Rectovaginal Fistula
Tracy Hull
Perioperative Considerations
One of the most important aspects when repairing an anorectovaginal fistula is evaluating the patient before considering the operative approach and procedure.
The tissue must be soft, supple, and free of any sepsis.
An examination under anesthesia with seton placement (usually for a month) and unroofing of any cavity is essential.
We completely open a fistula tract to the level of the anal muscle to allow it to heal from the bottom up and have the shortest tract as possible. We then wait until the area has completely healed before proceeding.
When the tissue is not soft, consideration of a stoma should be entertained.
We have found hyperbaric oxygen to be extremely helpful when tissue is fibrotic from previous failed attempts at repair. It is also useful in radiation-induced fistulas.
Typically, 20 treatments (one daily for 5 days per week) before and then waiting 2-3 weeks after the last treatment before doing surgery is our preferred choice.
Then immediately after the repair, 20 more treatments are given.
Additionally, women who are menopausal may have improved supply of their tissue with vaginal hormone cream for a month prior.
For patients with Crohn disease, the appearance of the anal canal and rectum is extremely important.
The internal opening of a Crohn-related fistula will typically be at the base of an ulcer.
Placing a seton and aggressively treating with biologics many times will then leave the woman with a dry ulcer and repair then can be considered.
If the anal canal never becomes inflammation free, no repair will be successful.
The status of the anal sphincter anteriorly is also an important preoperative consideration.
Even when the perineal body is thick, the muscle may not be intact.
We have a low threshold for obtaining an anal ultrasound to look at the muscle as it may greatly influence our choice of repair (Fig. 14-1).
FIGURE 14-1 ▪ Anal ultrasound in a woman with an intact perineal body, but anterior defect in the IAS and EAS. EAS, external anal sphincter; IAS, internal anal sphincter.
We cannot stress enough the importance of being patient and ensuring the tissue is soft, supple, and sepsis free before embarking on any repair.
For all repairs, unless the patient has a stoma, a full bowel preparation is given. A Foley catheter is inserted, and intravenous (IV) antibiotics are given. The area is prepped with betadine (or baby shampoo if iodine allergic). During the procedure, the perineal wound is periodically irrigated with antibiotic irrigation (we currently use bacitracin).
Our algorithm for repair is shown in Figure 14-2.
 FIGURE 14-2 ▪ Algorithm for repair. RVF, rectovaginal fistula. |
Sterile Instruments/Equipment
Anal retractors, fiberoptic lighted: small, medium, and large
Hill-Ferguson retractors: often used for perianal cases positioned in lithotomy
Fansler retractors: small, used selectively for perianal cases such as those positioned in prone (ie, Kraske) or those with large redundant mucosa
Pratt bivalve anal retractor
Right-angle retractors
Set of Lockhart-Mummery fistula probes
Set of curettes
00-silk ties
Silicon, radio-opaque yellow (mini) vessel loop, 1.3 mm wide and 0.9 mm thick, or a blue (maxi) vessel loop, 2.5 mm wide, 1 mm thick
Monopolar electrocautery
We routinely use 40 cut/60 coagulation settings, pure or blend.
A needle tip may be used for endorectal advancement flap.
Pezzer (mushroom) drains, size ranging from 10 to 32Fr
¼ and ½ in Penrose drains
Hydrogen peroxide diluted 50-50 with sterile normal saline, placed in a 10-mL syringe with a 14-gauge angiocatheter or a blunt-tip needle
Positioning
Positioning of the patient is dependent on the approach to the fistula (vaginal or rectal).
In lithotomy
Emphasis on ergonomics cannot be understated. The edge of the operating table may need to be moved in the caudal direction, to ensure that the chair and feet of the operating surgeon are not restricted by the base of the operating table. In addition, the patient’s buttocks overhanging the edge of the operating table.
In prone jackknife:
We place two shoulder rolls under the chest (taking special care to protect the breasts) and a foam pillow (Kraske roll) under the pelvis (taking special care to protect the genitals from pressure injury).
We typically secure the patient with a belt to prevent inadvertent rolling.
We use tape to laterally retract the buttocks, with or without benzoin.
Excessive tape traction will result in iatrogenic tearing (fissuring) of the anoderm—avoid.
Techniques of Fistula Closure
Advancement Flaps
When the anal muscle is intact and the tissue is overall healthy, an advancement flap can be considered.
Semicircular Advancement Flap
Typically, the patient is placed in the prone jackknife position, but for a posterior fistula, we may rarely utilize the lithotomy position if we feel visualization for mobilization may be improved.
With the patient prone, we use #1 sutures to efface the skin in at the 2, 4, 8, and 10 o’clock positions. More sutures can be placed if needed. This allows visualization into the anal canal (Fig. 14-3).
FIGURE 14-3 ▪ Anal everting sutures are placed at 2, 4, 8, and 10 o’clock to efface the anal canal. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
A Hill-Ferguson lighted retractor is placed in the anal canal.
The fistula is identified, and a semicircular incision is made nearly 180-degrees, starting just distal to the internal opening.
The mucosa is initially mobilized cephalad, but with progression inward, a portion of the internal sphincter and then the full thickness of rectum are mobilized. It can be bloody due to vessels in the rectovaginal septum, and Bovie electrocautery or 3-0 absorbable sutures are utilized for hemostasis.
Mobilization is carried out until the reach comes down to cover the opening without tension (Fig. 14-4).
FIGURE 14-4 ▪ Mobilization is carried cephalad until the rectal flap comes down easily.
FIGURE 14-5 ▪ The tract is debrided and closed. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
The fistula tract is debrided. We only try to debride at the anal sphincter level aggressively to avoid making the internal opening excessively large. The internal opening is then closed in layers with 2-0 or 3-0 polyglactin sutures (Fig. 14-5). We tend to close from side to side and then front to back in at least two layers. This takes up dead space and relieves any tension on the neodentate line anastomosis.
The tip of the flap is trimmed and sutured to the neodentate line (Figs. 14-6, 14-7, 14-8, 14-9 and 14-10).
 FIGURE 14-6 ▪ The distal end is trimmed off. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.) |
 FIGURE 14-7 ▪ The flap is advanced down and sewn to the neodentate line. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.) |
 FIGURE 14-8 ▪ The flap is advanced down. |
 FIGURE 14-9 ▪ Final sutures placed. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.) |
 FIGURE 14-10 ▪ Final sutures placed. |
Sleeve Advancement Flap
When there is excessive scar or stricture in the anal canal, a sleeve advancement may be the best choice.
When consenting the patient and making your plans, it is important to realize that if there is too much tension via the transanal mobilization, then a transabdominal approach may be required.
Therefore, the patient and surgeon must be ready to mobilize via the abdominal approach.
Mobilization starts at the dentate line, and a mucosectomy is done for the proximal anal canal (Fig. 14-11).
When the rectum is reached, then the dissection deepens into the same plane used for an Altemeier procedure (Fig. 14-12).
The mobilization continues until there is the cuff or sleeve of rectum that can be advanced without tension to the neodentate line. The distal end is amputated (Fig. 14-13), and the internal opening is closed, as discussed earlier.
The sleeve is then sewn to the neodentate line and resembles a coloanal anastomosis when completed (Figs. 14-14 and 14-15).Related posts:
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