A Case of Low Rectovaginal Fistula of Obstetric Origin: Treatment by Fistulotomy and Reconstitution or Advancement Flap?

Abstract

Many small low rectovaginal fistulas represent incompletely healed (third degree) perineal lacerations i. e., involving the sphincters. An individualized, systematic approach to these fistulas based on their size, location, and etiology provides a more concise treatment plan. We report a case of a low rectovaginal fistula developed some years following forceps vaginal delivery. This was managed successfully by a fistulotomy in which the bridge of skin and scar tissue was divided, and the defect repaired as a classical third degree perineal laceration. On the background of coexisting or occult sphincter damage which usually follows obstetric trauma, a fistulotomy and immediate composite repair for small, low rectovaginal fistula may be advantageous and acceptable in a low resource setting where endoanal imaging and manometry are not available.

Isolated rectal buttonhole tears in obstetrics: case series and review of the literature

“…In two cases, it was extended to cut through the sphincter to create what appeared to be a fourth-degree tear. This method is sometimes used to repair rectovaginal fistulas [23]; however, it is not recommended for acute obstetric tears because of the risk of anal dysfunction, even with an adequate repair [19]. The only reason for extending a buttonhole tear to a fourth-degree tear is if the distal end of the tear cannot be visualised and therefore it will not be possible to perform an adequate repair of the anorectal mucosa.…”

Obstetric rectal buttonhole tears: A case series and literature review

“…Four cases [5][6][7]11 reported using the continuous method to repair the rectal mucosa, with one using Vicryl 2-0 and another using Vicryl 1-0 sutures; the last case 9 used a 0-Vicryl but did not specify whether continuous or interrupted repair was used. Repair of the vaginal epithelium was performed using continuous Vicryl 2-0 sutures in six cases, 4,5,7,8,10,12 while the remaining eight cases 4,6,9,11 did not detail what suture was used or how the vaginal epithelium was closed.…”

“…A potential standardized repair technique has been suggested, 2 though is supported by sparse evidence. Given the similarities with rectovaginal fistulae, 4 most buttonhole repairs are performed along similar principles, with primary closure of the defect with particular importance paid to an intermediate layer between the vagina and rectum 3 …”