Gracilis Muscle Transposition for Recurrent Rectovaginal Fistula

INTRODUCTION: Primary rectovaginal fistula (RVF) repair can fail. Several options exist to facilitate repair of recurrent RVF, including Martius flap, endorectal advancement flap, and gracilis muscle transposition. Despite high success rates, many urogynecologists may perceive gracilis muscle transposition to be prohibitively complex due to lack of exposure to and familiarity with thigh anatomy. OBJECTIVE: To demonstrate a gracilis muscle transposition technique for repair of recurrent RVF in collaboration with plastic surgery. METHODS: The patient is a 76-year-old G2P2 female who presented 3 months postoperatively with recurrent RVF. Primary transvaginal repair with diverting colostomy had previously been completed with colorectal surgery in the setting of a chronic rectal abscess secondary to diverticulitis. RESULTS: The patient underwent secondary repair with gracilis muscle transposition in collaboration with plastic surgery. Proper patient positioning, initial transvaginal excision of the fistula tract, and preparation for muscle graft interposition are shown. During gracilis muscle dissection, we highlight relevant anatomy and the use of Doppler ultrasound to ensure an intact neurovascular bundle is maintained. We demonstrate techniques for adequate tunnel creation from the thigh incision to the pelvis for rotation of the muscle flap into the vagina. Finally, we present a stepwise method for securing the muscle flap in place using a transvaginal approach. CONCLUSIONS: We demonstrate a step-by-step approach to repair of recurrent RVF using gracilis muscle transposition in a complex patient. The role of the urogynecologist in collaboration with plastic surgery is highlighted with detailed descriptions of key procedural steps to improve comfort and experience with this procedure.