A Novel Use of the Gracilis Muscle as a “Walking” Flap for Repair of a Rectovaginal Fistula

Abstract

INTRODUCTION: Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained.1–2 Case Report: We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30 mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed, but failed. The right gracilis flap was then re-used successfully as a “walking” flap. The medial femoral circumflex vessels were ligated and the proximal muscle was released and wrapped in a tubed piece of acellular dermal matrix (Figure 1). One week later, the fistula was divided and primary closure of the rectum and vagina was obtained. Subsequently, the proximal muscle was tunneled between the rectum and vagina and tacked 3 cm above the suture lines of both the rectal and vaginal defects and down to the opening of the perineal wound (Figure 2). At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later.Figure 1: Ligation of medial femoral circumflex vessels and release of the proximal gracilis muscle followed by wrapping in a tubed piece of acellular dermal matrix (ADM).Figure 2: Inset of the delayed gracilis flap between the rectum and the vagina - saggital view (green color = proximal end of the muscle, yellow color = distal end of the muscle).CONCLUSION: To our knowledge, this is the first report of the use of a gracilis muscle as a “walking” flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.