Operative Principles

Surgical options are categorized by approach: perineal or abdominal. The perineal approaches are divided into transanal, transperineal, and transvaginal. The route chosen depends on the severity of symptoms, patient medical status, location of the fistula, underlying etiology, the surgeon's expertise, the presence of a sphincter defect, and the number of failed prior attempts. Patients with minimal symptoms may elect not to undergo any intervention. Elderly patients or those with multiple comorbid conditions should undergo minimally invasive procedures such as placement of setons to control sepsis or fibrin glue instillation before embarking on complex interventions. Although success rates with fibrin glue in the treatment of rectovaginal fistulas have not been reported, it is used by our faculty as a minimally invasive approach in those who are unfit or do not desire to undergo surgical treatment. Location is particularly important for high and complex fistulas that may require an intraabdominal approach to facilitate repair.

Underlying etiology has an important role in determining approach to surgical treatment. Rectovaginal fistulas resulting from infection are amenable to successful repair after the appropriate treatment and resolution of the underling infection. Operative repair of rectovaginal fistula in the setting of medically controlled Crohn's proctitis may be possible; however, at a higher risk of recurrence. Re-ctovaginal fistulas in patients with medically refractory Crohn's proctitis may be controlled with seton placement and possibly infliximab. However, definitive repair usually requires fecal diversion or proctectomy. Repair of recto-vaginal fistulas secondary to radiation proctitis demands the introduction of new and well-vascularized tissue into the area of radiation. These techniques involve mobilization of flaps from either the abdomen or leg often in conjunction with fecal diversion.

The surgeon's expertise has a role in surgical decision-making. Gynecologists approach repairs through the vagina or perineum whereas colorectal surgeons approach through the rectum. If an associated sphincter defect is present, a concomitant sphincteroplasty is performed. A history of prior failed attempts often requires fecal diversion and muscle flap transpositions that can be performed in a single or staged procedure.

Table 13-2.3. Types of rectovaginal fistula repairs

Repairs for Simple Fistulas

Repairs for Complex Fistulas







Tissue interposition

Low anterior


(i.e., gracilis flaps)


Layered closure

Cutting seton

Onlay patch


Conversion to

Proctectomy with



laceration with


layered closure




Fecal diversion

The most important factor in obtaining good outcome is ensuring the health of the involved tissue by minimizing inflammation and infection and optimizing the underlying disease process. A waiting period is advocated, because some fistulas will heal spontaneously with treatment of localized sepsis. In those fistulas secondary to obstetric trauma, the patient need not wait until child-bearing is completed, but a period of 3 to 6 months may be prudent. In those that do not heal spontaneously, this time period allows resolution of inflammation and normalization of surrounding tissues to facilitate a successful, local repair. Repair of recurrent fistulas is facilitated by delaying repair.3 In contrast, large or high fistulas, or those secondary to irradiation, IBD, or cancer, have a low likelihood of spontaneous healing.5 However, a period of waiting may be necessary to optimize medical management in the case of IBD or to allow resolution of inflammation in the case of radiation proctitis after fecal diversion has been performed. As with management of all fistulas, optimizing nutrition is paramount before embarking on surgical intervention.

Despite choice of surgical repair, several intraoperative principles are important to a successful outcome. Appropriate mobilization of flaps or rectum to facilitate a tension-free repair, gentle dissection to minimize tissue trauma, apposition of healthy tissue edges with resection of diseased bowel if appropriate, and transposition of healthy well-vascularized tissue if localized tissues are insufficient, are the guiding principles during the operative procedure that should be used to maximize the likelihood of success. A description of various procedures and their indications is outlined in Table 13-2.3.

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