Complications - Rectovaginal fistula: Anterior levatorplasty and external sphincter plication

With proper technique, careful dissection and subtle hemostasis (electrocautery, suture ligation), intraoperative complications are very rare.

Secondary bleeding
Significant postoperative bleeding after fistula repair is quite rare and is more common, e.g., after hemorrhoidectomy. Immediate postoperative discharge of fresh blood or prolonged blood-stained oozing are indications of a bleeder overlooked during surgery. Depending on the intensity of the bleeding, this may require revision surgery, and in case of cardiovascular reactions as an emergency. Secondary bleeding due to coagulation disorders should be the exception.

Wound infections
The most significant postoperative complication is an infection with possible secondary suture line dehiscence, usually accompanied by fistula persistence.

Prevention:
Adequate drainage of the deeper parts of the wound, by only closing the wound with a few loosely adapting interrupted sutures, will mostly prevent the development of superinfected secondary hematomas and allow regular probing of the wound (see figure).

Postoperative urinary retention
Postoperative urinary retention after proctological procedures is usually due to inadequate analgesia and excessive intravenous fluids.

Prevention:
Adequate analgesia and Foley catheter for the first few days after surgery.

Dyspareunia
Up to 25% of sexually active patients report painful sexual intercourse due to suture-related constriction of the vagina or scarring.

Prevention:

Careful intraoperative examination of adequate vaginal lumen.

Continence disorder
Impaired fecal continence due to fistula repair cannot always be avoided and is reported in the literature with rates of up to 30%. The most important risk factors are:

• Extent of the surgical procedure
• Number of previous operations or previous injuries (e.g. due to deliveries)
• Extent of sphincteric substance loss

In fistula recurrences, therefore, definitive healing and potential continence disorder must be carefully considered and should be at the center of extensive patient information. On the other hand, concurrent sphincter repair may improve any present continence disorder.