V2-01: Repair of a complex vaginal J-pouch fistula utilizing a gracilis muscle interposition flap
Rectovaginal and J-pouch vaginal fistulae are abnormal epithelialized connections between the rectum or J-pouch to the vagina. Symptoms, such as fecal incontinence, can be distressing to patients. These fistulae can be a challenge to repair and multiple repair methods have been described in the literature including transvaginal, transrectal, and flap interposition repairs. Success rates in the literature range from 10-100% and with each subsequent repair the success rate of closure decreases.
We present the case of a 35 year-old woman with a history of ulcerative colitis who developed a fistula following a total proctocolectomy and ileal-anal pouch anastomosis. When she presented she had already undergone more than ten attempts at repair. Prior to our fisula repair she had a fecal diversion with a loop ileostomy. We performed a transvaginal repair utilizing a gracilis muscle interposition flap. Indocyanine green was given intravenously and the SPY Elite imaging system was used to enable the visualization of microvascular blood flow and perfusion to the gracilis flap and to the bed of the fistula repair intraoperatively.
Our patient did well after the procedure. She was discharged home with the foley in place on post-operative day 1. At her one month follow-up the repair was intact and she was healing well.
In cases of complex rectovaginal and vaginal J-pouch fistulae, especially those that are reoperative cases, fistula repair with a gracilis interposition flap is a viable repair option. Success from this repair can be aided by assuring complete excision of non-viable tissue and a healthy flap. In our case these steps were aided by the use of the SPY Elite imaging system.