CORRECTION OF RECURRENT RECTOVAGINAL FISTULA WITH MARTIUS FLAP – CASE REPORT

Case Presentation A 53-year-old female patient, with a history of hypertension, underwent drainage of a perianal abscess in 2020. Subsequently, she developed an anterior anorectal fistula, which was corrected using the mucosal advancement technique in 2021. Afterward, the patient presented with fecaluria, and a rectovaginal fistula was diagnosed, likely of cryptoglandular etiology after the diagnostic workup. She underwent two unsuccessful surgical attempts via transverse perineal approach in 2021 and 2022. In June 2022, another surgery was performed using a transverse incision in the perineum, which involved the resection of the fistulous tract and fibrotic edges at the anal fistula orifice, followed by suturing in two layers with absorbable sutures. Additionally, an incision was made on the right lateral portion of the labia majora, and a Martius flap was rotated into the rectovaginal space. The posterior vaginal wall was reconstructed with simple sutures and absorbable sutures, followed by a multi-layer closure and insertion of a Portovac drain. The patient returned for follow-up visits without complaints or signs of fistula recurrence.

Discussion Rectovaginal fistulas (RVF) are abnormal connections between the lower gastrointestinal tract and the vagina. They may result from obstetric trauma, pelvic radiation, Crohn's disease, malignancy, or an anorectal abscess. High RVFs are above the pectinate line, while “low” RVFs are those involving the vagina and anus. Symptoms include uncontrollable passage of feces and gases through the vagina. For asymptomatic RVFs, a watchful waiting approach may be sufficient. Several factors should be considered when choosing a surgical approach, such as the number and type of previous repairs, the patient's risk factors, concomitant fistulas, and sphincter integrity. If the RVF is refractory or if the adjacent tissue is significantly damaged, interposition techniques are often recommended. The Martius flap is particularly useful for patients with a thin rectovaginal septum and a history of radiation injury, with a healing rate of 79%. The use of a diversion when employing flap techniques remains controversial.

Conclusion In this reported case, the patient with a cryptoglandular RVF and recurrent episodes achieved resolution with the Martius flap technique. This case demonstrates the complexity of the technique and its significant success rate.

Publication History

Article published online:
25 April 2025