Rectovestibular Fistulas

Patients with rectovestibular fistulas are frequently erroneously diagnosed as having a rectovaginal fistula. Rectovestibular fistula is by far the most common defect in females, It has an excellent functional prognosis. The precise diagnosis is a clinical one requiring only a meticulous inspection of the newborn genitalia. The clinician observes a normal urethral meatus, a normal vagina, and a third hole in the vestibule, which is the rectovestibular fistula (Fig. 21.2). About 5% of these patients also have two hemivaginas, and a vaginal septum is visible, which should be removed at the time of the pull-through.

This defect may be repaired without a protective colostomy. This is a well-recognized trend in the management of ARM [6, 7], avoids the potential morbidity of a colostomy, and reduces the number of operations to one rather than three (colostomy, main repair, and colostomy closure). Many patients do very well with a single neonatal primary operation without a protective colostomy. However, a perineal infection followed by dehiscence of the anal anastomoses and recurrence of the fistula provokes severe fibrosis, which may interfere with the sphincteric mechanism. In such a case, the patient may have lost the best opportunity for an optimal functional result, because secondary operations do not render the same good prognosis as successful primary operations [8]. Thus, a protective colostomy is still the safest way to avoid these complications. The decision related to the opening of a colostomy or operating primarily must be taken by individual surgeons, taking into consideration his or her experience and the clinical condition

Rectovestibular Fistula

Fig. 21.1 Perineal fistula ([11], with permission)

Fistula Recto Vestibular

Fig. 21.2 Vestibular fistula ([11], with permission)

Fig. 21.1 Perineal fistula ([11], with permission)

Fig. 21.2 Vestibular fistula ([11], with permission)

Rectovestibular Fistula

Fig. 21.4 Repair of the rectovestibular fistula. The perineal body is repaired ([11], with permission)

Fig. 21.3 Repair of rectovestibular fistula. The rectum is completely separated from the vagina ([11], with permission)

Fig. 21.4 Repair of the rectovestibular fistula. The perineal body is repaired ([11], with permission)

Rectoperineal Fistula
Fig. 21.5 Repair of the vestibular fistula. Muscle complex sutures anchor the rectum ([11], with permission)
Vestibular Fistula
Fig. 21.6 Repair of the vestibular fistula. Anoplasty ([11], with permission)

of the patient. At our institution, patients who are born with this kind of malformation without serious associated defects are operated primarily as newborns without a colostomy.

The term "rectovaginal fistula" is often misused in patients who actually have a rectovestibular fistula or a cloaca. A real rectovaginal fistula occurs in less than 1% of all cases [9, 10].

The complexity of the rectovesticular fistula defect is frequently underestimated. Multiple 6-0 silk stitches are placed at the mucocutaneous junction of the fistula. The incision used to repair this defect is shorter than that used to repair the male rectourethral fistula. The incision continues down to the fistula and around the fistula into the vestibule. Once the entire sphincter mechanism has been divided, the posterior rectal wall is evident by its characteristic whitish appearance. The fascia that surrounds the rectum must be removed to be sure that the dissection is performed as close as possible to the rectal wall. The dissection continues creating the plane of dissection along the lateral walls of the rectum while applying traction on the multiple silk stitches. The last part is the most important part of this dissection, which is the separation of the rectum from the vagina.

There is a long common wall, and two walls must be created out of one using a meticulous technique, trying to keep both walls of the rectum and vagina intact. The dissection continues cephalad until both walls of the rectum and vagina are fully separated (a location identified when the surgeon encounters are-olar tissue between rectum and vagina). At this point both walls are full thickness (Fig. 21.3). If the rectum and the vagina are not completely separated, a tense rectal anastomosis would be created, which, as for the rectoperineal fistula, would predispose the patient to dehiscence and retraction.

Once the dissection has been completed, the peri-neal body is repaired (Fig. 21.4). The anterior edge of the muscle complex is reapproximated as described previously. The muscle complex must be reconstructed posterior to the rectum, with the stitches including the posterior edge of the muscle complex and the posterior rectal wall to avoid rectal prolapse (Fig. 21.5). The anoplasty is then performed (Fig. 21.6).

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Responses

  • aleksandra
    What is anorectal vestibule fistula?
    7 years ago
  • pinja
    How to code rectivestibular fistula?
    2 months ago

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