Rectovaginal Fistula

A nine month old female with a history of anal rectal malformation was found to have a rare malformation with normal urethra, normal vagina, and a rectal fistula high in the vagina. She underwent initial colostomy. On examination, she has a normal appearing urethra and vagina. We found in a similar case a septum of the vagina which needs to be removed at the time of rectal repair. Following total body prep, laparoscopy was performed using 5 millimeter ports in the umbilicus, bilateral upper and right lower quadrants. We dissected the distal rectum all the way to its insertion below the peritoneal reflection in the back of the vagina. The distal rectum's blood supply was dependent on the inferior mesenteric artery and this was preserved. This dissection was similar to the one done for males with rectal bladder neck or high rectal prosthetic fistulas. Using electrocautery, the fistula is divided, and a preloaded PDS endo loop is placed over a 3 millimeter Maryland clamp on the divided fistula and the distal rectum. Here we demonstrate intraoperatively placed foley located in the urethra, as well as the vaginal lumen shown by the pickups. The muscle complex is stimulated and marked. With the legs lifted, a perineal incision is performed at the site of the planned anoplasty. Laparoscopic insufflation is reestablished following the delineation of the sagittal plane between the muscles in the midline. A clamp is placed into the abdomen under laparoscopic control to grasp the distal rectum and pull it through without twisting it. The muscle complex and posterior sagittal fibers are seen here, and vicral sutures are placed from the posterior edge of the muscle complex incorporating the posterior wall of the rectum. This allows the rectum to lay within the muscle complex which lies along either side of the rectum. This maneuver helps to avoid rectal prolapse. The anoplasty is performed with multiple interrupted stitches of the rectum to the perianal skin at the center of the sphincter. The anus is stimulated again, demonstrating central location of rectum within the sphincter mechanism.