ENDORECTAL ADVANCEMENT FLAP FOR CORRECTION OF VAGINAL-POUCH FISTULA: VIDEO-ASSISTED TECHNIQUE

Case Presentation A 60-year-old obese woman with chronic ulcerative colitis refractory to medical treatment developed a rectovaginal fistula during the first week after total proctocolectomy with ileal pouch and elective loop ileostomy. Despite the intestinal diversion, the patient experienced daily mucus discharge from the vagina and recurrent urinary infections until reoperation. A pouchoscopy revealed an ileorectal anastomosis 3 cm from the anal verge with a 1 cm fistulous opening at the staple line in the anterior wall. The chosen surgical correction was an advancement endorectal flap. The patient was placed in a prone position. Despite the use of an endoanal retractor, the dissection of the fistula was difficult due to a narrow anal canal and a high fistula. The introduction of a 30° scope through the anal canal assisted in all stages of the surgery, allowing the surgeon to better visualize the operative field. The steps were: 1. removal of the metal staples from the anastomosis surrounding the fistula; 2. dissection and resection of the fistula; 3. dissection of the rectovaginal septum; 4. vaginal suturing in two layers with separate Vycril 3.0 stitches; 5. dissection of the flap from the ileal pouch segment and advancement into the distal rectum with separate stitches of the same suture. The patient was discharged on the third postoperative day and is currently under follow-up with no complications.

Discussion Rectovaginal fistulas are abnormal communications between the rectum and vagina, which can occur after perineal trauma, pelvic radiation, local infection, inflammatory bowel disease, tumors, or surgeries, especially obstetric procedures. Various surgical techniques exist for treating rectovaginal fistulas, but they are associated with high recurrence rates. Intestinal diversion provides better control of local infection, and the interposition of well-vascularized tissues in surgical reconstruction (such as the Martius or gracilis flap) enhances healing. In this case, the clinical presentation shortly after the surgery suggests that the fistula occurred due to technical failure of the ileorectal anastomosis, where the posterior vaginal wall was inadvertently included in the stapling.

Conclusion This video demonstrates the surgical steps for the endoanal correction of a complex rectovaginal fistula assisted by video, providing the surgeon with better visualization of the operative field. This technique is particularly valuable in cases with a narrow anal canal and high rectovaginal fistulas.

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

Publication History

Article published online:
25 April 2025