Purpose/Background: Obstetric anal sphincter injuries (OASIS) are an uncommon but serious complication of vaginal delivery, reported to complicate with 1.4% of all vaginal delivery in Japan. In some cases, wound breakdown or infection after primary repair can cause persistent defect such as rectovaginal fistula. In these cases, simple fistula closure might not be enough as a deficient perineal body may undermine simple repairs. A layered repair approach with simultaneous perineal body reconstruction can reestablish normal anatomy and hence optimize fistula healing and continence. Here we report our clinical results of layered fistula closure with perineal body reconstruction for rectovaginal fistula complicating in vaginal delivery.
Methods/Interventions: From January 2023 to December 2024, three patients who developed rectovaginal fistula several months after OASIS underwent surgical repair. Written informed consent was acquired from all patients before surgery. All were female and the average age of the patients was 30.3 years. The following standardized surgical procedure was used: All procedures were performed under spinal anesthesia. With the patient in the prone jackknife position, transverse incision was made at the perineum, allowing wide dissection of the rectovaginal septum to separate the rectum and vagina. The entire fibrous fistula tract was identified and completely excised. The rectal defect was closed with interrupted Gambee sutures to achieve a full-thickness, inverted closure of the rectal wall, and the vaginal defect was closed with a running absorbable suture. Attention was then turned to multilayered perineal body reconstruction: the perineal body and surrounding musculofascial tissues were reapproximated in 3–4 layers, with 3–4 interrupted sutures placed in each layer to restore a robust, thick perineal body. This layered closure of rectum and vaginal wall with simultaneous perineal body repair effectively converts the area into a fresh surgical repair, tightly reconstructing the septum without tension.
Results/Outcomes: The mean operative time was 184±55 min. There was no major complication during or after surgery. Though follow up is currently short 6–12 months, complete fistula healing was achieved in all cases, with resolution of rectovaginal leakage. After median 14 (12-29) months follow up, all patients report complete resolution of their fistula symptoms.
Conclusion/Discussion: In this preliminary series, layered fistula closure combined with multi-layer perineal body reconstruction yielded 100% short-term success without major morbidity for obstetric rectovaginal fistula. By addressing both the fistula tract and the underlying structural deficit, this one-stage approach appears safe, anatomically sound, and clinically effective. Larger cohorts and longer follow-up are warranted to confirm durability and functional outcomes.
