Gracilis transposition for repair of recurrent rectovaginal fistula
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KeywordsEndoscopic Submucosa Dissection Fistula Tract Rectovaginal Fistula Contrast Enema Soft Tissue Defect
M.-gracilis-Transposition zur Fisteldeckung bei Rezidiv einer Rektovaginalfistel
Gracilis muscle transposition is an option for simultaneous fistula closure and repair of soft tissue defect in rectovaginal fistulas.
Recurrent rectovaginal fistulas and local defects surrounded with scar tissue have a high failure rate after conventional fistula operations. The graciloplasty has the potential of covering the fistula and refill soft tissue defects. Due to the optimal perfusion of the muscle fistula, healing may be supported.
A 69-year-old woman with a multirecurrent rectovaginal fistula underwent surgery. The fistula had existed since an endoscopic submucosa dissection (ESD) for a high-grade rectal adenoma had been performed. An attempt to close the fistula with a flap procedure was undertaken three times. A temporary stoma had already been formed. Thus, excision of the fistula, closure of the fistula tract, and covering the fistula with gracilis muscle was performed.
Gracilis muscle transposition was performed by adopting a tunneling technique as described by Cor Baeten for incontinence therapy (see supplementary video: gracilis muscle transposition of rectovaginal fistula). This technique avoids the painful incision of the perineum and prevents wound infections. Another advantage is the optimal positioning of the gracilis muscle at the level of the closed fistula.
Patients are advised to reduce physical activity for 2 weeks postoperatively. Clinical tests including rectoscopy and contrast enema were scheduled after 6 weeks. When the fistula was closed, stoma resection was planned.
Side effects and fistula persistence
Due to the minimally invasive technique, wound infections are rare. In case of fistula persistence, conventional techniques (e.g., flap procedures) can be used to close the remaining fistula tract.
Transposition of the gracilis muscle seems to be an effective procedure especially for recurrent rectovaginal fistula when conventional surgery fails.
Compliance with ethical guidelines
Conflict of interest
A. Fürst declares that he has no competing interests.
This article does not contain any studies with human participants or animals performed by any of the authors.
Additional video: Gracilis muscle transposition to repair a rectovaginal fistula