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FIG. 3 Sacral nerve stimulator placement with fluoroscopic guidance.
5 years. Benefits of the rechargeable battery include smaller size and
avoidance of additional operations to change the battery. However, it
requires the patient to charge the battery every couple of weeks using
a charging device placed on the skin over the battery. The decision
of whether to choose a rechargeable or non-rechargeable battery
will depend on the patient’s ability to charge the device and the risks
and benefits of routine battery charging versus surgical replacement
every 5 years. Currently marketed SNS devices are MRI-compatible.
The SNS study group reported results of a prospective multi-institutional trial conducted on 133 patients with FI who underwent test
stimulation. In this study, 90% of the patients had a 50% or greater
reduction in the number of incontinence episodes and underwent
permanent battery implantation. At 12 months, 83% of implanted
patients reported therapeutic success, which was 75% of overall
patients. The mean number of incontinence episodes decreased from
9.4 per week to 1.9 per week at 12 months. At 5 years, 89% of patients
had sustained benefit, and 36% reported perfect continence. Risks of
SNS are generally minor and include pain and surgical site infection,
which are seen in about 10% of patients. Either of these complications can be treated with removal of the device. Reimplantation can
be attempted after the infection has cleared, and the contralateral
side can be used in either group of patients. At 5 years, 36% of
patients required revision or replacement. Overall, SNS placement is
an intervention that has low complication rates, is reversible, and has
been shown to achieve good long-term improvement in continence.
It is now the first-line treatment in many patients who are considered
candidates.
Overlapping Anterior Sphincteroplasty
An overlapping anterior sphincteroplasty may be performed in
patients with an anterior anatomic defect with the goal of reconstituting the circular configuration of the sphincter muscle around
the anal canal. These sphincter defects are most commonly seen
in women as a result of obstetric injuries. When sphincter injury is
suspected, ultrasound imaging should be performed to confirm. The
best postoperative results are seen in patients with defects of 60 to
180 degrees. When defects are seen immediately following delivery,
they should be repaired primarily. If the patient continues to have a
sphincter defect and symptoms of FI, definitive operative intervention should be delayed for 3 to 6 months to allow time for swelling to
subside and for scar tissue to form.
Patients should undergo preoperative mechanical bowel preparation. Patients are placed in the prone jack-knife or lithotomy
position. A curvilinear incision is made anterior to the anus within
the perineum, and the two sides of the sphincter are identified and
mobilized. The ends of the sphincter muscle should be mobilized
as much as necessary to allow for an overlap, but not too much in
order to avoid pudendal nerve injury or ischemia. An anterior levatorplasty is often performed in conjunction with sphincter repair to
approximate the levator muscles. The two sides of the sphincter are
reapproximated in an overlapping fashion with 2-0 monofilament
sutures. The sutures should be placed within any scar tissue that
is present as it holds suture better than muscle. The skin is closed
loosely to allow for drainage (Fig. 4).
Short-term results for this procedure are very good, with up to
80% of patients reporting good to excellent functional results. However, the benefits deteriorate over time, and less than half of patients
remain continent at 5 to 10 years. This surgical technique is most
useful in patients with an associated rectovaginal fistula that requires
repair. Repeat anal sphincter reconstruction after a failed sphincteroplasty should be avoided unless other treatment modalities
are not possible or have already been attempted and failed. Repeat
repairs are unlikely to be more successful than the original repair
unless a specific factor responsible for the failure can be identified
and avoided.
Fecal Diversion
In patients who fail medical or surgical therapy, those with very
large defects that are not amenable to repair, or in cases of patient
preference, stoma creation may be offered as an effective solution for
FI. In most patients, creation of a sigmoid colostomy is appropriate
and provides for an ostomy that is easy to care for. A laparoscopic
approach is preferred and feasible in most patients. Stoma placement
is important, as many of these ostomies will not be reversed. Trained
stoma nurses should be involved in the patient’s care both preoperatively and postoperatively. In patients who had a stoma created for
FI, 83% reported an improvement in quality of life, and 84% would
choose a stoma again.
Additional Surgical Interventions
Several products have been developed to artificially increase anorectal outlet resistance in patients with incontinence caused by a weak
or dysfunctional anal sphincter. These include an artificial bowel
sphincter, a magnetic sphincter, radiofrequency administration,
318 SURGICAL MANAGEMENT OF FECAL INCONTINENCE
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Incision
site
Skin flap
Functional sphincter
Scarred nonfunctional
sphincter
Sphincter
dissected free
and divided
Rectal mucosa
elevated to expose
sphincter
Divided sphincter
overlapped
Flap repaired and incision closed
Perineal body restored
FIG. 4 Overlapping anterior sphincteroplasty. (From Fleshman JW. Atlas of Surgical Techniques for Colon, Rectum and Anus. Philadelphia: Saunders; 2013.)
Sphincter overlapped
and sutured
Vagina
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products show variable results, and overall evidence for their efficacy
is weak. Artificial bowel sphincters provide the best results, however
they are associated with high complication rates, with up to 80% of
patients requiring explantation or revision within 5 years. Many of
these products have been taken off the market in the United States.
Tibial nerve stimulation is a new therapy undergoing evaluation
for treatment of FI. Stimulation is delivered with a needle electrode
or an adhesive pad. Two randomized controlled trials comparing
the therapy to sham neurostimulation have been performed and
reported differing results. One trial reported patients undergoing
percutaneous therapy to have higher rates of improvement in FI
episodes, while the other trial showed similar rates of improvement
in both intervention and sham groups. Little is known about the
frequency, interval, and intensity of stimulation needed to optimize
results of this therapy, but it may be most useful in conjunction with
other therapies. Studies regarding this therapy are ongoing.
CONCLUSIONS
Fecal incontinence is a common problem that is often underreported
because of its stigma. Evaluation tools include validated scoring
Rectovaginal Fistula
Eric G. Weiss, MD, and Emanuela Silva Alvarenga, MD
ectovaginal fistulas (RVFs) are extremely life altering for women
who develop this condition, but thankfully it is not common.
R
Regardless of the low incidence, RVFs are vexing problems both for
physicians and patients. Expertise in evaluation and management
is often needed yet is rarely available in the communities where the
patients live and often requires tertiary referral if a patient is not
initially being managed in such a center.
Patients can present with a multitude of signs and symptoms,
from minor drainage to flatulence via the vagina to frank stool leaking out of the vagina. One can imagine the psychological impact this
has on a women’s self-image and relationship with her significant
other and impact on work life and quality of life overall.
Most series of repairs are small, single-institution procedures and
often are limited in the types of procedures performed. In addition,
RVF classification varies, and treatment by procedure type is often
linked to the fistula classification or its etiology.
This chapter will focus on a variety of repairs and a stepwise process to determine which repairs may be appropriate for which RVFs
in the hopes that the most favorable outcomes and least morbidity
can be achieved.
ETIOLOGY AND CLASSIFICATION
There are three main etiologies for RVFs: obstetric injury, cryptoglandular sepsis, and Crohn’s disease. Each etiology tends to form
the fistula by different means, and the locations, other associated
injuries, and treatment options vary as a result of these and other
factors. Less common but more difficult to manage are those formed
as a complication of radiation therapy or following anastomotic
complications related to colorectal surgery with stapled anastomoses
that have leaked.
Obstetric injury is the most common etiology, typically resulting
from an episiotomy or a third- or fourth-degree tear. These fistulas
can occur in the immediate postpartum period or can present several
weeks to months later with failure of laceration repairs or episiotomy
systems to quantify symptom severity, anorectal ultrasound, and
anorectal physiology testing. Medical management can often provide significant improvement in symptoms. Surgical management
depends on the underlying pathophysiology. Current options that
have been proven to be most effective at treatment of symptoms
include SNS, sphincteroplasty, and diversion.
S u g g e S t e d R e a d i n g S
Bharucha AE, Rao SS, Shin AS. Surgical interventions and the use of
device-aided therapy for the treatment of fecal incontinence and
defecatory disorders. Clin Gastroentrol Hepatol. 2017;15(12):1844–
1854.
Brown HW, Dyer KY, Rogers RG. Management of fecal incontinence. Obstet
Gynecol. 2020;136(4):811–822.
Katuwal B, Bhullar J. Current position of sacral neuromodulation in treat-
ment of fecal incontinence. Clin Colon Rectal Surg. 2021;34(1):22–27.
Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty JF. The American
Society of Colon and Rectal Surgeons’ clinical practice guideline for the
treatment of fecal incontinence. Dis Colon Rectum. 2015;58:623–636.
Sharma A, Rao SSC. Epidemiologic trends and diagnostic evaluation of fecal
incontinence. Gastroenterol Hepatol. 2020;16(6):302–309.
repairs. These are often associated with anterior external sphincter
muscle defects and at times clinical fecal incontinence.
Crohn’s disease involving the anal canal and/or rectum can lead
to a RVF by poor control of the underlying disease resulting in a
full-thickness penetration of the Crohn’s disease and fistula into the
vagina. Often these are associated with some degree of anal stenosis
and other perianal manifestations of the underlying Crohn’s disease.
Other etiologies as mentioned earlier have a variety of locations,
sizes, and factors associated with them depending on which etiology
is responsible for formation of the fistula.
Classification can also be useful in planning repairs. Classification is based on several factors including etiology, location, and
underlying conditions. Simple fistulas tend to be low in relation to
the sphincter mechanism, caused by obstetric or iatrogenic injury,
and smaller than 2.5 cm in diameter. Complex fistulas are larger,
located higher in the vagina, and associated with other underlying
diseases or mechanisms such as radiation therapy, inflammatory
bowel disease, or colorectal or gynecologic cancers (Box 1).
EVALUATION
The clinical evaluation, classification, appropriate workup, and multidisciplinary approach is important and should allow for the most
optimal control of symptoms before repair and ultimately the most
favorable outcomes following surgical management.
A thorough history is required. The timing of the development of
the fistula to the inciting event should be well documented because
regardless of the type of repair that is appropriate, it is usually necessary to wait an obligate amount of time from the initial event.
Obtaining prior operative reports, delivery reports, treatment notes,
and prior diagnostic studies is optimal. Obtaining images and not
only reports allows for review with radiology and comparison to any
future studies. Documenting the patient’s current and prior bowel
function, continence level, and sexual function is important.
Physical examination in the office should be performed but may
be limited as a result of patient discomfort or pain. Visual examination of the perianal skin, anal verge, and vaginal introitus should be
performed in all patients. The condition of the skin, any incisions, any
secondary fistulous openings, if the anus is patulous, and any readily
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BOX 1 Causes of Rectovaginal Fistulas
Obstetric Injury
Episiotomy, third- and fourth-degree perineal lacerations
Inflammatory Bowel Disease
Crohn’s disease
Iatrogenic
Anorectal surgery (fistulotomy)
Vaginal surgery (hysterectomy, rectocele repair)
Abdominal surgery (hysterectomy, low anterior resection, J pouch,
procedure for prolapse andhemorrhoids)
Infectious
Cryptoglandular abscess, diverticulitis, tuberculosis
Neoplastic
Anal cancer, rectal cancer, vaginal cancer, cervical cancer
Radiation Induced
External beam radiation, brachytherapy
identifiable drainage or stool should be noted. Next, a digital vaginal
and rectal examination should be performed if possible. Determining
the quality of the rectal and vaginal tissue and site of the fistula may
be possible. Anoscopic examination and vaginal speculum examination may also be possible in the office. If any of the aforementioned
physical examinations cannot be performed in the office, then it may
be appropriate to perform an examination under anesthesia either in
the operating room or in the endoscopy suite. Ultimately knowing
the anatomy of the fistula tract and levels and size of the fistula are
mandatory in classification and for surgical planning.
Adjunct procedures including flexible sigmoidoscopy or colonoscopy, contrast enemas, pelvic magnetic resonance imaging (MRI), or
computed tomography (CT) may all be necessary. Evaluation of the
sphincter muscles with endoanal ultrasound may be useful if there
is concomitant fecal incontinence. For patients with Crohn’s disease,
understanding the distribution of disease with magnetic resonance
enterography (MRE) or computed tomography enterography (CTE)
may also be required, and communicating with their treating physician about their current medical management may be important and
may influence their surgical plan, particularly if they are on steroids
or biologics.
Once a surgical plan is decided upon, a thorough discussion and
informed consent should occur with realistic outcomes and expectations being discussed. Emphasizing the complex nature of these
fistulas, the difficulties in some operations and the less than 100%
success rates should be fully discussed.
ABDOMINAL APPROACHES
Abdominal approaches are typically used for higher RVFs, those
associated with anastomotic etiologies, and those in which local
tissue loss of the rectum and vagina are not amenable to local procedures for repair and reconstruction. Often, the rectum as it is at
the time of diagnosis is unsuitable for a local repair because of a
concomitant stricture or chronic leak or sepsis in addition to the
known RVF. Thus, resection and reanastomosis are required. This
most commonly results from fistulas caused by anastomotic leaks
that initially form a pelvic abscess and drain into the vagina for
decompression. Alternatively, mobilizing the rectum during proctectomy can devascularize the posterior vaginal wall, or a portion of the
vaginal wall can unfortunately be incorporated into the staple line
during stapling, leading to a RVF.
Regardless, once the decision to perform an abdominal approach
has been reached, specific considerations for the conduct of the
surgery to minimize complications and appropriate discussion and
informed consent is necessary to set reasonable expectations. As this
is likely reoperative pelvic surgery, timing of abdominal reentry is
important. A minimum of 3 months and at times 6 months or more
should be the waiting time before attempting a redo-anastomosis
with takedown/closure of the fistula. One does not want to get into
the situation of a hostile abdomen, multiple enterotomies, or worse,
an aborted procedure. Ureteral stent placement should be strongly
considered. Liberal use of a diverting ileostomy with appropriate
preoperative counseling and stoma marking should be utilized.
Although minimally invasive approaches may be attempted and
at times completed, often conversion to laparotomy or an initial plan
for laparotomy may be made. As long as there is a well-thought-out
plan and specific situations leading to conversion before complications, it is appropriate to approach in this fashion. The approach
regardless is to initially either develop adequate working space if
minimally invasive or full entrance in the abdomen if via laparotomy. Once that is accomplished, the next step is to get everything
out of the pelvis except the colon/rectum heading down to the fistula
and anastomosis. Once this is achieved, the next step is to get back
into the pelvis. Often this is best approached by going posterior and
into the presacral plane, going distal to the anastomosis and fistula,
and then coming around laterally and anteriorly with the colon or
rectum now only attached to the vagina. Next is separating the fistula, which at times leads to larger defects in the colon, rectum, and/
or vagina. Once the fistula is divided, than one needs to get to healthy
rectum below that level. Once that is achieved, then one can redivide
the rectum distally. This typically requires a small TA type stapler
such as a TA-30/45 or Contour stapler. Once stapled and divided,
the colon or rectum above the anastomosis or fistula can be brought
out of the pelvis. Next, adequate reach for a tension-free colorectal
or coloanal is necessary. This may require division of the inferior
mesenteric artery and vein, full mobilization of the splenic flexure,
and at times more complex maneuvers such as derotation or the creation of an ileal mesenteric window. If technically possible, closure
of the vaginal opening should be performed but may not be possible.
At times, repairing transvaginally may be necessary as opposed to
transabdominally, depending on exposure. Consideration of having
gynecology available might help mitigate the difficulties in performing the closure transvaginally. Adequate blood flow can be assessed
in traditional ways, but consideration for indocyanine green (ICG)
angiography should also be utilized liberally. Once the stapled anastomosis is performed, flexible endoscopy with air leak testing and
assessment should be performed. Based on the results of the endoscopy, conduct of the surgery, blood loss, patient stability, and the
patient’s ability to tolerate an anastomotic leak, a proximal diversion
with a loop ileostomy should be considered. Typically, prior radiation
therapy, an anastomosis less than 4 cm from the anal verge, or a less
than ideal anastomosis should be diverted.
Consideration for omental pedicle interposition should always be
considered at this point. If adequate omentum is present, it can be
made into a pedicle based on the right or left gastroepiploic vessels
and then brought down into the pelvis anterior to the anastomosis
and posterior to the vaginal defect/repair to act as a physical separator, keeping the repair and anastomosis separated. There are multiple
methods of securing the flap within the pelvis, but often it will stay in
place just based on the narrowness of the distal pelvis and interposition within the rectovaginal septum.
PERINEAL APPROACHES
Transanal Fistulotomy
Transanal fistulotomy entails the direct opening of the entire fistula
tract. This method is preferably indicated for superficial fistulas and
should be performed after the fistula tract is well defined by the
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local fibrosis. This is normally promoted by a pretreatment period of
draining seton once the local infection has been treated and the tract
has matured. In the operating room setting, the seton is removed,
and the residual fistula tract is curetted and cut open.
The procedure results in high rates of a long-lasting fecal incontinence, likely caused by a combination of the violation of the anterior
anal canal, where sphincter muscle is sparser, and a resulting deforming wound defect.
Despite its theoretical indications, the transanal fistulotomy has
fallen out of favor for the management of RVFs.
Endorectal Advancement Flap
The endorectal advancement flap (ERAF) is the most standard treatment for low-lying simple posttraumatic RVFs. It is a compelling
approach, especially when there is a concern for fecal incontinence as
it does not cause any surgical division of the external sphincter muscle.
Advancement of the anterior rectal wall with the aim to obliterate
the internal opening by sliding a flap of healthy rectal wall consisting of
mucosa, submucosa, and a circular muscle from proximal to cover the
opening and suture it into place was first described by Noble in 1902
and since then has been extensively reported with slight modifications.
Preoperatively, patients undergo bowel preparation with either
oral mechanical bowel preparation the night before the surgery or
two sodium phosphates enemas the morning of the surgery.
The patient is placed in the jack-knife prone position over a
Kraske roll. The buttock is taped widely apart, and the patient is
prepped and draped in normal sterile fashion. Exposure can be
further optimized by effacing the anus with the use of a Lone-Star
retractor. A lighted Hill-Ferguson retractor or a Pratt bivalve anoscope is placed into the anal canal to expose the anterior rectal wall.
The fistula tract is identified and assessed by a probe passed from the
vaginal side. Using Bovie electrocautery, a U-shaped flap is outlined
with its apex sited distally to the location of the fistula. The rectal
wall is incised through the mucosa, submucosa, and down to the
internal sphincter for a partial-thickness flap. The base of the flap
should be two to three times as wide as the apex to ensure adequate
blood supply of the flap. Care should be taken to avoid making a hole
in the repair. The flap is raised for a distance sufficient to allow tension-free anastomosis, normally 4 to 5 cm. Once the flap is created,
the fistula tract is debrided and closed by approximating the fibers
of the internal sphincter. Additional mobilization might be required
to allow to the edges of the internal muscles to be sutured over the
fistula opening. The closure is performed in one or two layers using
interrupted 2-0 Vicryl sutures. After hemostasis is reassured, the distal end of the flap containing the fistula is trimmed, and the healthy
flap is anastomosed distally (Fig. 1). The vagina side is left open for
drainage.
The addition of a biologic graft to reinforce the rectovaginal
repair has been described by some surgeons. A manufactured
AB C
D
E
FIG. 1 Endorectal advancement flap. (A) Probe identifies the fistula tract. (B) Endorectal advancement flap. (C) Depth of the flap containing mucosa,
submucosa, and circular muscle. (D) Mobilization of the flap without tension. (E) Flap sutured in place. (From Cleveland Clinic Center for Medical Art &
Photography. Copyright 2021. All Rights Reserved.)
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porcine small bowel submucosa is sized accordingly and employed in
the rectovaginal space, with the flap sutured over the graft.
The overall success rate for ERAF for RVF is short term. It ranges
widely in the literature from 29% to 93%. Most publications are made
up of heterogeneous series of varying sizes, with mixed complex and
simple fistulas and diverse closure techniques including ERAF alone
or in combination with other approaches.
Flap failure is a dreaded complication. The most common cause
for flap failure is retraction of the anastomosis, ischemia, and consequent necrosis with dehiscence of the anastomosis leading to flap loss
and a potentially larger rectal defect after surgery.
Flap loss within 7 days is considered early failure and has been
reported to be up to 6%. Late flap loss/failure rates range from
16% to 37%. Hence, enough flap mobilization for a tension-free
anastomosis is paramount. Crohn’s disease, complex fistula, and
recurrent fistula and prior failed attempts at fistula repair are a risk
factor for ERAF failure. Main contraindications to the ERAF include
active Crohn’s disease, acute anal abscess, and scarred or stenosed
anorectum.
If an associated sphincter defect is present and a concomitant
sphincter repair is performed, the success rate of the ERAF for RVF
is higher and has been found to be as high as 100% in a small series
of patients with obstetric low RVFs by Chew et al.
All women with an obstetric-related RVF should undergo evaluation for occult sphincter injury.
Fibrin Glue
The injection of fibrin glue can be performed for low RVFs with an
intact rectal sphincter complex. The procedure is performed in the
operating room. After the fistula tract is debrided, a fibrin adhesive
is injected into the fistula tract until it exits the secondary opening.
The theory is that the glue seals the fistula while also promoting
fibrous tissue ingrowth and subsequent fistula healing without violating anorectal anatomy. Although this procedure does not threaten
continence and causes minimal disruption to tissue planes, reported
healing rates less than 60% have been frustrating enough to cause the
fibrin glue to have a very limited place in the management of RVFs.
The advantage is that potential future repairs are possible (Bhama
et al., 2019).
Fistula Plug
The currently available fistula plug is made from lyophilized porcine
intestinal submucosa, (Surgisis Biodesign Button; Cook Surgical)
which provides a matrix for ingrowth of connective tissue. As for the
fibrin glue application, the fistula tract is first curetted, the plug is
prepared as per manufacturer recommendations, and with the guidance of a suture tied to the tip of the plug, the plug is passed from
the rectum to the vagina until it is snug in the tract. The plug is the
then sutured to the rectal mucosa. The excess fistula plug is trimmed
flush to the opening at the vaginal side and sutured or not sutured to
it; both ways have been described (Fig. 2).
The plug is costly, and there has not been enough experience with
this technique. Reported results are extremely variable, with some
series reporting an over 75% failure rate.
Like the fistula glue, the fistula plug carries very low complication
rates with preservation of sphincter function and no violation of the
perineal planes, however it is rarely performed.
TRANSVAGINAL REPAIRS
Transvaginal Approach Vaginal Advancement Flap
This approach is more extensively described in the gynecologic literature. In this instance, a flap is created in the vaginal wall instead.
FIG. 2 Fistula plug. Plug placement within the rectum and the vaginal openings. (From Cleveland Clinic Center for Medical Art & Photography. Copyright
2021. All Rights Reserved.)
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Supporters of this procedure emphasize optimized access and ease
when mobilizing the flap and closing the opening of the fistula from
the vaginal aspect compared with the transanal approach. They also
claim a better-quality flap with well-vascularized vaginal tissue.
As the rectal advancement flaps, a flap of the vaginal mucosa is
raised, the fistula tract is resected, the apex of the flap is trimmed
to excise the fistula opening, and it is sutured into position to close
the wound. An important technical aspect with this method is that
the rectal mucosa still should be repaired. Because the rectal side
constitutes the infected, high-pressure side of the fistula, failing to
address the rectal mucosa significantly decreases the chances of a
successful repair. The rectal wall is typically closed with interrupted
absorbable sutures.
Despite published satisfactory success rates and described technical advantages of the approach, the transvaginal repair has been
less commonly used than the ERAF. This is perhaps because of the
theoretic possibly of increased pressure from the rectal side or an
ongoing infection process compromising the vaginal flap.
A transvaginal advancement flap may be a good option when
the rectal mucosa is diseased, such as in Crohn’s disease, or when an
ERAF has previously failed. Small series have reported a transvaginal
flap for Crohn’s-related RVF, with a success rate up to 93%, with fecal
diversion.
Bhome et al. described a flapless transvaginal technique for the
repair of primary and recurrent low- and mid-level RVF of varying
etiology in which the fistulotomy and the closure of the rectum is
performed from the vaginal side followed by closure of the rectovaginal septum and vagina. The authors reported 15 cases of RVF. The
healing rate was 67% in a median follow-up of 48 months. Seven
patients had fecal diversion. They concluded that the method was a
safe, effective, faster, and technically less challenging alternative to
ERAFs.
Transperineal Repairs
Most of the transperineal approaches are accomplished by a transverse
or circumlinear incision made over the mid portion of the perineal
body, dissection of the rectovaginal septum, division of the RVF tract,
closure of the fistula openings in the rectum and vagina, and layered closure of the incision. These approaches include the transperineal repair
with levatorplasty, ligation of the intersphincteric fistula tract (LIFT),
and sphincteroplasty. The episioproctotomy is a transperineal approach
in which a fistulotomy is carried out with transection of full-thickness of
the perineal body followed by subsequent sphincter repair.
Transperineal Ligation with a LIFT Procedure
The LIFT procedure has been performed for management of
transsphincteric fistulas-in-ano with acceptable success rates. More
recently, the technique has been incorporated as an alternative
for treatment of RVFs. The fistula tract is identified with use of a
fistula probe, and a transverse or semi-circumferential incision is
performed at the mid-portion of the perineal body. Then the subcutaneous tissue is dissected toward the intersphincteric groove,
and the intersphincteric plane is entered and mobilized from the
rectal mucosa posteriorly through approximately one-third of the
circumference of the anus and rectum. The fistula tract is isolated
and completely transected in this plane. The dissection extends
in the rectovaginal septum 2 to 3 cm proximal to the fistula. The
fistula openings in the mucosa of the rectum and vagina are closed
or imbricated with interrupted, absorbable sutures. A bioprosthetic
graft can be interposed in the intersphincteric plane and is advocated
by some authors. Benefits of this method include its low impact on
fecal continence and low complication rates. Sphincteroplasty can be
combined if there is an associated sphincter defect. An ERAF can be
included depending on the state of the rectal wall (Fig. 3).
AB
FIG. 3 Ligation of the intersphincteric fistula tract (LIFT). (A) Probe illustrating the rectovaginal fistula tract. (B) Closer view of the dissection
of the fistula tract at the intersphincteric plane. (C) The fistula tract is completely transected in this plane. (From Cleveland Clinic Center for Medical Art &
Photography. Copyright 2021. All Rights Reserved.)
C
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There is still no robust experience with LIFT for RVF, with or
without bioprosthetic material. Published success rates from a paucity of studies range from 57% to 94%. Ellis et al. published the only
series assessing the use of bioprosthetic material added to the LIFT
procedure in 27 patients. In this study, an undetermined number of
patients underwent concomitant sphincteroplasty. Healing occurred
in 81%. Long-term, comparative, randomized controlled studies are
needed.
Overlapping Anterior Sphincteroplasty
For patients with RVF who have a palpable sphincter defect and a
thin anovaginal septum, an overlapping anterior sphincteroplasty is
indicated.
After entering the rectovaginal septum, lateral dissection is
undertaken to identify the edges of the external anal sphincter. The
scarred edges are grasped with an Allis clamp, and the dissection
continues laterally along the external sphincter, until the edges are
mobilized enough to come together. To avoid injury to the pudendal nerves bilaterally, care must be taken not to dissect too far
laterally. The ends of the external sphincter are then overlapped for
1 to 2 cm and sutured together using a delayed absorbable suture.
The incision is then closed in layers, with the medial portion left
open for drainage. Patients must avoid straining and hard stools
in the postoperative period, which may lead to early failure of the
repair.
As described earlier in this chapter, the success rate of the ERAF
combined with sphincteroplasty for RVF caused by obstetric injury
is higher and has been found to be as high as 100%.
Episioproctotomy
In this technique, the rectum and vagina are separated from one
another, the fistula tract is divided, and all tissue between the rectum and vagina is split through the perineal body, converting the
fistula into a complete perineal laceration. Next, the vaginal wall
is dissected from the perineal body, the rectal mucosa is closed in
layers by approximation of the internal and external sphincters, and
perineal body reconstruction is performed with or without an interposed muscle between the rectum and vagina with a levatorplasty
or sphincteroplasty (Fig. 4). The combined methodology technique
is especially suitable to obstetric-related fistulas associated with an
extensive sphincteric defect with incontinence as it addresses both
issues.
The overall success rate for this technique ranges from 70% to
88% in the literature, with described restoration of continence in 70%
to 98% (Khanduja et al.) and significant improvement in both defecatory and sexual function in comparison with ERAF (Hull et al.). The
combined interposition of biologic grafts has been described, with a
success rate of 80% (Ellis et al.).
The downside of this procedure is that is creates a much larger
wound, which can result in a larger fistula with worse incontinence,
should the repair fail. Therefore, this procedure should only be performed by or with the assistance of experienced surgeons.
Transperineal Stapled Repair
Lately, a novel procedure utilizing a transperineal stapled transection
of the RFV fistula was published in seven patients with RVFs of
various etiologies, excluding Crohn’s disease and malignancy. The
authors performed a concomitant levatorplasty in four patients and
sphincteroplasty in two patients. Two patients had a stoma. Their
preliminary results reported no recurrence, no complications, and
100% satisfaction rate in a median follow-up of 6 months (range
3–33 months) (Lin et al., 2019).
Interposition Flaps
The gracilis muscle and bulbocavernosus (Martius) flaps are the
two most popular pedicled flaps for RVFs. Other flaps have been
described but never gained popularity. Those include gluteoplasty
with bilateral tongues of the gluteus maximus and Lotus flap, a fasciocutaneous flap that is raised on perforators around the perineum,
mostly described in the gynecologic literature.
The interposition of healthy, substantial tissue between the rectum and vagina confers the highest success rates of all transperineal
repairs. The bulk added to the rectovaginal septum also increases
the distance between the rectum and vagina. The morbidity related
to these repairs is not high but includes wound healing complications, pain, dyspareunia, and undesirable cosmesis, particularly
with gracilis interposition. Yet for the gracilis muscle interposition,
caution is recommended in patients with muscle atrophy, myopathy,
or impaired mobility.
These are complex operations, typically performed in tertiary
centers by a surgeon with expertise on the technique. Fecal diversion
is usually recommended, and most patients had previously undergone fecal diversion because of various prior failed repairs.
Gracilis Muscle Transposition
Gracilis muscle is a resourceful, well-vascularized tissue for perineal reconstruction because of its long length, substantial bulk, and
single proximal neurovascular pedicle in most patients. The patient
is placed in the Lloyd-Davies position using Allen stirrups or, alternatively, in a frog-leg position with a sterile bump under the knee.
The groove between the gracilis muscle and the sartorius muscle is
identified in either thigh. Approximately 2 cm above the knee joint,
a 4-cm longitudinal incision is made, and the dissection is deepened
through the subcutaneous tissue to expose the fascia overlying the
tendon of the gracilis muscle. Then fascia is incised, and muscle is
mobilized until all perforating vessels are identified. The perforating
vessels can be divided and ligated between clamps or with ultrasonic shears or a bipolar cutting instrument. A tunnel under the
fascia is created by blunt digital dissection that is gently continued
as proximal as possible, with care to stay superficial to the muscle.
Next, a second incision is made immediately proximal to the apex
of the tunnel, approximately at the mid-medial thigh, immediately
posterior to the saphenous vein from 4 to 8 fingerbreadths distal to
the anterior superior iliac spine. The fascia is incised, and the muscle is dissected free in a similar fashion. The tendon is subsequently
divided distally, and the distal muscle is delivered to the proximal
incision.
Another incision is made at a higher level at the top of the thigh.
The gracilis muscle is exposed and dissected free to the level of the
proximal neurovascular pedicle. Sufficient blood supply is ensured,
and sufficient length to reach the perineum is assessed.Following, a
tunnel is made from the upper aspect of the upper incision and dissected. The tip of the tendon is exteriorized at the ipsilateral edge of
what will become the perineal incision and then securely sutured to
the skin. The patient is repositioned in the prone jack-knife position
with the thighs fixed. The dissection is initiated with a 5- to 7-cm
anterolateral circumanal incision made through the perineal body
and deepened into a plane between the subcutaneous and superficial
portions of the external anal sphincter and the vagina. Once adequate wide cephalad and lateral mobilization into soft areolar tissue
in all directions is accomplished, the edges of the fistula are resected
to leave soft and viable tissue for further closure of the fistula. Both
the rectal and vaginal sides can be closed directly or with an advancement flap. The muscle is then secured to the apex of the dissection
with interrupted Prolene sutures (Fig. 5).
The wound is copiously irrigated. A 15-Fr drain is placed into the
bed of the gracilis muscle harvest and secured to the skin using silk
suture. A 10-Fr drain is placed through a separate stab incision along
the muscle and into the perineal sinus. The perineal incision is closed
ANORECTAL 325
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BA
C
D
FE
FIG. 4 Episioproctotomy. (A and B) Separation of the rectum and vagina with division of the fistula tract including all tissue between the rectum
and vagina through the perineal body. (C–E) Rectal mucosa closure in layers by approximation of the internal and external sphincters and perineal body
reconstruction with sphincteroplasty. (F) Perineal closure. (From Cleveland Clinic Center for Medical Art & Photography. Copyright 2021. All Rights Reserved.)
326 RECTOVAGINAL FISTULA
AB
CD
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FIG. 5 Gracilis muscle interposition. (A) Thigh incision marking sites. (B) Division of the tendon. (C and D) Mobilization of the gracilis muscle.
AB
C
FIG. 6 Martius flap. (A) Subcutaneous tunnel is created up to the rectovaginal septum. (B) Mobilization of the labia majora after primary closure of the
rectovaginal fistula tract. (C) The graft is rotated and placed in the rectovaginal septum. (From Cleveland Clinic Center for Medical Art & Photography. Copyright
2021. All Rights Reserved.)
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