A 61-year-old Japanese woman was admitted to our hospital with a chief complaint of fecal discharge from the vagina. She received laparoscopic LAR for early stage rectal cancer 2 years and 9 months ago in another hospital. Surgical site drainage and diverting ileostomy were also performed due to anastomotic leakage on the 4th day after surgery. Anastomotic leakage seemed to have healed 4 months after ileostomy; therefore, stoma reversal was performed. Immediately after surgery, she noticed fecal discharge from the vagina and was diagnosed with an RVF. Despite a second diverting ileostomy and transvaginal repair, the RVF had not cured. Colonoscopic examination revealed a rectovaginal fistula measuring 10 mm in diameter, situated 3 cm from the anal verge, on the oral side (Fig. 1a). Gastrografin enema showed influx of contrast medium into the vagina (Fig. 1b). Magnetic resonance imaging showed a fistula between the rectum and the vagina. Pelvic abscesses or recurrent tumors were not observed (Fig. 2).
Local minor surgical procedures, including diverting ileostomy, were unsuccessful; therefore, we thought that a major procedure with coloanal reanastomosis was necessary. Laparoscopy-assisted repair of the RVF was performed under general anesthesia with the patient in the lithotomy position. The procedure consists of three steps.
The first step involves carefully dissecting the sigmoid colon and retroperitoneal tissue, avoiding injury to the mesocolonic vessels. Mobilization of the splenic flexure was then performed to decrease tension on the coloanal anastomosis. In the pelvic cavity, the sigmoid colon was detached from the anterior surface of the sacrum, and adhesions around the uterus next to the RVF were removed. Intracorporal sigmoid colon transection was performed with a linear stapler on the oral side of the RVF.
In the second step, a transverse skin incision was made on the perineum. The connective tissues between the rectum and the vagina were dissected up to a depth of approximately 6 cm from the skin level. During this dissection, the fistula was released (Fig. 3) and the surrounding infectious tissue was removed completely. The fibrous connective tissues around the RVF were exposed clearly on each of lateral sides. Additionally, using the laparoscopic route, the sigmoid colon, including the previous anastomosis was transected and removed at the level of the superior border of the puborectal sling (Fig. 4).
In the third step, the defect on the posterior vaginal wall was closed using interrupted 3 − 0 polyglactin sutures. Subsequently, redo coloanal anastomosis was performed by hand-sewn. Furthermore, firm longitudinal suturing of the innermost portion of the dissected fibrous tissues around the RVF on each of the lateral sides was performed by making 3 stitches using 3 − 0 polyglactin (Fig. 5). The dissected fibrous tissues were repaired in 4 layers from bottom to top, by making 3 stitches per layer, and the repaired tissues were interposed between previously anastomosed vagina and colon (Fig. 3b). The operation lasted for 691 minutes and the estimated blood loss was 795 g.
The postoperative clinical course was good and the patient was discharged from the hospital on the 16th day following surgery. Stoma closure was performed 11 months after surgery. She had no recurrence of RVF and no complaint of fecal incontinence one year after diverting stoma closure.
A 64-year-old Japanese woman was referred to our hospital with a chief complaint of fecal discharge from the vagina. She received laparoscopic LAR for early stage rectal cancer 1 year prior to her referral. On the 3rd day after surgery, she complained of fecal discharge and flatulence from the vagina, and she was diagnosed with RVF. Diverting ileostomy was performed 8 months prior to her referral but the RVF had not cured. A fistula measuring approximately 2 mm in size, was found 4.5 cm from the anal verge, on the oral side.
Laparoscopy-assisted repair of RVF was performed in the same way as the previous patient. The operation lasted 615 minutes and the estimated blood loss was 700 g. The postoperative clinical course was uneventful. She had no recurrence of RVF and did not complain of fecal incontinence 10 months after stoma closure.