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Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap

The surgical management of rectovaginal fistulas remains difficult, as they tend to be recurrent and vary widely in location and complexity. We present a case of a 63-year-old woman with a low-lying rectovaginal fistula who initially underwent chemoradiation and a Low Anterior Resection for a low-lying rectal cancer. Her course was uneventful until two years post-operatively, at which time her anastomotic staple line became stenotic with associated bleeding. This was initially addressed by Gastroenterology who executed a dilation and achieved hemostasis with Argon Plasma Coagulation. This remedied the stenosis, however, it was complicated by the formation of a rectovaginal fistula. Due to the low-lying location and its presence in an irradiated field, a transvaginal approach with an interposed gracilis flap was elected for repair.

The patient was positioned in lithotomy in order to permit a transvaginal approach to access the fistula. The posterior fourchette of the vagina was incised, and a plane was developed between the rectum and vagina. This allowed the fistulous tract to be identified and excised. Additionally, the defect in the rectum was located and repaired. Following this, Plastic Surgery harvested and tunneled a vascularized gracilis flap into the field to buttress the repair. Finally, a diverting loop ileostomy was created, with a planned reversal in 3-6 months. Post-operatively, the patient recovered well, and her ileostomy was reversed in 3 months. Maintenance of full continence of bowel and bladder and no further signs of communication between her rectum and vagina were achieved.
Transvaginal approach with an interposed vascularized gracilis muscle flap was indicated for repair due to the irradiated field and low-lying location of the rectovaginal fistula.
Contraindication for this procedure would be a high-lying rectovaginal fistula.
Patient is positioned in lithotomy in order to permit a transvaginal approach to access the fistula.
Mechanical and antibiotic bowel preparation was used preoperatively.
Identification of the posterior fourchette of the vagina is important in order to incise and develop a plane between the rectum and vagina to identify and excise the fistulous tract. For harvesting the gracilis muscle, the location of the gracilis muscle is marked proximally from the ischium to the medial condyle of the knee distally. This location is confirmed by palpating the adductus longus muscle and then marking 2-3 finger breadths posterior. The gracilis muscle tendon forms the pes aserinus with the sartorius and semitendous tendons. The primary vascular pedicle of the gracilis muscle arises from the medial femoral circumflex vessels off the profunda femoris artery which lies within the upper third of the muscle.
Advantages: Transvaginal approach is suitable for low and middle-lying fistulas. Interposing a well vascularized muscle flap from outside the radiation field over the repaired rectovaginal fistula offers an increased chance of healing with a decreased recurrence rate. In addition, the gracilis flap has adequate length and can be rotated easily into the perineum. Disadvantages: This technique cannot be used for high-lying fistulas.
Complication rate after gracilis muscle transposition is generally minimally, however there is a risk of injury to the saphenous nerve which runs superficial to the tendons at the pes anserinus. If the saphenous nerve is injured the patient can experience medial leg paresthesia and dysesthesia. There is also a risk of rectovaginal fistula recurrence
None of the authors have any financial disclosures with any commercial interest.
None
1. James Mok WL, Goh MH, Tang CL, Tan BK. Gracilis pull-through flap for the repair of a recalcitrant recto-vaginal fistula. Arch Plast Surg. 2019;46(3):277-281. doi:10.5999/aps.2018.00416 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536868/ 2. Abdou AH, Troja A, Raab HR, Antolovic D. Feasibility of Gracilis Muscle Flap Interposition for Management of Recurrent Rectovesical/Rectourethral Fistulas: A Single Centre Expertise. Viszeralmedizin. 2013;29(4):250-252. doi:10.1159/000354775 https://www.karger.com/Article/Fulltext/354775# 3. Wan Loong James Mok, Ming Hui Goh, et al. Gracilis pull-through flap for the repair of a recalcitrant rectovaginal fistula. Archives of Plastic Surgery. 2019, 46(3): 277-281. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536868/ 4. Byrnes, N., Jenifer, Schmitt, J., Jennifer, Faustich, M., Benjamin, et al. Outcomes of Rectovaginal Fistula Repair. Female Pelvic Medicine & Reconstructive Surgery. 2017;23(2):124-130. doi:10.1097/SPV.0000000000000373 https://journals.lww.com/fpmrs/Fulltext/2017/03000/Outcomes_of_Rectovaginal_Fistula_Repair.12.aspx 5. Debeche-Adams TH, Bohl JL, et al. Rectovaginal fistulas. Clin Colon Rectal Surg. 2010;23(2):99–103. doi:10.1055/s-0030-1254296 https://europepmc.org/article/pmc/2967329

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