Rectovaginal fistula: Anterior levatorplasty and external sphincter plication

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).