In the operating room, it may still be difficult to identify the fistula. It is important to avoid probing the tract aggressively and making false passages that may result in new fistulas. In addition, internal openings may be difficult to identify on the rectal side with either direct observation or endoscopy. For rectovaginal fistulas, placing a sterile gauze or “tampon” in the vagina and instilling dilute methylene blue into the rectum can help identify the presence and/or location of the fistula by seeing blue on the vaginal gauze. Once the fistula is identified, its location, size, quality of the surrounding tissue, sphincter involvement, and prior surgical interventions should be noted and recorded. Any evidence of local sepsis should prompt drainage to allow for adequate tissue healing prior to definitive intervention, including the use of a seton or drain. If the patient has a history of radiation, then the rectum should be evaluated with either rigid or flexible proctoscopy (Hrabe and Hull 2020). Biopsies can be performed if there is a concern for malignancy, Crohn’s disease, or any other concerning findings on examination. It is critically important at this stage to take full note of the integrity of the surrounding tissue. Remember, options for local flaps are dependent on the quality of this tissue to allow for a successful repair. Active inflammation, ongoing sepsis, or poor quality will almost guarantee failure even with a technically proficient operation.