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478 D. Morte et al.
ends of the tract are then suture ligated with absorbable suture, and the tract is
divided sharply. Hydrogen peroxide can be injected to ensure closure of the
intersphincteric tract. The anoderm is closed with a running absorbable suture.
Healing rates for this procedure have been found to be between 47% and 95%
(Vander Mijnsbrugge et al. 2019). Patients have reported lower rates of incontinence,
and failures have been associated with tracts greater than 3 cm long, obesity, and
prior fistula surgery. Additionally, it is felt that failures are associated with the
conversion of, in many cases, transsphincteric to intersphincteric fistulas – the latter
of which is much easier to manage.
Transabdominal approaches to high fistulas have been described ranging from
primary repair with omental interposition (classically for upper rectal or colovaginal
fistulas) to resection with coloanal anastomoses or more commonly pull-through
procedures. These approaches are indicated in high fi stulas, presence of adhesions in
the pelvis from prior surgery, inflammatory bowel disease causing circumferential
involvement, neoplasm, or radiation. They are also required in the setting of chronic
fibrosis and poor surrounding tissue quality. Primary repair and omental transposition have been associated with success rates of 95% (Van Der Hagen et al. 2011).
In rare conditions, patients that have severe anal canal stricturing or ulcerations,
but healthy rectal tissue may benefit from a rectal sleeve advancement with circumferential mucosectomy of the distal rectum and pull-through. This is associated with
a healing rate of 75–79% but with a high postoperative complication rate of 32–41%
(Schouten and Oom 2009).
Episioproctotomy is an option for patients with a rectovaginal fistula and associated anterior sphincter defect generally resulting from obstetrical trauma or
cryptoglandular fistulas. This procedure is completed by performing a fistulotomy
of the vaginal wall, anal sphincter, and rectal wall. This will turn the fistula into a
complete perineal tear. The fistula tract is then excised and debrided, and the wound
is closed in several layers with the addition of a sphincteroplasty. This procedure has
been found to have good results with success rates as high as 78% and reduced
incontinence rates to 8% postoperatively (Hull et al. 2011; Halverson et al. 2011).
3 Flap Reconstruction
3.1 Overview and Considerations for Flap Reconstruction
Flap reconstruction is a useful approach for the management of fistulas and dates
back to 1902 when Noble originally described the use of an endorectal advancement
flap. They have the benefit of using healthy and well-vascularized tissues to repair
defects and buttress closures to prevent recurrence. These flaps range from small
advancement flaps to large muscle transpositions. These flaps will be discussed with
specific emphasis on muscle transposition flaps such as the gracilis interposition flap,
Martius flap, and gluteal fold flap.
Advancement flaps are a useful tool for the treatment of fistulas as they
involve removal of the affected tissue and replacement with a healthy tissue via a
29 Additional Surgical Options to Treat Anal Fistulas: Gracilis... 479
partial-thickness flap of the rectal or vaginal wall. They have been associated with
success rates of 60% and have become the procedure of choice for many surgeons
for recurrent or high transsphincteric fistulas (Gottgens et al. 2014). They should be
avoided when there is the risk of poor quality rectal tissue such as in the case of
patients with prior radiation, Crohn’s disease, ulcers, or strictures (Hrabe and Hull
2020). This procedure can be performed through the vagina, perineum, or the
rectum, but preference is often placed towards utilizing the rectal approach as this
allows the repair to be buttressed on the high-pressure side of the fistula. Proponents
of a vaginal approach quote that there is a benefit in the greater redundancy of the
vaginal wall and avoids suturing through inflamed rectal mucosa. A perineal
approach will allow for separation of two structures and closure but is used less
commonly. Ruffolo et al. (2010) compared the rectal and vaginal approaches in
Crohn’s disease patients and found no differences in the success rate. In the event of
a failure of either of these approaches, it is feasible to consider a repeat repair
through the alternative approach.
The endorectal advancement flap is performed with the patient in the prone
jackknife position, but the lithotomy position can be considered for patients with
posterior midline fistulas. The fistula tract is cannulated, and a U-shaped flap is
marked with the opening forming the apex. The flap is then raised with a distal to
proximal dissection staring 1 cm distal to the fistula opening. Depending on the
quality of the tissue, this flap can consist of the mucosa, mucosa and submucosa, or
even extending down to include a portion of the sphincter muscle. A critical step in
the creation of this flap is ensuring that the base of the flap is wide, described as two
to three times the size of the apex, to ensure that there is adequate perfusion.
Excessive manipulation of the flap should be avoided as this can lead to hematoma
formation and flap necrosis. Flaps should typically be around 2–4 cm long. The
internal fistulous tract can then be curet ted and closed with absorbable suture, and
the external or vaginal opening should be left open to allow for drainage. The
adequacy of the closure can be tested with the injection of hydrogen peroxide
through the external opening. The flap should then be pulled distally after amputation of the portion containing the opening of the fistula and the edges
re-approximated with interrupted absorbable sutures (Fig. 1). Early flap loss can
be as high as 6% and late flap loss as high as 37% (Bernstein and Schehebar 2020).
Repeat advancement flaps can be attempted with fairly good success, although this
should be approached with caution as they can increase the risk for tissue ischemia
and hamper future repairs.
Vaginal advancement flaps are performed similarly to rectal advancement flaps. A
flap of the vaginal mucosa is raised and the fistula tract excised. The rectal mucosa is
closed separately, and the rectovaginal septum is repaired. The flap is created with
care to have a base 2
–3 times the size of the apex, trimmed, and then secured over the
fistula tract. The advantages of this approac h, as previously mentioned, are the use of
pliable vaginal tissue and better exposure through the vagina at the cost of
performing the repair on the low-pressure side of the fistula. This approach is of
more use in patients with scarred rectums, fibrostenotic disease, or a history of prior
failed transanal approach. In both of the flaps above, it is important to ensure good
480 D. Morte et al.
Fig. 1 Completion of an
endorectal advancement flap
with rectal mucosa closed
over distal internal fistula
opening. (Reprinted with
permission, Cleveland Clinic
Center for Medical Art &
Photography © 2020. All
Rights Reserved)
hemostasis to avoid a hematoma between the layers that will hinder flap contact with
the apposed tissue.
As mentioned above, there has been an increased interest in the use of biological
materials to assist in fistula closure. Two bioprosthetics developed from lyophilized
porcine intestinal submucosa have been used in the treat ment of rectovaginal
fistulas. They are SURGISIS Soft Tissue Graft mesh and the Biodesign Fistula
Plug Set (Cook Medical LLC; Bloomington, IN). These have been used to separate
both ends of the fistula tract and have been described in combination with advancement flaps and the LIFT procedure with success rates of up to 71–81.5% (Moore
et al. 2004). Schwandner and Fuerst (2009) evaluated the use of bioprosthetics in
patients with Crohn’s disease and found an overall success rate of 75% at a median
of 9-month follow-up. These studies suggest that these adjuncts have a promising
future for the treatment of anorectal and rectovaginal fistulas, although further
analysis with longer-term follow-up is needed.
Prior to undergoing surgical repair, one has to consi der the potential need for fecal
diversion. Diversion allows for the improvement of perianal suppurative disease and
clearing of pelvic sepsis and is thought to lead to improved surgical outcomes for
appropriate patients. It is more commonly required in severe Crohn’s perianal and
rectal disease, where diversion occurs in 10– 20% of patients (Singh et al. 2004).
Radiation-related fistulas may also warrant consideration of temporary diversion,
due to the overall poor quality of tissue distally. However, studies have yet to
consistently show an improvement in outcomes, but it is worth noting that these
results may be due to a selection bias. Patients requiring diversion often have more
complicated diseases and anticipated lower rates of success or are undergoing
complex procedures. Diversion can be obtained with loop or end ileostomy or
colostomy with a preference for loop ileostomy as the colon may be required for a
pull-through procedure. Mennigen and associates performed a review of the use of
temporary fecal diversion in the management of Crohn’s disease-related fistulas and
found either complete or partial remission in 16/29 (55%) of patients, while 19/25
(76%) of patients were able to have their stoma reversed (2015). However, follow-up
29 Additional Surgical Options to Treat Anal Fistulas: Gracilis... 481
showed relapse of the disease in 15/19 (78.9%) of the patients that underwent
reversal of their stomas, leading to further interventions. Thus, temporary fecal
diversion can induce remission in patients and assist with the healing of complex
repairs, but the chance of long-term remission remains low. Unfortunately, some
Crohn’s disease patients, and especially those with a recalcitrant severe anorectal
disease, will eventually require a permanent stoma (Mueller et al. 2007).
Muscle Interposition flaps are another popular repair as they allow for the
interposition of healthy, well-perfused tissue between the rectum and vagina or
rectum and skin . They are typically used after a patien t has undergone several
prior failed attempts at local repair. They will add bulk and distance between the
fistula openings as well as increased blood supply to the region decreasing the
risk of recurrence. One major disadvantage is the increased risk of dyspareunia.
The most common procedures are the gracilis interposition flap, Martius
(i.e., bulbocavernosus) flap, and gluteal flap, all of which will be discussed in
greater detail below.
4 Gracilis Interposition Flap
4.1 Background and Indications
Gracilis muscle flaps were first described by Corman et al. (1979) for the repair of
anal incontinence. The gracilis muscle is a convenient donor due to its proximity to
the perineum and ability to provide a large amount of well-vascularized tissue. It is
used to repair recurrent rectovaginal fistulas or bolster repairs in patients with poor
tissue quality. Fecal diversion is frequently used to assist with healing, though not a
mandatory portion of the procedure. It is associated with good outcomes, with
success rates of up to 90% (Zmora et al. 2006;Furstetal.2008; Lefevre et al.
2009). Disadvantages associated with the procedure are that patients tend to
experience decreased quality of life and sexual activity scores postoperatively,
even in the setting of a healed fistula (Lefevre et al. 2009). However, prospective
studies with long-term follow-up have put these findings into question (Chen et al.
2013). Despite these setbacks, it remains a safe and effective option for the
treatment of rectovaginal fist ulas.
4.2 Operative Technique
Many surgeons prefer a mechanical bowel preparation with oral and intravenous
antibiotics for all flap procedures. The patient can then be placed in a supine position
with the legs abducted or a modified lithotomy position using stirrups. The fistula is
further characterized and a trans-perineal incision is then made separating the rectum
and vagina to allow for division of the fistula tract (Figs. 2 and 3). Dissection should
continue proximally until healthy tissue is reached. After the closure of the vaginal
and rectal openings, attention can be placed on either thigh for the gracilis muscle
482 D. Morte et al.
Fig. 2 Identification and
intraoperative interrogation of
rectovaginal fistula.
(Reprinted with permission,
Cleveland Clinic Center for
Medical Art & Photography ©
2020. All Rights Reserved.
With permission from Steven
D. Wexner, MD)
Fig. 3 Perineal incision to
separate rectum and vagina,
and allow for division of the
fistula tract. (Reprinted with
permission, Cleveland Clinic
Center for Medical Art &
Photography © 2020. All
Rights Reserved. With
permission from Steven
D. Wexner, MD)
harvest. This can be performed with a single long incision along the length of the
gracilis or through multiple, separate smaller incisions near the muscle’s origin at the
ischial tuberosity, and attachment to the proximal tibia (Fig. 4). A subcutaneous
tunnel can be bluntly created between the proximal thigh and the perineal incision.
The gracilis muscle is then mobilized with care taken to ligate the smaller perforating
vessels along the inferior surface of the muscle. It can then be divided above its
insertion and tunneled through the subcutaneous tissue in the groin (Fig. 5). This will
allow it to be maneuvered into the perineal incision. Care should be taken to avoid
excessive rotation or kinking of its blood supply, to allow for tension-free positioning of the muscle. The body of the muscle can then be inserted between the rectum
and vagina, and absorbable sutures are used to affix it proximally at the apex of the
vaginal-rectal dissection. The cut distal end of the muscle can be secured to the
contralateral pubic or ischial periosteum (Fig. 6). The trans-perineal and thigh
29 Additional Surgical Options to Treat Anal Fistulas: Gracilis... 483
Fig. 4 Multiple small medial
thigh incisions to allow
gracilis harvest. (Reprinted
with permission, Cleveland
Clinic Center for Medical Art
& Photography © 2020. All
Rights Reserved. With
permission from Steven
D. Wexner, MD)
Fig. 5 Following gracilis
mobilization and ligation of
small perforating vessels, the
muscle is tunneled through
subcutaneous groin tissue
(gracilis harvested via single
long groin incision in this
example). (Reprinted with
permission, Cleveland Clinic
Center for Medical Art &
Photography © 2020. All
Rights Reserved. With
permission from Steven
D. Wexner, MD)
incision can be closed in the typical fashion with absorbable sutures. Fecal diversion
can then be performed during this operation, but this is more commonly done
preoperatively.
4.3 Results/Complications
Zmora et al. (2006) reported success rates of 83% with no recurrence at 18-month
follow-up, and the only complication encountered being mild thigh numbness in two
patients. In a study of 10 patients receiving a gracilis transposition flap by Torres
et al., success rates were found to be 100% – though this study was notable for
abscess formation occurring in all patients. Korsun et al. (2019) performed a
retrospective review of gracilis flaps and reported a primary healing rate of 47%
and a definitive healing rate of 71% after additional procedures. Complications were
484 D. Morte et al.
Fig. 6 The cut distal end of the muscle is maneuvered into the perineal incision and placed between
rectum and vagina. The muscle may be secured to the contralateral pubic periosteum. (Reprinted
with permission, Cleveland Clinic Center for Medical Art & Photography © 2020. All Rights
Reserved. With permission from Steven D. Wexner, MD)
encountered in 21% of patients and ranged from wound infection to ischemia of the
gracilis muscle, as well as fistula recurrence in 58% of patients. Additional studies
have found primary success rates of 75–92% in patients without Crohn’sdisease
and 33– 66% in Crohn’s disease patients (Wexner et al. 2008;Pintoetal.2010;
Furstetal.2008).
5 Martius Interposition Flap
5.1 History and Indications
The Martius flap was first described by Dr. Heinrich Martius, a gynecologist in
Gottingen, Germany. He describes the use of the bulbocavernosus muscle and labial
fat pad for the repair of vaginal wall defects citing the benefit of their proximity
allowing for one surgical field (White et al. 1982). It was originally described in the
repair of the cystovaginal and urethral-vaginal fistulas but has since gained widespread in the repair of rectovaginal fistulas due to its ability to provide a local wellvascularized pedicle of adipose/muscular tissue with minimal morbidity. However, it
is a nuanced procedure and is best used for the repair of complex, recurrent, or
recalcitrant rectovaginal fistulas (Kin et al. 2012) that are approximately 2–5cm
proximal to the vaginal introitus.
5.2 Surgical Technique
Prior to any complex surgical intervention, it is important to ensure that the perineal
sepsis has been completely resolved. This is done by treating the underlying disease
29 Additional Surgical Options to Treat Anal Fistulas: Gracilis... 485
as described above (i.e., medical therapy for Crohn’s disease and/or drainage of an
abscess) including possible fecal diversion. A full mechanical bowel preparation
with oral antibiotics and a preoperative dose of intravenous antibiotics is typically
recommended.
Kniery, Johnson, and Steele describe the following steps for performing a Martius
flap (Kniery et al. 2015). The patient should be placed into the high-lithotomy
position with the use of yellow-finor“candy cane” stirrups. The perineum should
then be prepped with povidone-iodine solution, and the vagina prepped separately
with the placement of a Foley catheter. The region should be inspected for any
regions of undrained sepsis that would prevent proceeding with the repair. The
anatomy of the fistula should be confirmed with a fistula probe. An incision is
made at the vaginal introitus distal to the fistula opening to create a large broadbased vaginal flap, exposing the rectovaginal septum. The vaginal flap can then be
elevated, and dissection continued along the rectovaginal septum until the fistula is
encountered. Dissection should be continued above the fistula until it is circumferentially dissected and divided. The tract can then be curetted on the rectal side and
closed primarily with an absorbable 2-0 Vicryl suture in an interrupted figure-ofeight fashion. The vaginal segment of the fistula should be excised from the vaginal
flap ensuring that only healthy vaginal tissue remains.
Moistened gauze should then be placed in the rectovaginal septum and attention
turned to the labia. The choice of the labia is determined by prior surgeries and
variation in anatomy but can generally be the side closest to the fistula. A vertical
incision is made in the labia majora to allow mobilization of the labial fat pad and
bulbocavernosus muscle, though occasionally this muscle can be small and difficult
to visualize (Fig. 7). The blood supply for the flap comes from an inferior and
posterior location and derives from branches of the internal pudendal artery. Thus,
the dissection is performed in a lateral-to-medial dissection (Fig. 8). A Penrose is
used to encircle the flap and can be sutured to the distal end (Fig. 9). Once an
Fig. 7 A vertical incision is
made within the labia majora
to allow for mobilization of
the labial fat pad and
bulbocavernosus muscle.
(Reprinted with permission,
Cleveland Clinic Center for
Medical Art & Photography ©
2020. All Rights Reserved)
486 D. Morte et al.
Fig. 8 Dissection is
performed in a lateral-tomedial fashion. (Reprinted
with permission, Cleveland
Clinic Center for Medical Art
& Photography © 2020. All
Rights Reserved)
Fig. 9 The bulbocavernosus
flap is encircled with a
Penrose drain and later
sutured to the distal end such
that it can be tunneled
inferiorly/posteriorly.
(Reprinted with permission,
Cleveland Clinic Center for
Medical Art & Photography ©
2020. All Rights Reserved)
adequate length has been obtained the flap can be transected superiorly. A RochesterPean clamp is used to form a subcutaneous tunnel from the base of the labial incision
into the rectovaginal septum. Avoidance of injury to the lateral blood supply to the
rectum and creation of a large enough tunnel to accommodate the fl ap so as to not
constrict the blood supply is critical to this step. The Penrose drain that was
previously sutured to the flap will help with bringing the flap through the tunnel.
The flap can then be rotated at a slight angle to avoid kinking of the blood supply and
extended to cover the rectovaginal septum. Approximately three 3-0 Vicryl sutures
are used to tack the pedicle into place. A watertight seal can be confirmed by filling
the rectum with diluted hydrogen peroxide via a bulb syringe. Hemostasis should
then be assured.
29 Additional Surgical Options to Treat Anal Fistulas: Gracilis... 487
Fig. 10 Vaginal flap is closed
over the top of the
bulbocavernosus flap and
sutured to the vaginal
introitus. (Reprinted with
permission, Cleveland Clinic
Center for Medical Art &
Photography © 2020. All
Rights Reserved)
Fig. 11 Labia majora closed
over a Penrose drain.
(Reprinted with permission,
Cleveland Clinic Center for
Medical Art & Photography ©
2020. All Rights Reserved)
The vaginal flap is closed over the top of the bulbocavernosus flap and sutured to
the vaginal introitus with 2-0 Vicryl absorbable sutures (Fig. 10). The labia majora
can be closed over a Penrose drain (Fig. 11). The vagina is packed with an absorbent
dressing coated in estrogen-based cream. Postoperatively, patients receive a single
dose of broad-spectrum intravenous antibiotics and are observed overnight.
5.3 Results/Complications
Success rates range from 65 to 100%, though most studies have been small and
poorly describe the full outcomes including morbidity of these procedures (Gottgens
et al. 2014). The largest case series was performed by Pitel et al. (2011) and reported