Martius flap repair for complex rectovaginal fistula.

Complex rectovaginal fistulas are uncommon but can be very difficult to manage. There are various techniques for repair, including endorectal advancement flaps, transperineal and transvaginal approaches, and fistula plugs, with varying success rates from 50-60% for the primary procedure to >70% after multiple procedures (1, 2, 3). For women with inflammatory bowel disease, history of radiation, or for those who failed multiple other repairs, surgical options may involve the use of autologous muscle grafts or proctectomy with colonic pull-through (4, 5, 6). The Martius graft is well-described for repair of cystoor urethrovaginal fistulas (7). Adaptation of the Martius flap for complex rectovaginal fistulas have been reported in the colorectal surgery literature. Success rates range from 60% to 100% (8-13). The principles of repair involve transplanting a pedicle muscular graft harvested from the labia majora and transposition of the graft through a subcutaneous tunnel. The graft overlies the rectal closure and separates the rectal and vaginal walls, filling in the dead space and enhancing granulation tissue. A consecutive series of patients with complex rectovaginal fistulas were retrospectively reviewed from a prospective database between 2008 and 2012 at a single institution. Patient demographics, prior attempts at repair, and preand postoperative functional status were documented. Colonoscopy was done in patients with inflammatory bowel disease or in whom diagnostic or screening colonoscopy was indicated. Patients with uncontrolled perineal sepsis or severe fecal soiling due to the fistula underwent fecal diversion. Repair of the fistula was not attempted until perineal sepsis and inflammation had resolved.