Refining Approaches to Surgical Repair of Rectovaginal Fistulas

Abstract

Introduction Rectovaginal fistulas are notorious for both their morbidity and their difficulty to treat effectively. A variety of methods for repair has been described; however, there is no consensus on the ideal repair. A better understanding of the anatomical relationship of fistulas to the anal sphincter and detrusor muscles is one of the components necessary to develop an effective treatment plan for repair and preservation of sphincter mechanics. Methods A review of the literature was conducted to determine the types of methods typically used by reconstructive surgeons for repair of rectovaginal fistulas. A critical clinical analysis of our series of 10 patients was performed to determine optimal strategies for and pitfalls of repair in the context of recent reports in hopes of refining surgical techniques. Results Detailed anatomical understanding of the relationship of fistulas to the surrounding sphincter muscles is described. Etiology of the fistula and its anatomical relationship to the surrounding sphincter complex is used to help develop an algorithm for repair. Suprasphincteric fistulas will necessitate a laparotomy for repair, intersphincteric fistulas will often require muscle interposition with recreation of the vaginal and rectal walls, and low/transphincteric fistulas will require local flaps mostly for coverage and repair of the sphincter muscles. Conclusions Complex rectovaginal fistulas are both debilitating for the patient and extremely difficult to manage. Plastic surgeons are often involved in such cases only after previous attempts at repair have failed. The success of surgery in treating these patients with rectovaginal fistulas depends on a variety of factors. Unfortunately, the available literature describing these repairs lacks uniform guidance regarding approach to repair. Herein, we attempt to detail the possible anatomical variations of fistulas in relationship to the sphincter muscles to begin the discussion necessary for the development of an algorithm for repair that considers preservation of sphincter mechanism function.

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

“…Rectovaginal fistulae are difficult to repair, have a high recurrence rate [26] and can lead to the need for a stoma to defunction the bowel during healing [8]. A diverting stoma is rarely indicated in acute OASI unless the tear is large and extends above the pelvic floor, or there is faecal contamination [4,19].…”

“…A diverting stoma is rarely indicated in acute OASI unless the tear is large and extends above the pelvic floor, or there is faecal contamination [4,19]. Although there is a paucity of evidence in the literature about primary repair of obstetric isolated rectal buttonhole tears, there are many publications on repair of rectovaginal fistulae [5,8,20,26]. There are several alternative techniques describing repair of rectovaginal fistulae although there is no consensus on the ideal repair [8].…”

“…Although there is a paucity of evidence in the literature about primary repair of obstetric isolated rectal buttonhole tears, there are many publications on repair of rectovaginal fistulae [5,8,20,26]. There are several alternative techniques describing repair of rectovaginal fistulae although there is no consensus on the ideal repair [8]. Rectovaginal fistula can be caused by obstetric injury, congenital malformation, trauma (some from sexual violence), perianal sepsis, Crohn's disease, during another surgical procedure or treatment with radiation for malignancy [5].…”

“…Rectovaginal fistula can be caused by obstetric injury, congenital malformation, trauma (some from sexual violence), perianal sepsis, Crohn's disease, during another surgical procedure or treatment with radiation for malignancy [5]. Surgical options for repair include muscle transposition, plugs, fistula excision or even laparotomy [5,8,27]. Reisenauer describes closure of obstetric rectovaginal fistulae using the transvaginal route with excision of the epithelialised fistula, haemostasis and tension-free closure of the fistula in several layers [28].…”

“…This type of injury is rare in humans but is commonly described in veterinary (mostly equine) case reports [6,7]. Successful repair of these injuries is known to be particularly difficult because the anovaginal septum is a thin, poorly vascularised structure with faecal matter constantly passing it [8]. Furthermore, during defaecation and straining the pressure in the rectum is much higher and therefore can potentially predispose to disruption of the repair, highlighting the importance of a good repair technique.…”