Transperineal Approach

C. Neal Ellis

Indications/Contraindications

Selection of the Procedure

There is no one technique that is considered the “gold standard” for the management of rectovaginal fistulas. Instead, the surgical technique chosen depends on the training and experience of the surgeon, the etiology and anatomy or the fistula, and the presence or absence of a sphincter defect and incontinence. Options include fistulotomy with repair of the perineal body and sphincters, some type of local tissue flap, and transperineal ligation of the intersphincteric fistula tract (LIFT).

Fistulotomy with perineoproctotomy recreates a fourth-degree perineal laceration and provides excellent exposure allowing complete identification and excision of the fistula and all of its extensions followed by a precise, layer by layer closure of the vaginal and rectal walls and the perineal body. This approach is usually reserved for women with a rectovaginal fistula and a sphincter defect with incontinence. This approach can address both problems by combining closure of the fistula with overlapping sphincter repair (1).

A local tissue flap is another option for the management of rectovaginal fistulas. They can be constructed from the rectal mucosa, submucosa and circular muscle (mucosal flap), the anoderm (island pedicle flap), or the labial fat pad (Martius flap). These flaps can be created and used to cover the rectal side of the fistula (2,3). Possible complications of these flaps include creation of a mucosal ectropion with
resultant mucus leakage and rectal bleeding (mucosal flap), and dyspareunia (Martius flap) (4,5).

The most recent addition for the management of rectovaginal fistulas is the transperineal LIFT. While LIFT alone has been successfully used for other anal fistulas, the one publication using LIFT for rectovaginal fistulas added a bioprosthetic graft to cover the closure of the fistula tract (2). This is the technique which will be described in this chapter.

Contraindications

The only absolute contraindication to the LIFT procedure for rectovaginal fistula is the medical inability to tolerate a surgical procedure. Relative contraindications include an acute fistula resulting from obstetric trauma or fistulas associated with acute inflammation.

The treatment of rectovaginal fistulas in patients with Crohn’s disease is a special problem. Given the recurrent nature of the disease, patient satisfaction and the reduction in the number of septic events should be considered in addition to fistula recurrence rates. Also the chronic diarrhea associated with Crohn’s disease will make any associated sphincter defect even more problematic. Many would consider active anorectal Crohn’s a contraindication to the surgical repair of a rectovaginal fistula (6). For these patients, the use of a noncutting seton to reduce the number of perianal septic events may be a better choice.

Preoperative Planning

History and Physical Examination

The initial step in the evaluation of a patient with a suspected rectovaginal fistula is a problem-specific history and physical examination. The patient should be questioned for any history of inflammatory bowel disease, diverticular disease, or cancers of colon, rectal, anal, or gynecologic origin. It is important to determine whether the patient has had any vaginal deliveries complicated by a significant perineal injury, gynecologic or colorectal surgical procedures, or radiation therapy. The degree of continence should be assessed. In general, the success of a rectovaginal fistula repair is related more to the underlying etiology and associated patient factors than to the technique of management.

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