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Transabdominal RVF Repair

An abdominal approach is useful when a rectovaginal fistula (RVF) cannot be repaired adequately through a local approach or when the rectum or prior colorectal anastomosis also requires reconstruction. Direct separation and interposition, restorative bowel resection, and proctectomy with permanent diversion are different operations with different goals. Before choosing a reconstructive route, define the tract and sphincter anatomy and function; examination under anesthesia and imaging are used when needed. Assess active infection and malignancy before definitive closure.[1]

ASCRS 2022 states that RVFs arising from colorectal anastomotic complications often require abdominal repair (Grade 1C); selected radiation-associated or recurrent complex fistulas may require completion proctectomy, with or without reconstruction of bowel continuity (Grade 2C).[1]

For local options, see ERAF ± Sphincteroplasty, Episioproctotomy and Nonoperative RVF Management.

Define the reconstructive goal​

Clinical problemPlanning considerations
High defect with usable rectum and vaginaSeparation, closure and vascularized interposition may preserve the bowel; confirm exposure, tissue viability and absence of disease requiring resection.[5]
Failed colorectal or coloanal anastomosisAssess pelvic sepsis, the extent of dehiscence, stenosis and viable proximal bowel. Diversion, redo anastomosis or a staged reconstruction may be appropriate.[1][3][4]
Radiation injury or repeated failureDetermine whether the remaining rectum and sphincter can provide useful function. In selected patients, gracilis or Martius interposition may permit closure without rectal excision; ASCRS recommends these flaps for recurrent or otherwise complex RVF . Resection may relieve symptoms but carries substantial healing and functional risks.[1][9][12]
Crohn's diseaseCoordinate medical treatment and source control; active proctitis can make local closure unsuitable. ECCO 2024 suggests medical treatment and counseling about surgical closure in selected patients with anogenital or rectogenital Crohn fistulas (EL5); it suggests diversion for refractory complex perianal disease (EL4) and proctectomy if that disease persists despite a defunctioning stoma (EL4).[8][15]
Cancer or an unreconstructable anorectumIntegrate oncologic requirements, life expectancy, symptoms and patient preferences; permanent diversion may be the appropriate endpoint.

There is no requirement to fail a fixed sequence of seton, advancement flap, muscle flap and coloanal reconstruction before discussing permanent diversion.

Operative options​

Separation, closure and omental interposition​

A laparoscopic or open approach can separate the rectum and vagina, close each viable defect and bring vascularized omentum between them. In van der Hagen's laparoscopic method, the tract was excised, the septum opened to the pelvic floor, the rectal defect closed in two layers and the vaginal defect in one, and the interposed omentum fixed to the pelvic floor.[5] When needed, perineal exposure can be combined with abdominal dissection. Preserve a suitable gastroepiploic blood supply and confirm that the flap reaches without tension or torsion; either side may be used according to anatomy.[5][6]

In van der Hagen's prospective series, 40 women underwent an intended laparoscopic omental repair, but omentoplasty was feasible in only 38; two had closure and diversion without it. Two of the 40 developed recurrent fistulas at a median 28-month follow-up. Radiation-associated and malignant fistulas were excluded. One omental necrosis required reoperation and another patient required abscess drainage.[5]

Smaller combined abdominal-perineal series support feasibility. Schloericke's nine-patient series reported no recurrent RVF at median 22 months, but one persistent sphincter fistula required another repair.[7] The de Bruijn report describes healing in its selected series with prior diversion; neither provides a reliable head-to-head comparison with another technique.[6][7]

Resection and immediate or delayed anastomosis​

Resection removes the diseased rectal segment or failed anastomosis, followed by a colorectal or coloanal reconstruction when adequate bowel, sphincter function and pelvic conditions permit. This must be distinguished from simple tract excision.

With delayed coloanal anastomosis (Turnbull-Cutait), viable colon is brought through the anal canal and anastomosis is completed in a subsequent stage. Timing, assessment of the exteriorized bowel and use of a covering stoma follow the colorectal team's operative protocol.[3][4] Published RVF series report both healing and substantial morbidity.[3][4]

A sleeve excision and pull-through variant removes diseased mucosa while retaining a distal muscular cuff, then brings healthy colon through for anastomosis.[1]

Proctectomy or abdominoperineal resection with permanent diversion​

When preserving the anorectum would leave severe disease, unmanageable leakage or unacceptable function, proctectomy or abdominoperineal resection may be considered. APR removes the rectum and anal canal and leaves a permanent stoma. The extent of resection and stoma type depend on the remaining bowel and underlying disease; total proctocolectomy is a different operation.[1][8]

APR is usually a last-resort operation for a multiply recurrent RVF, an unsalvageable irradiated rectum, refractory Crohn's disease with severe rectal involvement, a destroyed sphincter complex with incontinence, or concurrent rectal pathology. In Corte's mixed-procedure series, APR accounted for 9 of 286 procedures (3%).[1][2][8]

The operation has two phases. In the abdominal phase, the sigmoid and rectum are mobilized, with the inferior mesenteric artery ligated or preserved according to the indication. Dissection closer to the rectal wall than a cancer total mesorectal excision has been described for benign disease. The posterior vaginal wall is separated from the rectum and the tract is divided. In the perineal phase, the rectum, anal canal and sphincter complex are excised through a circumferential perineal incision, the vaginal defect is closed, and an end colostomy is matured in the left lower quadrant. A flap may be used for the perineal wound in an irradiated or repeatedly operated field.

Pelvic sepsis, perineal wound problems, urinary or sexual dysfunction and stoma complications remain risks. Plan vaginal closure and any reconstruction of pelvic or perineal tissue with the relevant teams. Oncologic operations require their own resection principles.

Outcomes: preserve the denominator and endpoint​

StudyPopulation and endpointResult and limits
Corte 201579 women, 286 procedures across local, interposition, resection and diversion strategies57/79 met the study's overall success endpoint at mean 33-month follow-up. Nineteen procedures involved colorectal/coloanal anastomosis and nine APR. Per-procedure multivariate associations with success were a major procedure (OR 6.4), a diverting stoma (OR 3.5), under 9 months from diagnosis to first surgery (OR 2.3) and first surgery at the study institution (OR 3.2). Etiology was Crohn's disease in 43%, postoperative in 32%, obstetric in 9% and radiation in 5%.[2]
GRECCAR, Collard 202578 delayed coloanal reconstructions; success required RVF healing and bowel continuity63/78 succeeded at median 31 months; morbidity 45%, major morbidity 23%, anastomotic leak 17%. Severe LARS or a stoma retained for poor function affected 24/57 assessed patients, not 42% of all 78.[3]
Blondeau 202228 postoperative RVFs treated with delayed coloanal anastomosis24/28 had neither stoma nor recurrent RVF symptoms at mean 23 months. Success with versus without diversion was 20/22 versus 4/6 (P = .191).[4]
Zhong 201710 selected radiation-RVF patients underwent restorative resection + coloanal anastomosis + protective colostomy, versus 16 with colostomy aloneBoth groups improved; selected resection patients had better relief of tenesmus and discharge. Three of ten had stoma reversal and three developed an asymptomatic anastomotic leak. The groups were not randomized; all 10 resection patients were ASA I/II, versus 11/16 colostomy patients (P = .015).[9]
Sapci 2023Of 80 Crohn's RVF referrals, 20 underwent selected closure surgery with adequate follow-up14/20 healed at median 33 months.[13]

Diversion and function​

Diversion can control contamination, protect a reconstruction or provide lasting symptom relief. In some early anastomotic failures, immediate reassessment and redo surgery may be preferable. Observational associations between diversion and healing are vulnerable to selection bias.[1][2][4]

In Zelga's 50-patient radiation-RVF cohort, 48 underwent diversion alone and two rectal resection; six fistulas healed. A distance from the anal verge above 7 cm correlated with healing before adjustment; distance from the anal verge was the only factor that remained significant on multivariate analysis.[12]

Discuss the possibility of a permanent stoma before embarking on restorative surgery. A Dutch cohort of 1,170 rectal-cancer patients found reduced quality of life with both a stoma and major LARS.[11]

Perineal reconstruction: distinguish wound endpoints​

Vascularized flap closure may be considered for a large or compromised perineal defect, but benefits depend on the flap and endpoint. BIOPEX-2 randomized 175 rectal-cancer patients undergoing APR; 165 entered modified intention-to-treat analyses. Gluteal turnover flap closure did not improve the primary 30-day uncomplicated-healing outcome (42/76 versus 49/82 after primary closure). Presacral abscess was less frequent with the flap (7/78 versus 19/86; P = .02).[10]

In an NSQIP analysis of 8,449 primary closures and 550 flap closures after APR for rectal adenocarcinoma, deep surgical site infection was associated with African American race (OR 1.5), ASA class 4 or higher (OR 3.2), BMI 35 or higher (OR 1.7), weight loss (OR 2) and flap closure (OR 1.9). Wound dehiscence was associated with ASA class 4 or higher (OR 2.2), smoking (OR 2.2), COPD (OR 1.7), BMI 35 or higher (OR 1.9) and flap closure (OR 2.9). The authors concluded that flap closure was not protective against wound complications in the presence of other risk factors; this is an observational association. Optimizing medical condition before surgery applies whichever closure is chosen.[14]

References​

1. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473

2. Corte H, Maggiori L, Treton X, et al. "Rectovaginal fistula: what is the optimal strategy? An analysis of 79 patients undergoing 286 procedures." Ann Surg. 2015;262(5):855–860. doi:10.1097/SLA.0000000000001461

3. Collard MK, Tuech JJ, Fernandez B, et al. "Delayed coloanal anastomosis for rectovaginal fistulas: insights from a multicenter cohort (GRECCAR)." Surgery. 2025;188:109767. doi:10.1016/j.surg.2025.109767

4. Blondeau M, Labiad C, Melka D, et al. "Postoperative rectovaginal fistula: can colonic pull-through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutive cases." Colorectal Dis. 2022;24(8):1000–1006. doi:10.1111/codi.16124

5. van der Hagen SJ, Soeters PB, Baeten CG, van Gemert WG. "Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients." Int J Colorectal Dis. 2011;26(11):1463–1467. doi:10.1007/s00384-011-1259-8

6. de Bruijn H, Maeda Y, Murphy J, Warusavitarne J, Vaizey CJ. "Combined laparoscopic and perineal approach to omental interposition repair of complex rectovaginal fistula." Dis Colon Rectum. 2018;61(1):140–143. doi:10.1097/DCR.0000000000000980

7. Schloericke E, Hoffmann M, Zimmermann M, et al. "Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas." Colorectal Dis. 2012;14(5):604–610. doi:10.1111/j.1463-1318.2011.02719.x

8. Lichtenstein GR, Loftus EV, Afzali A, et al. "ACG clinical guideline: management of Crohn's disease in adults." Am J Gastroenterol. 2025;120(6):1225–1264. doi:10.14309/ajg.0000000000003465

9. Zhong Q, Yuan Z, Ma T, et al. "Restorative resection of radiation rectovaginal fistula can better relieve anorectal symptoms than colostomy only." World J Surg Oncol. 2017;15(1):37. doi:10.1186/s12957-017-1100-0

10. Kreisel SI, Sharabiany S, Tuynman J, et al. "Perineal wound closure using gluteal turnover flap after abdominoperineal resection for rectal cancer: the BIOPEX-2 randomized clinical trial." JAMA Surg. 2025;160(4):378–385. doi:10.1001/jamasurg.2024.6818

11. van Kooten RT, Algie JPA, Tollenaar RAEM, et al. "The impact on health-related quality of a stoma or poor functional outcomes after rectal cancer surgery in Dutch patients: a prospective cohort study." Eur J Surg Oncol. 2023;49(9):106914. doi:10.1016/j.ejso.2023.04.013

12. Zelga P, Tchórzewski M, Zelga M, Sobotkowski J, Dziki A. "Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies — new patients, old problem?" Langenbecks Arch Surg. 2017;402(7):1079–1088. doi:10.1007/s00423-016-1539-4

13. Sapci I, Zutshi M, Akeel N, Hull T. "What are the outcomes in patients referred to a tertiary referral centre for Crohn's rectovaginal fistula surgery?" Colorectal Dis. 2023;25(8):1653–1657. doi:10.1111/codi.16660

14. Althumairi AA, Canner JK, Gearhart SL, et al. "Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database." Colorectal Dis. 2016;18(7):O260–O266. doi:10.1111/codi.13384

15. Adamina M, Minozzi S, Warusavitarne J, et al. "ECCO guidelines on therapeutics in Crohn's disease: surgical treatment." J Crohns Colitis. 2024;18(10):1556–1582. doi:10.1093/ecco-jcc/jjae089