MUSCULAR FLAP IN THE TREATMENT OF RECURRENT RECTOVAGINAL FISTULA – CASE REPORT

Case Presentation A 20-year-old female patient presented with a foreign body in the vagina, evolving into sepsis secondary to a complicated rectovaginal fistula. An ileostomy was performed. A pelvic MRI revealed extensive discontinuity of the posterior vaginal wall, with signs of communication with the anterior rectal wall and small, partially defined collections. The patient underwent a new surgical treatment involving perineal reconstruction using a gracilis muscle flap.

Discussion Rectovaginal fistulas are abnormal communications between the rectum and the vagina. Predisposing factors include trauma, inflammatory bowel disease, infection, tumors, and a history of pelvic radiation. Symptoms are characterized by the uncontrollable passage of feces and gases through the vagina. For asymptomatic patients, a period of vigilant waiting may resolve the issue. When choosing a surgical approach, factors such as risk factors, previous repairs, and sphincter integrity should be considered. Interposition techniques are well-indicated in cases of refractory fistulas or when adjacent tissue is damaged. Among these techniques, the use of the gracilis muscle has been shown to be versatile due to its easy dissection, well-defined tendinous and muscular portions, long muscle length with great contractile potential, and minimal morbidity at the donor site.

Conclusion The presence of inflammation, infection, and scar tissue makes primary repair inadequate and is associated with failure in subsequent surgical procedures. Local treatments with advancement flaps or biomaterials are associated with relatively high recurrence rates, likely due to the inadequate volume of well-vascularized tissue. Reconstruction using autologous tissue interposition, such as the gracilis flap, seems more promising as it introduces healthy, vascularized tissue and creates better conditions for local healing and defect correction. Managing rectovaginal fistulas remains a challenge. Regardless of the surgical option chosen, the failure and recurrence rates remain high.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025