EP685 - Reconstrucción of recurrent rectovaginal fistula using Martius flap and cyanoacrylate glue reinforcement with laparoscopic loop iliostomy

Purpose/Background: Rectovaginal fistulas (RVFs) are complex complications of perineal surgery, mainly caused by obstetric trauma. Other etiologies include radiation, malignancy, inflammatory bowel disease, and diverticulitis. Diagnosis is primarily clinical, supported by imaging such as MRI or ultrasound to define the tract and evaluate sphincter integrity. Surgical repair often requires vascularized tissue interposition. The Martius flap provides well vascularized adipose tissue that enhances healing and reduces recurrence, achieving success rates up to 95% in experienced hands, particularly for low and mid-vaginal RVFs.

Methods/Interventions: We present a 53-year-old woman with recurrent rectovaginal fistula after three failed repairs. Endoanal ultrasound showed a high transsphincteric tract involving 60% of the external sphincter. Definitive repair was achieved using a right Martius flap reinforced by applying cyanoacrylate surgical adhesive.

Results/Outcomes: This is the case of a 53-year-old woman with no relevant personal medical history, originally from Guadalajara. Her relevant gynecological history includes a complicated vaginal delivery 30 years ago, with a third-degree perineal tear and anal sphincter injury which was repaired immediately. She subsequently developed a rectovaginal fistula, The patient underwent three unsuccessful surgical procedures to correct the rectovaginal fistula (RVF): the first, a transanal repair 15 years ago which recurred after 6 months; the second, a rectal flap advancement 8 years ago, with recurrence after 4 months; and the third, 3 years ago, involving the placement of a collagen plug which resulted in initial closure but with recurrence of the fistulous tract after 90 days.

The patient came to the consultation due to persistent intermittent fecal discharge from the vagina, accompanied by mild fecal incontinence, which had been going on for 15 years. Preoperative imaging studies showed an endoanal ultrasound with a rectovaginal fistula located in the middle third with a high transsphincteric tract, affecting 60% of the external sphincter, with no evidence of abscesses; colonoscopy revealed no lesions in the rectal mucosa. It was decided to perform a Martius flap reconstruction, beginning with positioning in modified lithotomy, identification and canalization of the fistulous tract using a stylet, followed by local debridement (Figure 1,2). A longitudinal incision was made in the right labia majora, dissecting an 8 x 3 cm vulvar fat flap with preservation of the external pudendal artery (Figure 3), which was tunneled to the rectovaginal space (Figure 4) and fixed to the rectal defect with 3-0 absorbable suture in two planes (Figure 5).

The repair was reinforced by applying cyanoacrylate surgical adhesive to the interface between the flap and the posterior vaginal wall. Finally, the vaginal mucosa, fascia, and skin were closed in layers with 4-0 monofilament sutures, maintaining the protective ileostomy. (Figure 6)

The postoperative course was uneventful, and was discharged on postoperative day five without complications.

Conclusion/Discussion: In this recurrent rectovaginal fistula, Martius flap interposition with protective ileostomy achieved complete healing without recurrence. The technique provided neovascularization and effective tissue separation, promoting functional recovery and improved quality of life. These findings support the Martius flap as a safe, effective option for complex fistulas, and suggest that cyanoacrylate reinforcement may enhance closure integrity.

Figure 1
Identification of the fistoulous tract and canalization of the fistulous tract using a stylet
Figure 3
Incision in the right labia majora, dissecting an 8 x 3 cm vulvar fat flap with preservation of the external pudendal artery.