Rectovaginal Fistula

A nine month old female with anal rectal malformation was found to have a rare malformation with normal urethra, normal vagina, and a rectal fistula high in the vagina.

In a similar case a septum of the vagina was found which needs to be removed at the time of rectal repair.

Laparoscopy was performed using 5 millimeter ports in the umbilicus, bilateral upper and right lower quadrants.

The distal rectum was dissected 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.

The fistula is divided using electrocautery, and a preloaded PDS endo loop is placed over a 3 millimeter Maryland clamp on the divided fistula and the distal rectum.

The muscle complex is stimulated and marked.

A perineal incision is performed at the site of the planned anoplasty.

The sagittal plane is delineated 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.

Vicral sutures are placed from the posterior edge of the muscle complex incorporating the posterior wall of the rectum, allowing the rectum to lay within the muscle complex which lies along either side of the rectum.

Suturing the posterior rectal wall to the posterior muscle complex 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.