Open Journal of Gastroenterology, 2013, 3, 35-37 OJGas Published Online February 2013 (
Laparoscopic stapler repair of high rectovaginal fistula:
A case report
Amit Kumar Parmar, Mittu John Mathew, Prasanna Kumar Reddy*
Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospital, Chennai, India
Email: *
Received 3 October 2012; revised 3 November 2012; accepted 11 November 2012
For thousands of years, women simply tolerated the
distressing symptoms generated by rectovaginal fis-
tulas (RVFs). This is no longer necessary because
most RVFs can be surgically corrected via a number
of approaches. Most rectovaginal fistulas are acquired;
obstetric injury alone accounts for nearly 88% of the
cases. The high fistulas are repaired by abdominal
approach, while middle or low fistulas are best ap-
proached perineally. There are only few case reports
of laparoscopic RVF repair noted in literature till
date. Laparoscopic repair of RVF is challenging and
requires advanced laparoscopic skill. Laparoscopy is
a better alternative in selected cases of RVF and
yields faster recovery and good patient compliance.
We present a case of high RVF managed laparo-
scopically by using stapler.
Keywords: Laparoscopy; Rectovaginal Fistula; Stapler
Obstetric trauma is the most common cause of rectovagi-
nal fistula. Most of the RVFs are managed by conven-
tional open surgery. Abdominal surgeries such as hys-
terectomies, low anterior resections and ileo-anal anas-
tomosis also carry the risk of developing an RVF. RVF
can also develop secondary to radiation, pelvic malig-
nancy, and diverticular disease. Low RVF can be re-
paired through perineal approach but high RVF requires
transabdominal approach. Laparoscopic approach is fea-
sible in high RVF.
A 36-year-old female patient underwent total abdomi-
nal hysterectomy with bilateral salpingoophorectomy for
endometriosis 6 months back elsewhere. On postopera-
tive day 3, she had severe abdominal pain and distension
for which she was re-explored and found to have a rectal
perforation. Primary closure of perforation and diverting
ileostomy was performed. Post operatively she devel-
oped high RVF which did not healed even after 3 months
of conservative management. She was referred to our
hospital for further management. After doing all routine
investigations and methylene blue leak test, she was
posted for laparoscopic repair of RVF.
Under general anaesthesia in modified lithotomy position,
pneumoperitoneun was created by veress needle through
Palmer’s point. 10 mm supraumblical telescopic port was
placed. 5 mm and 12 mm ports inserted in left and right
iliac fossae respectively. Adhesiolysis was done with
sharp dissection. The rectum was mobilised. A short,
wide fistulous tract was identified Figure 1 and dissected
all around and divided with articulating stapler (Echelon
flex 60, ETHICONTM). Air leak test was performed w h i ch
showed no leak. The omentum was placed between rec-
tum and vagina. Ileostomy was closed. The patient was
discharged on 3rd post operative day. She is symptom
free on 6 mon t hs fo l low up.
Figure 1. Intraoperative view of division of rectovaginal fistula
with articulating stapler.
*Corresponding a uthor.
A. K. Parmar et al. / Open Journal of Gastroenterology 3 (2013) 35-37
Rectovaginal fistula is epithelial lined communication
between rectum and vagina. Most common cause of RVF
is obstetric trauma. It can occur as a complication after
variety of rectal, vaginal and pelvic operations including
hysterectomy, low anterior resection, ileal-pouch anal
anastomosis and stapled hemorroidectomy [1]. RVF can
be associated with pelvic malignancy or radiation ther-
apy for malignancy, and inflammatory bowel disease.
RVFs can be classified into low and high varieties. Low
RVF is between the lower third of the rectum and the
lower half of the vagina. A high RVF is between the
middle third of the rectum and the posterior vaginal
fornix. Small-sized fistulas are less than 0.5 cm in di-
ameter, medium-sized fistulas are 0.5 - 2.5 cm, and
large-sized fistulas exceed 2.5 cm [2]. Clinical features
of the rectovaginal fistula are stool and air passage from
the vagina. Other symptoms include recurrent urinary
tract infection and perineal skin inflammation or infec-
tion. Symptoms of chronic inflammat ion and irritation in
these patients have an effect on their social life and psy-
chology and lead to sexual dysfunction. Most fistulas at
the lower rectum are palpable by digital rectal examina-
tion. Contrast radiography is the most dependable meth od
for diagnosing small and high rectovaginal fistulas. High
fistulas may not be readily apparent on physical exami-
nation or vaginal inspection and may even be missed by
endoscopy. Methylene blue enema with a vaginal tam-
pon in place, looking for staining on the tampoon is used
to confirm the diagnosis. Vaginography with a water
soluble contrast medium has a reported sensitivity of
79% to 100% [3-5]. CT and MRI also play a role in the
diagnosis and evaluation of the RVF as they may give
insight into the un derlying cause of the fistula.
Spontaneous healing may occur with adequate medical
treatment such as total parenteral nutrition, antibiotics,
and long-time fasting. However, surgical therapy re-
mains the mainstay for managing complex fistula was
not suitable for conservative management or underwent
prolonged conservative management (without resolution).
Operative access to this type of lesion includes fecal di-
version, and/or transperineal approach of resection, or
rectal anastomosis or repair. Operation of the middle and
lower rectum is associated with complications, including
urinary and sexual dysfunction. The management of RVF
depends on size, location, cause, anal sphincter function
and overall health status of the patient. Low fistulas can
be repaired through perineal approach. Transabdominal
approach is standard for high fistula. Total laparoscopic
repair of RVF is still rare. Nezhat CH et al. [6] reports
correction of two cases of RVF by laparoscopy. Pelosi et
al. [1] reported laparoscopic upper rectovaginal mobili-
sation with transvaginal repair of recurrent RVF. Pala-
nivelu et al. [2] reported 2 cases of high RVF managed
laparoscopically. Schwenk et al. [7] reported a case of
intracorporeal colorectal anastomosis for which they had
performed a laparoscopic resection of the sigmoid colon
with the fistulous tract and. They all concluded that
laparoscopic repair of RVF is feasible but it demands
adequate experience in advanced laparoscopic proce-
dures and proper identification of tissue planes. Good
preparation of the bowel is essential to avoid any faecal
contamination of the operative area. Fistulous tract is
generally divided and closed by using suture. But, in our
case we used linear stapler for this purpose. The idea
behind using it was to make procedure simpler and faster
and avoidance of faecal contamination as well. And thus,
we were able to close the ileostomy at the same time and
avoided one more surgical burden on the patient. This is
probably first case of laparoscopic stapler repair of RVF
in literature.
Laparoscopic repair of RVF is challenging and requires
advanced laparoscopic skill. Laparoscopy is a promising
alternative in selected cases of RVF and yields faster
recovery and good patient compliance. We found that
stapler repair as compared to primary intracorporeal clo-
sure makes the procedure simpler, faster, and easy.
Safety and long term outcomes of laparoscopic repair is
yet to be proved by long term follow up and further
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