Timothy F Tirrell, MD, PhD
timothy.tirrell@childrens.harvard.edu
Timothy F Tirrell, MD, PhD; Prathima Nandivada, MD; Alex G Cuenca, MD, PhD; Farokh R Demehri, MD; Erin R McNamara, MD, MPH; Jill M Zalieckas, MD, MPH; Belinda H Dickie, MD, PhD; Boston Children's Hospital
Congenital rectovaginal fistula is a rare type of anorectal malformation. Laparoscopy has been used in rectal mobilization for other anorectal malformations but its use in repair of rectovaginal fistulas is not broadly reported.
We have utilized laparoscopy in repair of several rectovaginal fistulas and present a case highlighting its advantages. Rectal mobilization and division of the common rectovaginal wall were performed laparoscopically. The motility gained by laparoscopic dissection of abdominal structures enabled a more limited perineal incision than usual, and sparing of the perineal body.
Intended audience: Healthcare professionals and clinicians.
Congenital rectovaginal fistula is a rare type of anorectal malformation. The location of the fistula determines operative approach. While high fistulas may need abdominal mobilization and posterior sagittal incisions, low fistulas may be repaired from a posterior sagittal approach only, but the incision must be large enough to accommodate rectal mobilization and separation from the posterior vaginal wall. This generally requires division and reconstruction of the perineal body. Laparoscopy has been used in the rectal mobilization of anal rectal malformations, but its use in repair of rectal vaginal fistulas is not broadly reported. We have utilized laparoscopy in the repair of two congenital rectovaginal fistulas and present in detail here one of our cases. This patient was born at term and found to have multiple congenital anomalies including imperforate anus, lipomyelomeningocele, solitary left kidney, and a perineal examination significant for two orifices with stool noted at the posterior orifice. The differential diagnosis of the anorectal malformation based on this examination included recto vestibular fistula with absent vagina, recto vaginal fistula, and neurogenital sinus with recto vestibular fistula. Preoperative contrast imaging demonstrated a long and narrow fistula connecting the rectum to the mid vagina. Cystoscopy and vaginoscopy were performed demonstrating a recto vaginal fistula near the distal vagina, approximately 1 centimeter from the introitis. Because of the length of the fistula, the decision was made to utilize laparoscopy to identify the rectum intraabdominally and assist with rectal mobilization. The patient is prepped anteriorly and posteriorly from nipples to feet, which allows access to both the abdomen and the perineum. Pneumoperitoneum is established after umbilical access, and additional instruments are placed in the right upper quadrant, right lower quadrant, and left mid abdomen. Rectal dissection is initiated with electrocautery, and care is used to stay close to the rectal wall while also preserving intramural blood supply. Although cautery dissection enables speed and hemostasis, a good portion of this dissection is performed sharply to minimize thermal injury. Properly identifying the recto vaginal plane is a critical component of this operation and requires patience and care. Anecdotally, we find that approaching the common recto vaginal wall from above facilitates finding the proper plane of dissection. Tension on the rectum helps open the angle between the fistula and the vagina, which assists sharp dissection of the common wall. Dissection is carried out fully along the lateral aspects of the fistula before taking down the common wall. Once dissection is carried down to the origin of the recto vaginal fistula, the patient is turned prone for the perineal portion of the procedure. A limited incision is made, sparing the perineal body. The rectum is identified and lateral and inferior attachments are taken down proceeding towards the vagina. Entering the lumen of the rectum allows identification of the fistula. Traction sutures are placed to assist with the final mobilization of the rectum off of the vaginal wall. After rectal separation, the vaginal defect is repaired with interrupted vicral sutures and buttressed with a layer of fat. Due to the motility obtained by the laparoscopic dissection, the rectum is quite mobile, and the incision does not need to be extended to finish the rectal dissection. The rectum is pulled into position within the sphincter complex and the anoplasty is completed in the usual fashion. The patient did well postoperatively and was started on clear liquids on postoperative day 3. She returned to her previous feeding regimen and was discharged home on postoperative day 6. She was last seen in clinic at approximately 1 month postoperatively and has been doing well. She is dilating twice per day and stooling spontaneously between dilations. In summary, we believe that laparoscopy can be a useful tool for mobilizing the rectum in recto vaginal fistula repair. It enables a more limited perineal incision and negates the need to disrupt the perineal body.
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