Rectovaginal fistula: Anterior levatorplasty and external sphincter plication - general and visceral surgery

Start the procedure by inserting the rectal retractor and probing the rectovaginal fistula. In the video it connects the rectum with the lower third of the vaginal tube. Percutaneous injection of normal NaCl solution will facilitate the dissection. Follow this by opening up the perineum with a slightly curved incision with the needle-tip electrocautery. Transect the subcutaneous tissue and then install the Lone Star Retractor System™.

Dissecting the rectovaginal space and exposing the external sphincter and puborectalis by carrying the dissection beyond the fistula tract, this allows reliable identification of the levator ani lateral to the vagina and anorectum. The goal is to have the levator limbs act as a barrier between the posterior wall of the vagina and the anterior wall of the rectum, as described in the following steps.

Before repairing the sphincter, locate the muscle stumps. Dissection is facilitated by injecting saline below the anoderm. After transecting the sphincter scar at 12 o'clock in lithotomy position, clear both sphincter stumps at the anterior circumference.

First, excise the rectal opening of the fistula and then close the defects in both the rectum and vaginal wall with absorbable sutures (e.g. Maxon®, size 2-0 for rectum and 3-0 or 4-0 for vagina).

Use non-absorbable monofilament sutures (e.g. Prolene® 2-0) for the levatorplasty. When preplacing the interrupted sutures, their bite should include as much of the levator limbs of the puborectalis as possible, before tying them such that there is good contact between the limbs

Tips:

Interposition of the levator limbs is only suited for fistulas located in the lower part of the middle third of the vagina. Higher located fistulas should be treated by gracilis muscle interposition.

In order to promote resilient scarring of the muscle, solely use non-absorbable sutures in the levatorplasty. With absorbable sutures the muscles will at most adhere to each other but not bond by scarring, resulting in secondary deviation of the levator limbs.

In order not to compromise muscular perfusion and to stop the sutures from cutting into the muscles, only 3 to 5 sutures should be placed and tied in moderation.

Sphincteroplasty is performed by plication of the external anal sphincter (EAS). To this end, first plicate both stumps of the EAS with two vertical mattress sutures and then anchor the free margin of the exposed inner stump to the EAS stump below with two simple interrupted sutures (Prolene® 2-0 each).

In order to repair the perineum, i.e. to restore the original distance between the anus and vaginal orifice lost due to the tear in the perineum during delivery, loosely adapt the horizontal wound lengthwise with interrupted sutures (Vicryl® 2-0). The sutures should be spaced such that secretions and hematoma fluid can drain and not be retained.

Tips:

A completely leak-proof closure of the wound should be avoided at all costs, as it promotes infection. Since secondary healing is recommended, space the interrupted sutures generously, as demonstrated in the video.

Another option is to drain the perineal wound by leaving it open in its center.