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To cite this article: Mahmoud Abu Gazala & Steven D. Wexner (2017): Management of
rectovaginal fistulas and patient outcome, Expert Review of Gastroenterology & Hepatology, DOI:
10.1080/17474124.2017.1296355
Download by: [University of Newcastle, Australia] Date: 21 February 2017, At: 16:33
Publisher: Taylor & Francis
DOI: 10.1080/17474124.2017.1296355
Review
Affiliation
*Corresponding author
Steven D. Wexner
Cleveland Clinic Florida, Department of Colorectal Surgery, 2959 Cleveland Clinic Blvd,
Weston, FL 33331
Tel: 954-659-6020
Email: wexners@ccf.org
ABSTRACT
Introduction: Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a
Areas covered: In this manuscript we discuss the etiology, classification as well as the
techniques and evaluate their success rates and perioperative considerations according to cited
sources.
Expert commentary: A deep understanding of the disease, treatment options, and familiarity
with the different surgical treatment options available is mandatory for choosing the correct
treatment. When the surgical treatment is tailored to the specific fistula and patient, many
patients can eventually have successful resolution. This review will address the management
fistulas, Gracilis interpositioning, Martius flap, Obstetric trauma, Rectovaginal fistula, Surgical
repair.
1. INTRODUCTION
Rectovaginal fistulas (RVFs), although relatively rare, can represent a devastating and disabling
condition for the patient, due to both psychological and physical sequelae. Its treatment also
poses great challenges for the colorectal surgeon. RVFs are abnormal epithelium lined
communications between the rectum and the vagina. Anovaginal fistulas arising from the anal
2. ETIOLOGY
RVFs may be acquired or congenital. In this review we will discuss only the acquired RVFs,
which account for about 5% of anorectal fistulas. (1) However, it is difficult to assess the exact
incidence and prevalence of RVFs due to their relative rarity, lack of structured reporting, and
small number of patients included in the published series. It is also difficult to ascertain the
precise incidence of the different etiologies due to the referral patterns to various surgeons and
institutions. Nevertheless, the most common etiologies for RVFs are traumatic, mainly obstetric,
iatrogenic complications.
Mechanisms for development of RVFs in obstetric trauma include prolonged or obstructed labor
with possible development of pressure necrosis of the rectovaginal septum. This mechanism is
more prevalent in underdeveloped countries. RVFs may also develop following unrecognized
3rd or 4th degree perineal tears, disrupted repair of perineal tears, or episiotomy sites due to
technical factors or infection. They may also be a consequence of traumatic injury during
instrumented delivery. The incidence of RVFs following vaginal delivery was reported by
tissue is usually well-vascularized and not otherwise diseased, good results can be expected
with surgical repair. Other causes of traumatic RVFs include sexual violence with forceful
penetration and use of foreign bodies, which may unfortunately result in large defects.
The rectovaginal septum is quite thin above the anal sphincter complex. Any surgical dissection
in this area runs the risk of injury and resultant RVF. During a proctectomy with colorectal, or
coloanal, or ileal pouch anal anastomosis, the vaginal wall may be inadvertently incorporated
into the stapler, resulting in a RVF. A similar mechanism may be causative during stapled
Approximately 5-10% of women with Crohn's disease will develop RVF, related to Crohn's
disease activity in the large bowel. RVFs secondary to Crohn's disease are a risk factor for
Early RVFs occur during radiation treatment as a result of tumor regression where the tumor
has fully or partially invaded the rectovaginal septum. However, most radiation-induced RVFs
occur 6-24months after treatment. Mechanisms of such fistula formation include chronic
radiation injury to the rectal and vaginal walls, resulting in inflammatory and ulcerative damage
due to progressive endarteritis obliterans and tissue hypoxia that gradually leads to fistula
formation. Risks for radiation-induced RVFs include dose of radiation and vascular disease risk
factors such as diabetes, smoking, and hypertension. The risk is also higher in patients who
have had abdominal or pelvic surgery. (5) It is imperative to distinguish radiation-induced RVFs
from tumor recurrence. In addition, cancers can be noted in chronic fistula tracts.
RVFs can also occur following treatment of gynecological and other malignancies, following
cryptoglandular infection, or, rarely, from stercoral ulcers from fecal impaction, use of pessaries,
Rectovaginal fistulas can be classified on the basis of etiology, size and location. Daniels
classified RVFs based on their location. (6) Fistulas arising from the distal third of the rectum to
the lower half of the vagina are considered “low” RVFs and are generally amendable to a
perineal approach. “High” RVFs are located between the middle third of the rectum and the
Location of the fistula varies based on the specific mechanism and etiology. Fistulas following
pressure necrosis of the rectovaginal septum and due to traumatic instrumented delivery are
usually high, where the rectovaginal septum is thin. (7) Fistulas following perineal tears are
Rothenberger et al. (8) classified RVFs as “simple” when located in the lower or middle third of
the vagina, are caused by trauma or infection, and have a diameter ≤ 2.5cm.Conversely, RVFs
are considered “complex“ when they arise in the upper rectovaginal vaginal septum, have a
diameter ≥ 2.5cm, and occur following inflammatory bowel disease (IBD), radiation, or cancer.
Symptoms of RVF greatly vary and are dependent on the size, location, and etiology of the
fistula. Most patients with RVF complain of uncontrolled passage of gas or stool through the
vagina. Stool passage is worse with diarrhea and larger defects in the rectovaginal septum.
Other symptoms include purulent, foul-smelling vaginal discharge, dyspareunia, perianal pain,
vaginal irritation, and recurrent genitourinary tract infections. Fecal incontinence could indicate
anterior disruption of the external anal sphincter. Such involvement of the anal sphincter may
alter the treatment options chosen. In patients with Crohn’s-related RVF or following malignancy
or radiation, the clinical picture may further be complicated by concomitant pathologies such as
assessment of the RVF may not be possible in the office setting, and might be undertaken in the
operating room under anesthesia. Presence, location, size, and associated pathologies and
underlying diseases should all be carefully assessed in the operating room, as well as exclusion
complex should be ascertained. One in three women with RVF may suffer from concomitant
sphincter injury. Failure to identify sphincter complex involvement in RVF may result in
continued or worsening fecal incontinence and/or failure of advancement flap repair. (9)
Small or high fistulas may be difficult to identify by physical examination alone. In one series,
Additional evaluative studies may be necessary to better identify and evaluate patients with
RVF. These include the methylene blue tampon test, computed tomography (CT) scan,
magnetic resonance imaging (MRI), endorectal ultrasound (EUS), gastrograffin enema (GGE),
vaginography, fistulography, and enteroscopy. MRI and EUS are the most useful imaging
modalities in identifying RVF,(11) and are especially beneficial in the evaluation of sphincter
involvement. The presence or exclusion of additional concomitant fistulas to other organs is also
essential for treatment planning. As previously mentioned, a high index of suspicion should be
The management approach for patients with RVF is largely dependent on several factors.
Fistula age, size, location, etiology, symptomatology, quality of surrounding tissue, prior surgical
treatment attempts, as well as patient factors including comorbidity, all play an important role in
the decision-making process. It has been suggested that up to half of the acute small RVFs
untreated collections, as well as antibiotics, seton placement, and local care should be provided
to allow tissue healing prior to definitive surgical treatment. Occasionally, in order to achieve
satisfactory symptom control and adequate tissue healing, stool diversion maybe necessary. In
some cases, stool diversion, accompanied by local treatments and sepsis control, may be
adequate to allow for spontaneous healing of the fistula. Reassessment for ongoing sepsis
should be performed with confirmation of resolution of active inflammation. Once tissue healing
has occurred with persistence of a mature RVF, directed surgical intervention could be
considered.
Small and asymptomatic RVFs may be treated by dietary modification and fiber
The surgical approach is specifically tailored to each fistula and patient, and at times a
dictated by fistula location and etiology. Low fistulas are potentially amendable to local repair
(transanal, transvaginal or trans-perineal approach), while high fistulas can generally be treated
via trans-abdominal approach. Regardless of the surgical approach, all patients should be
failure.
6. SURGICAL APPROACH
fistulectomy. However, because of the risk of fecal incontinence, fistulotomy is often avoided.
RVFs involving the anal sphincter complex or located higher in the rectovaginal septum can be
approached using different methods, including local repair, use of biomaterials, and tissue
approaches. There has been an immense diversity of different variations described in the
literature.
Acute RVF due to obstetric injury may be amendable to immediate primary repair, with or
exposure of the operative field and correct identification of the anatomy. The vagina can be
packed during the repair to improve vision from uterine bleeding. The edges of the internal and
external sphincters must be identified clearly to ensure accurate repair. The repair should be
performed in a multilayered fashion: Initially, the rectal mucosa is repaired using a 2-0 braided
absorbable suture starting from the most proximal edge of the tear distally. Next, the internal
sphincter is identified and repaired as a separate independent layer using long-term interrupted
2-0 absorbable sutures. It should be noted that once the sphincter is severed, it retracts
superiorly and laterally. Repair of the internal sphincter is of great importance for the strength
and integrity of the repair and for achieving maximal continence. Next the external sphincter is
eight long-term absorbable 2-0 sutures. Mobilization of the sphincter halves may be necessary
Once satisfactory repair of the sphincter complex has been achieved, subsequent repair of the
distal rectovaginal septum and perineal body is performed. The goal of the surgical repair is
reconstruction of a long anal canal, an intact sphincter complex, perineal body and rectovaginal
septum. Great care should be given for sepsis prevention using copious irrigation and
Surgery is deferred in patients who develop late RVF due to obstetric injury, such as
rectovaginal septum necrosis, infection and/or disruption of fourth degree perineal laceration.
One of the methods for local transperineal repair of RVFs involving the anal sphincter complex
includes conversion of the fistula to a fourth-degree perineal laceration. The fistula tract is then
debrided or excised, the sphincter muscles are identified and dissected as are rectal and
vaginal walls, which are then repaired in a multi-layered fashion. Anal overlapping
sphincteroplasty or levatorplasty can be performed in these patients, which allows for a mass of
muscle to interpose between the rectal and vaginal repair. This approach is especially
appropriate in patients with concomitant anterior sphincter defect and fecal incontinence.
Several variations of this technique have been described in the literature, including in
combination with rectal and vaginal advancement flaps and the use of interpositioning
bioprosthetic grafts, (15,16) with success rates ranging from64-100%. (17) This approach may
There has been growing popularity for treatment of perianal fistulas using the LIFT (ligation of
intersphincteric fistula tract) procedure. There has been limited experience with this technique in
the treatment of RVF. However, in patients with low RVF involving the anal sphincter complex,
LIFT is a feasible alternative, which does not compromise the function of the anal sphincters.
This procedure involves dissecting the avascular intersphincteric plane between the internal and
external anal sphincters. (Figure 1) The fistula tract is identified, isolated, and divided on both
sides between sutures. (Figures 2 and 3) Bioprosthetic material may be inserted to separate
Transanal approaches for repair of RVF involve closure of the rectal side of the fistula. This
method theoretically has the advantage of repair on the higher-pressure side, which serves to
buttress the repair. Different techniques have been described, with the endorectal advancement
flap first described by Noble in 1902, being considered by many colorectal surgeons as the
procedure of choice, especially for low RVF. The procedure consists of outlining and raising a
flap of mucosa, submucosa, and the circular muscle layer. (Figure 5,6,7) The flap extends at
least 3-4 cm cephalad to the fistula, with the base of the flap twice the width of the apex to allow
elliptical flap can be raised without dividing the flap in a caudal-to-cephalad direction. The fistula
opening on the rectal side is excised and the opening is derided and closed. It is possible to
approximate the lateral edges of the muscular layer over the fistula opening as an additional
layer of reinforcement. (Figure 8) The flap is then advanced over the internal opening of the
RVF, thus covering it by healthy tissue. (Figure 9) The vaginal side of the fistula is often left
procedure can be combined with overlapping sphincteroplasty. This approach separates the
suture line from the fistula site and interposes healthy muscle between the rectal and vaginal
walls. The overall success rate ranges from 43-93% (Table 1) (19,20, 21,22,23,24). Postulated
advantages of the transvaginal advancement flap include greater redundancy in the posterior
vaginal wall than the anterior rectal wall and avoidance of suturing inflamed rectal mucosa.
However, a disadvantage is that the fistula is repaired from the low-pressure side of the fistula,
where the relatively higher rectal pressure may theoretically disrupt the repair. Though not a
direct comparative study, Ruffolo et al (25) performed a systematic review of the literature and
found no significant difference between transrectal and transvaginal advancement flaps for
There have been several repair techniques using biosynthetic products developed for fistula
tract closure. The advantages of these procedures are that no tissue dissection is required, the
relatively easy application, and the lack of long-term consequences in case of failure. These
purported advantages explain their use by some surgeons as the first line of treatment for
promoting inflammatory response and scar formation, thus enabling fistula closure. Fibrin glue
has had low success rates, and thus is rarely indicated. (26) The collagen fistula plug has been
used more widely with better rates of success. It consists of a cylindrical plug made of acellular
collagen matrix, which is lodged into the previously debrided fistula tract and secured in place
by sutures on both fistula openings. (Figure 10) The plug promotes an inflammatory response,
which is gradually replaced by scar tissue. The design of the rectovaginal fistula plugwas altered
from anorectal fistula plugs to include additional components such as a button on the rectal
side. Success rates are usually low, in the range of 20-35%; however, success rates of up to
Biosynthetic materials can be implanted in combination with other procedures for fistula closure,
mesh, can be used to separate both ends of divided fistula tract in transperineal repairs and the
The rationale behind tissue transposition repairs is to interpose healthy, well-vascularized tissue
between the cut edges of the RVF tract. The added bulk of tissue, in combination with its unique
vascularity, allows for enhanced blood supply to the area, obliteration of dead space, and
protection of the suture lines on both the rectal and vaginal sides. These repairs allow for very
high success rates for RVF repair, but with the cost of added procedural complexity and the
these, the most widely used are the gracilis muscle and the Martius flap. Other options include
The Martius flap, first described by Dr. Heinrich Martius in 1928, uses the labial fat with
its posteriolateral vascular pedicle, which originates from internal pudendal artery branches. The
flap is then rotated and interposed between the cut and closed edges of the RVF, taking
extreme care not to torque its blood supply. One problem with this flap is its small size and
limited blood supply. Success rates for this procedure range between 60-100% in different
series. Pitel et al. (30) reviewed their experience with 20 patients with RVF treated using the
Martius flap technique; 40% of the fistulas were due to Crohn's disease. They reported an
overall success rate of 60%, and a success rate of 50% in patients with Crohn's disease.
Songne et al. (31) reported their experience with 14 patients with RVF treated with the Martius
flap. Seven patients had Crohn's disease and four had a pouch-vaginal fistula. Their
The gracilis muscle interposition offers a greater bulk of healthy vascularized tissue to allow
tissue healing. The procedure consists of harvesting the gracilis muscle from the thigh, using
either a single longitudinal incision over the medial aspect of the thigh or 2 smaller incisions.
The muscle is mobilized, dividing its perforating blood supply, and transecting its insertion to the
tibial plateau. Care should be taken to preserve its neurovascular bundle at its origin. The
muscle is then passed through a tunnel from the proximal aspect of the thigh towards the
perineum, and is then interposed between the rectum and vagina, which have been dissected
apart and the RVF is divided. The fistula openings on both sides are debrided and closed
primarily or using an advancement flap. Extreme care should be taken not to torque the
muscle’s blood supply nor to apply excessive tension on the neurovascular bundle.
Wexner et al. (32) reported a success rate of 75% in gracilis muscle interposition for RVFs in a
series of 8 women without Crohn’s disease and an initial success rate of 33% in 9 women with
Crohn’s disease. Pinto et al. (22) reported their experience with 24 patients with RVFs treated
with gracilis muscle interposition. Their overall success rate was 79%, and 66% in patients with
Crohn's disease. Furst et al. (33) reported a 92% success rate in treatment of recurrent
This option is generally reserved for patients in whom multiple other fistula repairs have failed.
A trans-abdominal approach for the treatment of RVFs may be indicated in high RVFs,
originating from the middle third of the rectum to the upper portion of the vagina, or in patients
with a severely damaged rectum such as after radiation. The exact procedure depends on the
specific anatomy of the fistula, the patient's condition and will, and also the condition of the local
tissue. When the patient has a high fistula with relatively healthy surrounding tissue, anterior
dissection between the rectum and the vagina is performed, with division of the fistula tract and
possible interposition of an omental flap. In a prospective study by Van der Hagen et al, (37)
patients. The procedure was feasible in 38 patients (95%), only two of whom had a recurrence.
In cases when local repair is not feasible, especially in patients with radiation damage, IBD or
neoplasm, resection of the diseased rectum with anastomosis at a lower level is necessary. In
an article from 1986, Cooke and Wellsted (38) reported a success rate of 93% in the treatment
of 42 patients who had received radiotherapy and had undergone proctectomy for RVF. More
recently, Schouten et al (39) described their series of 8 women who underwent rectal sleeve
advancement for the treatment of persistent RVF. Their overall success rate was 75%.
7. Special considerations
As previously mentioned, high or low RVF can develop due to invasive tumor regression or
chronic radiation injury. Low RVF may be amendable to local repair, although diffuse tissue
injury and scaring make the dissection of the fistula difficult and local microvascular injury may
significantly compromise success. These problems often prompt the use a healthy, non-radiated
and well-vascularized interposition graft. High fistulas can be repaired via a transabdominal
damaged local tissue, it may be necessary to perform the resection and anastomosis at a lower
level. Temporary diversion should be considered for all radiation-related fistulas. Permanent
In patients with Crohn's disease-induced RVF, disease activity, both in the rectum and in the
rest of the gastrointestinal tract, should carefully be determined. Other factors affecting
treatment approach include symptoms, quality of life, rectal compliance, and continence status.
Disease activity should be controlled using anti-TNF drugs and other anti-inflammatory
medications. Sepsis control is ideally accomplished with seton placement. Inflammation and
these patients differs from other etiologies, and should generally be more conservative.
Minimally symptomatic patients may not require surgical intervention. In some cases, medical
treatment may induce spontaneous healing of the RVF. In the ACCENT II study, Sands et al.
(40) reported a 64% response rate (defined as reduction of 50% in number of fistulas at the10-
week follow-up) at the 14-week follow up in patients with RVF who received Infliximab;72% of
preserving procedure in select patients, namely those with active disease who cannot undergo
Local surgical repair may be considered for patients with a persistent, mature, single fistula and
healthy non-inflamed rectal mucosa. Anal sphincter repair should also be performed in patients
with impaired continence. Numerous local repairs, transabdominal approaches, and tissue
Patients who fail to achieve disease control and suffer from severe disease refractory to
maximal medical management and have had seton placement may be candidates for
proctectomy.
Stoma
Fecal diversion has several uses in the treatment of RVF. Patients with severe symptoms
resulting from the RVF or who suffer from debilitating active Crohn's disease or radiation
proctitis may benefit from fecal diversion to allow tissue healing and symptom relief. In some
cases, stoma may be the definite treatment for patients with RVF, especially in those with
impaired continence.
Other considerations for stoma creation should include the magnitude of planned surgery and
contribution of fecal diversion for promotion of repair success. In cases of recurrent RVF, major
pelvic dissection, damaged local tissue, and in tissue transposition procedures, fecal diversion
should be considered. No definitive data is available if the mere existence of the stoma reduces
the risk for RVF recurrence, but usually, patients who undergo fecal diversion are theoretically
The success rates for surgery for RVF may depend on several factors including etiology,
characteristics of the specific fistula, condition of the surrounding tissue, history of prior surgical
In a review of our experience over a period of two decades, 184 procedures were performed on
125 patients with RVF. The success rate after the first procedure was 57%, and the overall
In our attempt to define the risk factors for fistula recurrence, several were identified. Tobacco
smoking had a higher risk of recurrence with an odds ratio of 1.94. Patients with Crohn's
disease as an etiology for the RVF also had a significantly higher risk of recurrence compared to
other etiologies. The success rate per procedure was 44.2% and 78% per patient after a mean
of 1.8 procedures.
Patients who had recurrent RVF had higher risk of procedure failure. The greater the number of
prior repair attempts, the higher the recurrence rate. In our experience, the success rate for
initial RVF repair was 67%, which dropped to 50% for repair of recurrent RVF. Lowry et al. (44)
had previously reported a similar trend. Despite this, revisional surgery is possible and
successful in most patients. Halverson et al. (45) reported an overall success rate of 79% after a
mean of two procedures for the treatment of recurrent RVFs in their series of 35 women. Timing
of revisional surgery may also be of importance. While some studies failed to demonstrate a
connection, others had better results with an interval time of at least 3 months between repairs.
(22,45)
9. CONCLUSION
treatment options, and familiarity of the different surgical treatment options available is
mandatory for choosing treatment. When the surgical treatment is tailored to the specific
fistula and patient, many patients can eventually have a successful outcome.
Rectovaginal fistulas pose a special challenge as they are relatively rare, diverse in etiology,
location and challenging to treat. A myriad of different treatment options is a testament to the
lack of a panacea therapy. Due to this significant heterogeneity in the etiology and treatment
options, it is difficult to conduct meaningful large randomized controlled trials. In the absence of
conclusive data from such trials, the management plan and surgical approach should still
be tailored to the specific fistula and patient. A thorough understanding of the disease and
familiarity with the different surgical treatment options is mandatory to try to optimize the
Future directions which may evolve in the treatment of RVFs may include advances in both
medical and surgical pathways. Novel research is directed at reducing radiation damage to
normal tissue, thus potentially reducing the risk for RVFs in patients undergoing radiation
therapy. Future advancements in the medical treatment of Crohn's disease may contribute
to RVF prevention and yield greater success rates. Other advances in the field of
biosynthetic plugs may also enhance closure rates. There have also been several reports of
novel treatment options for RVFs such fat injection (46) and autologous stem cell
transplantation. (47, 48) Other advances in endoscopic treatment options may offer additional
armamentarium for the treatment of RVFs such as endoscopic clips and self-expanding metal
Rectovaginal fistulas (RVFs) represent a relatively rare debilitating condition. The most
complications.
RVFs have been classified as “simple” when located in the lower or middle third of the
vagina, are caused by trauma or infection, and have a diameter ≤ 2.5cm. Conversely,
RVFs are considered “complex“ when they are recurrent, arise in the
upper rectovaginal vaginal septum, have a diameter ≥ 2.5cm, and occur following
A thorough understanding of the disease and familiarity with the different surgical
Preoperative evaluation should include assessment of the integrity of the anal sphincter
The surgical approach is specifically tailored to each fistula and patient, and at times a
Low fistulas are potentially amendable to local repair (transanal, transvaginal or trans-
perineal approach), while high fistulas can generally be treated via trans-abdominal
approach.
When the surgical treatment is tailored to the specific fistula and patient, many patients
Declaration of Interest
The authors have no relevant affiliations or financial involvement with any organization or entity
with a financial interest in or financial conflict with the subject matter or materials discussed in
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(23) Traumatic,
Malignancy
(21) Crohn’s,
Traumatic
(20)
(22)
RVF=rectovaginal fistula
Table 2. Outcomes for gracilis muscle interposition for rectovaginal fistulas.
rate (%)
Wexner et 2008 17 53 53 33
al (32)
(33)
Ulrich et al 2009 9 78 94 71
(34)
Lefevre et 2009 8 62 75 80
al (35)
Pinto et al 2010 24 25 79 66
(22)
al(36)
RVF=rectovaginal fistula
Algorithm 1.
1. Evaluation of a patient with a rectovaginal fistula should include through examination of the
rectum and vagina to carefully assess for fistula location, size, associated pathologies and
underlying diseases. MRI and EUS are the most useful imaging modalities.
may be performed. Alternatively, it is possible to attempt fistula plug repair, a LIFT procedure or
6. In case of failure, repair of the rectovaginal fistula using gracilis muscle interposition may be
performed.
7. In most cases, the repair should be successful. However, failure may be treated with an
8. Failure at this stage may warrant a transabsominal repair or keep the patient with permanent
stoma.
9. An acute rectovaginal fistula should be repaired via overlapping sphinctroplasty with repair of
Figure 1. Probe shown being passed through the rectovaginal fistula tract. The incision for LIFT
and Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health,
2011 (51).
Figure 2. Fistula tract is identified and isolated. Figure reproduced from Wexner, S. D. and
Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011
(51).
Figure 3. Fistula tract is divided on both sides between sutures. Figure reproduced from
Wexner, S. D. and Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters
Wolters Kluwer 2011. Figure reproduced from Wexner, S. D. and Fleshman J. W. Colon and
advancement flap with adequate width is shown. Figure reproduced from Wexner, S. D. and
Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011
(51).
Figure 6. A flap of of mucosa, submucosa, and the circular muscle layer is raised. Of mucosa,
submucosa, and the circular muscle layer. Figure reproduced from Wexner, S. D. and Fleshman
J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011 (51).
Figure 7. Adequate mobilization of the flap is necessary to avoid tension. Figure reproduced
from Wexner, S. D. and Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters
Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011 (51).
Figure 9. Flap sutured in place. Copyright Wolters Kluwer 2011. Reused with permission. (51)
Figure 10. Rectovaginal fistula plug sutured in place. Figure reproduced from Wexner, S. D. and
Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011
(51).