For complex rectovaginal fi stulas, attempts at local repair, as described above, are associated with signifi cant rate of failure and for high rectovaginal fi stulas are technically diffi cult. For these fi stulas, long-term success usually requires abdomi­nal resection and/or the interposition of healthy tissue. For abdominal procedures, a low anterior resection allows for excision of the diseased segment that contains the fi stula (this can be done laparoscopically or open). If the tissues surrounding the rectum and the vagina are normal, then one may dissect in the rectovaginal septum and perform a simple closure of the fi stula in several layers instead of performing a bowel resection. In those cases where one decides to primarily close the fi stula, it is recommended to perform an omentoplasty to provide a healthy tissue barrier between the repair vagina and rectum. There are only a couple studies examining laparoscopic resection of high rectovaginal fi stulas with the use of a pedicle of omentum between the anastomosis and the vaginal repair demonstrating high heal­ing rates and minimal complications [ 33 – 36 ]. This well-vascularized interposed tis- sue decreases the risk of fi stula recurrence. For those patient undergoing a resection for repair of the fi stula, indications for diversion with stoma are the same as those patients undergoing any elective rectal resection—patient comorbidities, tissue quality and confi dence in good vascularity, and lack of tension in the colon that is being brought down for the anastomosis.