Generally,thescientificliteraturedescribingthetechniqueof transvaginalapproachtobiologicmeshinterpositionrepairprimarily consistsofsmallsingleinstitutionalseriesandthereforethereader shouldbewillingtoacceptverygeneralstatementsregardingthe indicationforthistechnique.Theevidenceforthesuperiorityofone techniquecomparedwithanothersimplydoesnotexist,giventhe absenceofwell-designed,prospectivecomparativestudies.Thechosen operativeapproachreflectsmoreoftenthesurgeon’sspecialtytraining andfamiliaritywiththeanatomicdissection.Studiesinsupportofa transvaginalapproacharisefromthegynecologicspecialtyliterature, whereastransanalapproacheslikewiseoriginatefromstudiesbythe colorectalspecialty.Asacolorectalsurgeon,Iwouldofferthepotential followingadvantagesforatransvaginalapproach:inthecaseof recurrenceorpersistentfistulawhereinitialorprioroperationoccurred viaatransanalapproach,atransvaginaloperationofferssurgical dissectionintissuewithpotentiallylessscarringandfibrosis.Inaddition, thevaginaoffersalargerorificeimprovingexposurefordissection.On thecontrary,colorectalsurgeonsaregenerallylessfamiliarwiththe dissectionplanesfromatransvaginalapproach;thecomplexandrobust vascularsupplytothevaginalwallleadstonuisancebleeding;and whereasatransvaginalapproachprovidesabettervisualizationofthe vaginaldefectthelithotomypositioningrequiredmaylimittheexposure andrepairoftherectalmucosaldefect.