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Modified Martius Flap for Rectovaginal Fistula

Contributors: Dr. Jimmy Lin, Dr. Juana Hutchinson-Colas, Dr. Nell Maloney-Patel

Rectovaginal fistulas can occur for a number of reasons, including obstetric trauma, iatrogenic, radiation damage and Crohn’s disease. Symptoms range from asymptomatic to uncontrollable passage of gas or feces from the vagina leading to poor quality of life for some patients. For those patients whom surgery is indicated, there are several different approaches depending on the fistula etiology and previous attempts at repair. These range from simple fistulectomy to transabdominal repair with tissue interposition to Martius flap interposition. Our patient in the video had previously underwent multiple various repairs which failed to provide adequate resolution of her fistula and therefore presented for a Modified Martius flap repair. The benefit of such a repair is to provide neovascularity at the site of repair with minimal cosmetic effect.

Modified Martius flap for rectovaginal fistula
Repair of rectovaginal fistula after multiple failed attempts
Pre-existing dyspareunia (relative)
Lithotomy position
CT scan, digital rectal exam, vaginal exam, colonoscopy
vagina, introitus, rectum, rectovaginal septum, labial fat pad
Advantages: Interposition of healthy, vascularized tissue in the rectovaginal septum Disadvantage: Impaired labial function, poor cosmesis
Risks: Dyspareunia
No conflicts to disclose.
N/A
Hokenstad ED, Hammoudeh ZS, Tran NV, Chua HK, Occhino JA. 2016. Rectovaginal fistula repair using a gracilis muscle flap. Int Urogynecol J. 27(6):965-7. Khalil HH, Malahias MN, Karandikar S, Hendrickse C.2016, Internal pudendal artery perforator island flap for management of recurrent benign rectovaginal fistula. Plast Reconstr Surg Glob Open. 10;4(8):e841. Kniery KR, Johnson EK, Steele SR. 2015. Operative considerations for rectovaginal fistulas. World J Gastrointest Surg. 27;7(8):133-7. Lalwani S, Varma V, Kumaran V, Mehta N, Nundy S. 2015, Complex rectovaginal fistula- an experience at a tertiary care center. Indian J Surg. 77(Suppl 3):1142-7 Lo TS, Huang YH, Dass AK, Karim N, Uy-Patrimonio MC. 2016, Rectovaginal fistula: twenty years of rectovaginal repair. J Obstet Gynaecol Res. 42(10):1361-1368 Oakley SH, Brown HW, Yurteri-Kaplan L, Greer JA, Richardson ML, Adelowo A, Lindo FM, Greene KA, Fok CS, Book NM, Saiz CM, Plowright LN, Harvie HS, Pauls RN. 2015, Practice patterns regarding management of rectovaginal fistulae: a multicenter review from the Fellows’ Pelvic Research Network. Female Pelvic Med Reconstr Surg. 21(3):123-8.

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