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RECOMMENDEDREFERENCESAND READINGS
AllanRN,RhodesJM,HanauerSB,KeighleyMRB,Alexander-WilliamsJ,FazioV.Inflammatory
BowelDiseases.3rded.London,UK:ChurchillLivingstone,1997:304,343–7,477–8,713–6,
863–9,873–4. BurkeD,vanLaarhovenCJ,HerbstF,NichollsRJ.Transvaginalrepairofpouch-vaginalfistula.
BrJSurg2001;88:241–5. CorteH,MaggioriL,TretonX,LefevreJH,FerronM,PanisY.Rectovaginalfistula:whatisthe
optimalstrategy?AnnSurg2015;262:855–61. EtzioniDA,LowryAC.Benignanorectalandrectovaginalfistulas.In:SteeleSR,HullTL,ReadE,
SaclaridesTJ,SenagoreAJ,WhitlowCB,eds.TheASCRSTextbookofColonandRectal
Surgery.2nded.Berlin,Germany:Springer,2011:245–55. GöttgensKW,SmeetsRR,StassenLP,BeetsG,BreukinkSO.Thedisappointingqualityof
publishedstudiesonoperativetechniquesforrectovaginalfistulas:ablueprintfora
prospectivemulti-institutionalstudy.DisColonRectum2014;57:888–98. KeighleyMRB,WilliamsNS.Radiationinjurytocolonandrectum.In:SurgeryoftheAnus
Rectum&Colon.2nded.1993;2:2313–31. OmmerA,HeroldA,BergE,FürstA,SchiedeckT,SailerM.GermanS-3guideline:rectovaginal
fistula.GerMedSci2012;10:1–10. PintoRA,PetersonTV,ShawkiS,DavilaGW,WexnerSD.Aretherepredictorsofoutcome
followingrectovaginalfistularepair?DisColonRectum2010;53:1240–7. RuffoloC,ScarpaM,BassiN,AngrimaniI.Asystematicreviewonadvancementflapsfor
rectovaginalfistulainCrohn’sdisease:transrectalvstransvaginalapproach.ColorectalDis
2010;12:1183–91. SagarRC,ThorntonM,HerdA,BrayshawI,SagarPM.Transvaginalrepairofrecurrentpouch-
vaginalfistula.ColorectalDis2014;16:O440–2. ValenteMA,HullTL.ContemporarysurgicalmanagementofrectovaginalfistulainCrohn’s
disease.WorldJGastrointestPathophysiol2014;5:487–95.
Chapter14
RectovaginalFistula: TransanalRepairs
SheriefShawkiandMassaratZutshi

INTRODUCTION

Anorectal–vaginalfistulaistheabnormalconnectionbetweenthe anterioranus,ordistalorupperrectumwiththeposteriorvaginalwall.
Thisproblemisdevastatingtothepatientandchallengingforthe surgeonespeciallyincasesofrecurrentfistula.
Therearemultipleetiologicfactorsthatmayresultinarectovaginal fistula(RVF).Obstetricinjuryisthemostcommon,accountingforabout 85%ofcases,includingthird-andfourth-degreelacerationsand episiotomies.Obstructedlaborduetofetalimpactionresultsina prolongedlaborwithpressureofthefetalheadagainstthepelvicside wall,withapotentialischemicinjurythatmayeventuallyleadtoafistula. Crohn’sdiseaseisthenextmostcommoncauseofRVFwithareported incidenceofabout10%.Othercausesincludeinfections,priorradiation, malignancy,andiatrogenicorpostoperativecomplications.
UnderstandingthemultifactorialetiologyofRVFisimportantasthe etiologymayhaveimplicationsonpreoperativeevaluationandsurgical procedureselection.Forexample,inobstetric-trauma-relatedRVF, inquiringaboutcontinenceandevaluatingtheanalsphincterintegrityis crucialbeforedecidingthetypeofrepair.InCrohn’sdisease,itis importanttoinvestigatetheextentofthedisease(smallbowelor colonic),conditionoftheanalcanalandrectum,andseverityofloco­regionalinflammation(perineum,anus,andrectum).Thesefactors influencetheabilitytoachieveasuccessfulclosureoftheRVFandshould promptfurthertreatmentsorinterventionpriortoattemptingtoclose theRVF.Inpatientswithahistoryofpelviccancerand/orradiotherapy, bothlocalandsystemicmalignancyshouldbeexcluded.Treatment optionsmightbestincludetheuseofawell-vascularizedtissuegraft.
Recto-vaginalfistulacanbefurtherclassifiedbasedonthelocation relativetotheanalsphincter.Alowfistulapresentsatorbelowthelevel ofthesphinctersinthedistalrectumoranalcanal,andahighfistula wouldbemoreproximal.Asimplefistulaisusuallylow,lessthan2.5cm inlength,andusuallycausedbytraumaand/orinfection.Complex fistulaearehigher,larger,andusuallycausedbyotheretiologysuchas Crohn’sdisease,neoplasia,radiation,ortechnicalerrors.Location influencessurgicalapproachaccordingtotransabdominalor transperineal.Thischapterfocusesontransanal/transperinealrepair; RVFwillbereferringtolow,anorectal–vaginalfistula.
PrinciplesofTreatment
PREOPERATIVEPLANNING
Elementsforappropriateselectionoftreatmentincludeetiology,severity ofsymptoms,presenceandextentofinfection/inflammation,tissue quality,sphincterintegrityandcontinencestatus,prioranorectalsurgical intervention(s),andpriorrepairattempts.Theseelementsareall obtainedviaathoroughhistoryandmeticulousexamination.Thorough reviewofpreviousrecordsthatpertaintotheRVFisessential.
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Examinationincludesinspection,palpation,anddigitalexaminationof therectumandvagina.Adjunctsincludeimagingandendoscopyas needed.Theperineumisevaluatedforsignsofinfection/sepsis,skin excoriationandirritation,pathologiclesionssuggestiveofIBD,and/or surgicalscars.DelineatingtheanatomyofRVFisnecessary.Digital examinationofthevaginaandtheanorectumisperformedtoidentifythe fistulalocation,level,size,andtoruleoutneoplasia.Bimanual examinationhelpsinevaluatingtheanovaginalseptumandtissue compliance(induratedandscarredvs.softandpliabletissues). Assessmentoftheintegrityofthesphinctercomplexandsphinctertone isimportant.Withaninjectionofadilutedsolutionofbetadineor methyleneblueintheanorectumandatamponplacedinthevagina,the patientisaskedtowalkaroundtoaidinvisualizingtheaccountfistula tract.Alternatively,endoscopicinsufflationoftherectumwhileinstilling normalsalineinthevagina,withpatientintheTrendelenburgposition, mayhelpprovethepresenceofRVF.Examinationunderanesthesiais undertakentoconfirmthediagnosisandfulfilltheabovementioned fundamentals.
Althoughanalphysiologytestingisusuallynotneeded,further preoperativetestsaretailoredbasedontheetiology,especiallyifthe patientendorsesincontinenceasasymptom.Endoanalultrasoundwhen obstetrichistoryraisesconcernsaboutfecalcontinencecanbeusedto evaluatethesphincterintegrityandguideanatomicalrepair.Endoscopic evaluationandCTscanareusedtoevaluateconcurrentdiseasein patientswithCrohn’sdiseaseortoexcludesynchronousorrecurrent tumorsinapatientwithapasthistoryofmalignancyandor radiotherapy.
ThegoalsofsurgicalmanagementincludeclosureoftheRVFand preservationorrestorationoffecalcontinence.Controlofsepsisand decreaseininflammationreversesindurationandresultsinsoft,pliable,
andwell-vascularizedtissues.Thesubsequentchangesinlocaltissues afterfailedrepairintermsofrecurrentinflammation,fibrosis,rigidity, compromisedbloodsupply,andlossoftissuecompliancerendersfurther attemptsofrepairmorechallengingandmaybedoomedwithfailure.
Anysuspicionofoccultsepsisand/oractive/inadequatelydrained infectionshouldpromptanexaminationunderanesthesiaforproper evaluationandappropriatedrainage.Insevereconditions,with significantinflammationandskinexcoriation,temporaryfecaldiversion maybenecessary.Similarly,patientswitharecentobstetricinjuryora recentfailedrepairshouldhaveasurgicalrepairdeferredforabout3–6 monthstoallowforresolutionofinflammationandrestorationoftissue compliance.Placingasoftsilasticsetonmaybehelpfulinthese conditions.
Thediverseetiology,surgeonpreferences,numeroustreatment options,andabsenceofrandomizedtrialshaveresultedinlackof evidence-basedguidelinestostandardizesurgicalapproachesofsuch condition.Furthermore,patientsareusuallyreferredtotertiarycenters afterhavingundergonemultiplefailedattempts.Therefore,being familiarwithdifferentsurgicaloptions,indications,andoutcomesis necessaryforchoosingtherightsurgeryforapatient.
Onceapatienthasfulfilledtheprerequisitesforasuccessfulrepair,the surgicalapproachistailoredandindividualizedbasedonetiology,fistula characteristics,tissuequality,sphincterintegrity,andcontinencestatus asstatedearlier.
TreatmentOptions
WatchfulWaiting
Occasionally,somepatientspresentwithaverysmallRVFandhavemild orminimalsymptomssuchasminimalleakageofflatus.Itiscommonfor asmallfistularelatedtoobstetrictraumatohealspontaneouslywithin 6–9monthsafterchildbirth.Watchfulwaitingmaybeofferedaslongas symptomsaremildwithnoevidenceofactivetissueinfectionandpatient compliancewithaclosefollow-up.
SetonAlone
Asetontodrainsepsismaybeanoptioninsomepatients.Insome womenwithsignificantinflammationduetoradiationorCrohn’sdisease, theseverityofsymptomsiscloselyweighedagainstthepossibilityof makingtheconditionworse.Whenfacedwiththeworst-casescenarioof apermanentstomaversusmildsymptomslikeflatusthroughthevagina, arepairmaynotbethebestchoice.Therefore,settingrealisticgoalsof
therapybeforeembarkingondefinitiverepairareimportant.Patientswill needtoknowthattheymayhavetoacceptanimperfectqualityoflife livingwithaseton,versuslivingwithastoma,whenarepairmaynotbea possibility.Adrainingsetonmayalsobeusedpriortoarepair.
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ObliterationofFistulaTract
BiodegradableFistulaPlug
Thisoptioninvolvesusingabiologicmaterialtoobliterateafistulous tract.Theplug,ideally,shouldnotinduceaforeignbodyreactionand attracthostcellstopopulatethescaffoldoftheplug,promotingtissue regeneration.Theidealpatientshouldhavealongfistulatract(>1cm), noevidenceofinfection,andnoactivedisease.Adrainingsetonisleftin placeforatleast6weekspriortoplacingtheplug.
Duringsurgery,whichisdoneundergeneralanesthesia,thetractis gentlydebridedandirrigated.Dilutehydrogenperoxidemaybeinstilled intothetractforfurthercleaning.Theplugshouldbepreparedaccording tothemanufacturer’sinstructions.Afistulaprobeispassedfromthe vaginaintotherectum.Oneendofthesutureistiedtotheprobeandthe othertothenarrowendoftheplug.Theprobeiswithdrawnwiththe suture,andtheplugisthengentlypassedfromtherectaltothevaginal sideuntilthebuttonissnugagainstthemucosa(Fig.14-1).Thebutton restsintherectum.Thecircularbuttonhasfourholes,andtheplugis securedinplacebyfour2-0absorbablesutures,includingthemucosa, theunderlyingmuscle,andthebutton(Fig.14-2).Theexcessplugonthe vaginalsideistrimmedatthelevelofthevaginalwallbutnotfixedtothe vagina.Anundeniablebenefitofthisprocedureispreservingcontinence andmaintainingtissueintegrity,therebynotaffectinganysubsequent necessarytissuerepair.
FIGURE14-1Placementoffistulapluginthefistulatract.
Thesutureistiedtothetaperedendandispulledfromthe internalopeningintothevagina.
FIGURE14-2Thebuttonofthefistulatractisaffixedto
therectalwallandtheextralengthofthepluginthevaginais trimmedoff.
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Postsurgicalinstructionsincludeinactivityfor2weekswithdecreased activityfor2moreweeks.Nosexualactivityispermittedfor6weeks. Technicalissuesincludeplugfalloutandpainatthesiteofthebutton.
LocalAdvancementFlap
Proponentsoftransrectalflapsadvocatethatthisapproachaddressesthe higherpressureaspectofthefistuloustract.
RectalAdvancementFlap
ThepatientisintheKraskeposition.Goodlightingandexposurehelpin creatingagoodflap.Goodexposurecanbeobtainedbyanaleverting suturesoruseofaLoneStardevice.
Acurvilinearincisioninvolving1/3–1/2ofthecircumference, includingtheinternalopening,ismade.Salinemaybeinjectedtoliftthe
mucosa.Themucosaandsubmucosaaredissectedfromtheunderlying internalsphincter.Dissectioniscarriedoutcephaladuntiltheflapcanbe advancedwithouttensiontowardthefuturesutureline.Withmore cephaladdissection,theplanisdeepenedtoassureawell-vascularized flap.Sharpdissectionmaybeperformedwithcaretoavoidabuttonhole defect.Hemostasisshouldbeobtainedwithoutacharringeffect.The fistulatractisdebridedofgranulationtissueorepithelialcellsthatmight havegrownintothetract.Theinternalopeningintherectumisclosed usinganabsorbablesuture(Vicryl)byadvancingappropriatelyintothe deepertissues.Thedirectionofclosuredependsonhowthetissueslay. Subsequently,thedistaledgeoftheflapistrimmedtoincludethe internalopening.Theflapisadvancedandsuturedtotheneodentateline using2/0VicrylsutureonanUR-6needle.Stitchesareplacedbeforethe retractorisremoved.Subsequently,aknotistiedwiththetyingfingeron theknotpushingtheanodermtowardtheflapratherthanintheopposite directiontoavoidanypotentialtear.ThelightedHillFergusonretractor isreinsertedintheanalcanalandthesuturelineisevaluated.Anyclots thatmaylieundertheflaparegentlyflushedaway.Anygapsmaybe closedusinganotherstitch.Althoughthesuturelineisexpectedtobe bruised,therestoftheflapshouldbeviable,pink,andflat.
Somesurgeonsprefermakingahorizontalincision,creatingboth cephaladandcaudateflaps,withthelattertoavoidectropionandmucous leakage.Ithasbeenadvocatedthatthepresenceofweaksphincters, significantlyscarredanalcanalandthinrectovaginalseptumdecreasethe chanceforsuccessandhencewouldlimittheuseofrectaladvancement flap(RAF).
Althoughtension-freeflapsarepreferred,itisimportanttoprevent redundancyandavoidtipischemiaanddeadspace,bothofwhichwill leadtofailure.Postoperativeinstructionsincludebedrestfor1–2weeks, paincontrol,andkeepingthestoolsoft.
RectalSleeveAdvancementFlap
Theindicationsforthisrepairaremultiplefailedattempts.This procedureshouldbeattemptedbyexperiencedsurgeonsafterfecal diversion.
Theendresultinthistechniqueisahand-sewnrectoanalanastomosis. AlmosteverystepissimilartothoseinRAF,exceptthatthedissection includesacircumferentialrectalwallmobilization.Theincisionismade atthedentatelineandtheanalcanalisdissectedcircumferentiallyfrom thefibroticanddiseasedmucosa.Attheanorectaljunction,dissection includesfullthicknessrectalwall,extendsabovethelevators,and continuescephaladuntilenoughlengthofrectumisobtainedfora tension-freeanastomosis.
SimilarrulesofdissectionasthoseofanRAFapplyregardingtension, hemostasis,avoidingcharring,andredundancy.Thediseasedanal mucosaistrimmed.Thetrackisdebridedandtheinternalopeningis closed.Subsequently,ahand-sewnrectoanalanastomosisisundertaken. Stitchesareplacedfirstfollowedbyeliminatingtheretraction,thentying thesuturestowardtheflap.
Therearecertainimportantfacetsrelatedtothesurgeonandpatient regardingthistechnique.Thesurgeonshouldbecognizantofthe possibilitythatatension-freereachmaybeunachievable.Inthatcase, transabdominalapproachforrectaldissectionandpullthroughis necessary;patientsshouldbeappropriatelycounseledandconsented.
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ReconstructiveandLayeredClosure
OverlappingSphincterRepair
PatientswithanRVFandaconcurrentsphincterdefectmaybenefitfrom simultaneousoverlappingsphincterrepairwhilerepairingthefistula. Thetechniqueofsphincterrepairisdescribedelsewhereinthistextbook, butbasically,acurvilinearincisionisundertakenontheperinealbody. Cephaladdissectionisundertakenthroughthefistula,afterwhich overlappingsphincterrepairandrectalsidefistulaclosureareperformed.
Someadvocatescombineadvancementflapwithsphincteroplasty.
Episioproctotomy
ThistechniqueisindicatedinpatientswithlowandlargeRVF,sphincter defect,andsymptomsoffecalincontinence.Patientswithacloacaldefect mayalsobenefitfromthisprocedure.
Preparationfortheprocedureisthesameasmentionedforprevious perinealprocedures.WepreferpatientstobeinaKraskeposition.A probeisplacedthroughthefistulatrackandallthetissuesdistaltothe internalopeningincludingtheperinealskin,sphinctermuscle,andboth rectumandvaginaareincisedusinganelectrocauterycreatingacloacal defect(Fig.14-3).
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