can also result from breaks of sutures. In order to avoid this, it is recommend that absorbable sutures (e.g., Vicryl) be used, at least 3-0 size along the 2-0 sutures. If possible, plication of the vaginal wall can serve to shorten the distance between the base of the flap and the sphincter and can also increase the final reach of the flap while taking any unnecessary tension from the apex after suturing [35]. Anal stenosis is rare and only seen in some cases of failed repair.
Incontinence following the RAF procedure is usually mild, if at all present, and is related to the procedure itself, particularly if a large portion of the internal sphincter muscle is excised and incorporated into the flap (this is not recommended, as stated earlier). Some seepage might also be observed if a large portion of the flap creates ectropion, which is rectal mucosa protrusion at the anal verge. For symptomatic ectropion, it is best to allow the RVF repair to heal completely, wait 4–6 months, and then excise the ectropion, leaving the wound open or closing it with dermal advancement [36–38]. Fortunately, incontinence is a rare complication following a successful RAF procedure [39]. Preservation of the internal sphincter is crucial in maintenance of continence in these patients with already compromised sphincter mechanism.
Intraoperative bleeding is rare during flap procedures, although mild oozing can be disturbing to the patient if not controlled adequately. Repositioning the Lone Star ® retractor prongs (if used) to achieve optimal exposure can cause bleeding from the anoderm or hemorrhoidal plexus, thereby obscuring the deeper operative field. A simple suture ligature can control this bleeding more efficiently than cautery. Additionally, dissection of the flap in the submucosal plane along the internal sphincter muscle can cause bleeding from the internal hemorrhoidal plexus. Here again, excessive cautery should be avoided to prevent damage to the internal sphincter. Oftentimes, injection of the anoderm with a lidocaine/epinephrine solution can be helpful. During further dissection, some bleeding from the posterior vaginal wall can also be encountered if dissection veers off the avascular rectovaginal septum toward the perivaginal venous plexus. It is important to recognize this mistake. Again, small suture ligatures are better that cautery and decreases injury to the vaginal wall.
Hematoma can form in any dead space following the surgical dissection of well-vascularized tissues. This can include RAF repair. The amount of dissection should always be balanced to allow for appropriate tissue advancement, yet still minimize the amount of dead space. In the authors’ experience, redundant vaginal wall can be often plicated/imbricated during closure of the defect, reinforcing the repair just as the anterior rectum is plicated during transvaginal rectocele repair [35]. By doing this, flap is advanced distally while the amount of dead space is minimized.
Bleeding due to an increase in pelvic pressure from diarrhea or constipation can also cause hematomas. For this reason, postoperative constipation should be carefully addressed with stool softening but not forcing agents. Diarrhea can be controlled with bulking (fiber) or hypomotility (e.g., Imodium) agents.
Rectal Sleeve Advancement
Rectal sleeve advancement is a rarely used procedure reserved for RVFs that are associated with significant disease or scarring of the distal rectum or anorectal ring; and is seen mainly in patients with Crohn’s disease [40]. The dissection starts at the level of the dentate line, with preservation of as much sphincter as possible, and is then carried out in the perimesorectal plane in order to achieve adequate mobilization of the distal rectum. The vaginal opening is then closed and the rectum is advanced in a pull-through fashion [41]. The diseased anorectal segment is removed and a coloanal hand-sewn anastomosis is created.
Rectal sleeve advancements are typically performed under the protection of diverting stoma. The main complications are similar to those seen in the pull-though repairs that are done for rectal cancer. They include dehiscence of anastomosis, retraction of the advanced segment, pelvic sepsis, and anastomotic stricture. The recurrence rate of the fistula is low, as reported by a few studies [40, 42]. In some cases, closure of the fistula is seen, despite initial dehiscence of the rectal repair, and as long as the vaginal defect remains closed. In those cases, conservative management allows for secondary healing of the rectal defect. Certain modifications of this technique have also been described [43, 44]. As with most coloanal pull-through procedures, a certain degree of incontinence can be expected.
Vaginal Advancement Flap
Vaginal advancement flap (VAF) is a relatively simple technique with similar, basic principles associated with the rectal advancement flap [15, 45, 46]. Of note, it is rarely used in colorectal practice because most rectal surgeons agree that creation of the primary flap on the high-pressure side of the fistula (anorectum) should be the priority. It does, however, make sense if the underlying disease, such as Crohn’s disease, involves the anorectum and/or the patient is diverted. Similar to RAF, the other side of the repair (in this case the anorectum) can be left open for drainage and secondary healing, as long as the patient is diverted.
The VAF can also be used with the Martius flap, which involves transposition of bulbospongiosus (frequently named bulbocavernosus) muscle and labial fat pad (described later in this chapter) [45, 47–49].
Complications associated with the vaginal advancement flap are of similar nature to RAF, since the technique is the mirror image of the latter. It is important to note that the perivaginal venous plexus is concentrated mainly in the lateral aspect of the vagina with some extension on the posterior wall. Because of this, more venous bleeding is to be expected during lateral vaginal flap dissection.
Due to frequent disease in the anorectum, the recurrence rate of VAF is expected to be higher than the recurrence rate for RAF. If the fistula persists after VAF, there is the possibility of more than one vaginal opening (fistula branching), due to violation of the vaginal wall during flap creation.
Dermal Advancement Flap
The dermal advancement flap (DAF) technique for treatment of fistula-in-ano (including anovaginal fistulas) was introduced by Del Pino and Nelson in 1996 [50, 51]. The technique can be used selectively to treat low anovaginal fistulas in patients with sufficient amount of skin and subcutaneous tissue of the perineal body [52]. The technique involves excision of the internal opening within the anus, creation of a proximal anodermal mini-flap (lip), closure of the sphincter defect, and advancement of the mobilized flap which is comprised of skin, distal anoderm, and subcutaneous tissue into the anal canal. Subsequently, the flap is secured into its target site (lip) with the interrupted sutures.
Complications of the DAF procedure are similar to the above-mentioned flap techniques and, like those, the procedure follows the principles of vascular blood preservation. Complications are also similar to those associated with anoplasty. Candidates for DAF should be evaluated for true feasibility by taking into account previous episiotomy scars and the risk of vascular compromise if the perineum has previously been repaired. Patients with a short perineal body (the distance between the anus and introitus) and thin body habitus are usually not good candidates for this type of reconstruction, unless more soft tissue can be found just lateral to the perineal body (obesity is a favorable factor here). Similar to the advancement flap techniques used for anal stenosis, the risk for infection leading to flap failure is not low. In order to decrease the infection and suture line dehiscence, the harvest defect is often left open for healing by secondary intention.
Fistulectomy with Layer Closure
In selected patients, fistulectomy with layer closure can be considered. Because anovaginal fistulas have more available tissue for reconstruction than RVFs, the chances for success are higher for anovaginal fistulas. In these cases, the fistula tract epithelium is excised and the sphincter defect and anoderm are closed separately. If recurrence occurs, it often leads to creation of a wider fistula than before.
In patients with more proximal RVFs, there is a higher risk of recurrence due to two directly opposing suture lines from the rectal and vaginal sides. For this reason, some authors advocate interpositioning of the repairs with a biologic sheath of mesh [53]. The potential complication for this approach is mainly infection of the mesh, its liquefaction, foreign body reaction, and mesh extrusion.
Plug Repair
The fistula plug repair using biologic material was designed primarily for cryptoglandular fistulas. With time, however, it has also been used with some success for anovaginal fistulas [54]. The plug was commonly used for anovaginal fistulas but was found to be impractical to repair more proximal RVFs due to lack of supporting tissues, as well as shortness of the fistula tract. A modified plug was introduced to circumnavigate this problem, and consisted of a flat anchoring portion (button/disk) and a tail [55]. In recent years, the plug repairs have fallen out of favor due to their poor success rate [56].
A commonly mentioned statement about the safety of the plugs, despite their poor success is only partially true. It should be remembered that insertion of the plug into a tight fistula channel is inevitably associated with widening of the internal opening. In cases of failure, the plugs are commonly extruded, but significant infection (abscess) can form, leading to more tissue destruction and creation of a larger fistula than before.
Fibrin Glue
The use of fibrin glue was introduced by Hjortrup and colleagues for the treatment of fistula-in-ano and has had very minimal success in the treatment of RVF [57–59]. Logistically, it is difficult to use this technique for anovaginal fistulas and impossible to use for true RVFs. If an attempt is made to use it for anovaginal fistulas, it is recommended that the internal opening be closed to prevent the escape of glue into the anal canal. In theory, proximal diversion could increase the chances of success by eliminating the high-pressure zone in the anorectum, although this hasn’t been studied.
Complications associated with fibrin glue, although rare, include retention of fibrin glue material in the fistula tract, thereby risking the infection and redevelopment of abscess, which in turn can lead to further destruction of the rectovaginal septum.
Transperineal Approaches
Ligation of Intersphincteric Fistula Tract
Ligation of the intersphincteric fistula tract, or LIFT procedure, was invented by Rojanasakul in Thailand in 2007, as an option for treating anal fistulas, although it can also be incorporated into treatment of anovaginal and selected low RVF [60]. The procedure is relatively simple and is associated with a limited amount of dissection along the anatomical planes. It involves the transverse incision over the perineal body, at or close to the intersphincteric groove. Subsequently, the dissection is continued in the avascular intersphincteric plane to the level of the fistula tract. The tract is then ligated, divided, and the incision closed.
Because there is a limited amount of dissection and the dissection is performed in the avascular plane, complications of the LIFT procedure are rare. The main complication is recurrence (overall success rate 74% for all anorectal fistulas) which typically presents in the form of minor perineal infection [61]. In this case, the perianal body creates a T-type fistula (Fig. 10.4) or, in more favorable situations, an intersphincteric perineal fistula.
Fig. 10.4
T-type perineal type fistula complicating RVF after failed transperineal repair
Sphincteroplasty (with and Without Levatorplasty) with Repair of Fistula
Sphincteroplasty is best suited for patients with anovaginal fistulas and underlying fecal incontinence due to sphincter defect. The intent is to reconstruct the anal sphincter ring and to provide a locally harvested muscle tissue for a solid foundation under the fistula repair. In addition, an important and frequently underappreciated advantage is perineal body reconstruction, which can translate into improved sexual function and decreased frequency of urinary tract infections.
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