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Transabdominal RVF Repair

The transabdominal approach to rectovaginal fistula (RVF) repair is reserved for complex, high, recurrent, radiation-related, or anastomotic-complication-related fistulas that are not amenable to local perineal or transanal repair. The ASCRS 2022 guideline gives a strong recommendation (Grade 1C) that RVFs from colorectal anastomotic complications often require a transabdominal approach.[1]

For first-line local repair see ERAF ± Sphincteroplasty; for sphincter-disrupted / cloaca cases see Episioproctotomy; for the nonoperative pathway see Nonoperative RVF Management.

Indications​

  • Post-anastomotic RVF — fistulization of a colorectal or coloanal anastomosis to the vagina (≤ 2.2% in earlier series; higher in recent reports)[1]
  • Radiation-related RVF — fibrotic, devascularized tissue not amenable to local repair[1]
  • Recurrent complex RVF — after failed local procedure (advancement flap, episioproctotomy, tissue interposition)[2][3]
  • High RVF — between mid-rectum and posterior vaginal fornix; inaccessible perineally[4]
  • Crohn's disease — extensive rectal disease refractory to medical therapy[5]

Surgical Techniques​

1. Resection with colorectal or coloanal anastomosis​

Takedown of the prior anastomosis (if present) or resection of the fistula-bearing segment, then a new colorectal or coloanal anastomosis. Corte 2015 (n = 79; 19 with resection — 8 primary / 11 delayed coloanal): 91% overall success.[2]

2. Delayed Coloanal Anastomosis (DCAA) / Colonic Pull-Through (Turnbull-Cutait)​

Staged:

  1. Proctectomy or resection of the fistula-bearing rectum
  2. Pull-through of colon to the perineum, left exteriorized for 5–7 days
  3. Delayed sutured coloanal anastomosis after the colon has adhered to surrounding tissues

Outcomes:

  • Collard 2025 GRECCAR multicenter (n = 78): 81% success; overall morbidity 45%, major morbidity 23%, anastomotic leak 17%. With leak: success drops to 23% vs 92% without. 42% had severe LARS or remained with stoma due to poor functional outcome.[6]
  • Blondeau 2022 (n = 28 postoperative RVF): 86% success; higher with diverting stoma (91% vs 67%).[7]
  • Turnbull-Cutait reduces anastomotic leak (3% vs 7%) and pelvic abscess (0% vs 5%) compared with primary coloanal anastomosis.[1]

3. Sleeve excision technique​

Variation of proctectomy:

  1. Resection of the rectum proximal to the fistula tract
  2. Mucosectomy of the rectum at and distal to the fistula
  3. Pull-through of healthy colon through the remaining rectal muscular cuff
  4. Sutured coloanal anastomosis

Nowacki (radiation RVF) — 79% (11/14) healing with good function. Patsouras (n = 34) — 75% healing with 72% normal continence; early complications 51%, late 32%.[1]

4. Laparoscopic fistula excision with omentoplasty​

  1. Laparoscopic mobilization of the omentum (typically on the left gastroepiploic pedicle)
  2. Excision or closure of the tract on both rectal and vaginal sides
  3. Interposition of the vascularized omental flap into the rectovaginal septum

Outcomes:

  • van der Hagen 2011 (prospective, n = 40 high RVF): 95% healing (only 2 recurrences); GIQLI 85 → 120 (P = 0.0001).[4]
  • de Bruijn 2018 — combined laparoscopic-perineal omental interposition for complex / recurrent RVF: 100% healing at median 15 mo.[8]
  • Schloericke 2012 (n = 9, lap-assisted omental flap reconstruction): no recurrences at median 22 mo.[9]

5. Abdominoperineal Resection (APR)​

APR is a last-resort, definitive procedure that eliminates the fistula by removing the rectum and anal canal en bloc, leaving a permanent end colostomy.[1][2][10]

Indications:

  • Multiply recurrent RVF refractory to all sphincter-preserving options (advancement flaps, gracilis / Martius interposition, coloanal anastomosis)[1][2]
  • Severe radiation proctopathy with an unsalvageable rectum (extensively fibrotic, strictured, or nonfunctional) where proctectomy + reanastomosis is not feasible[1][11]
  • Refractory Crohn's disease with severe rectal involvement after maximal medical therapy and prior surgical repairs — ACG 2025 supports proctectomy / total proctocolectomy with permanent stoma in very severe scenarios; AGA positions proctectomy as a "last resort"[5][12]
  • Destroyed anal sphincter complex with concomitant fecal incontinence making sphincter-preserving reconstruction futile
  • Concurrent rectal pathology requiring proctectomy (e.g., rectal cancer with associated RVF)

Frequency: Corte 2015 — APR was 9 of 286 procedures (3%) and 9/69 major procedures (13%), performed only after failure of seton drainage, advancement flaps, gracilis interposition, and coloanal anastomosis.[2]

Stepwise algorithm before APR:

  1. Seton drainage → resolution of sepsis
  2. ERAF (41–78%)[1]
  3. Tissue interposition (gracilis, Martius; 50–92%)[1]
  4. Proctectomy + coloanal anastomosis (primary or delayed; 81–91%)[1]
  5. APR — only when all of the above have failed or are infeasible

Technique highlights:

  • Abdominal phase — sigmoid and rectal mobilization with IMA ligation (or preservation if non-oncologic). TME usually unnecessary for benign disease — dissect closer to the rectal wall. Separate posterior vaginal wall from rectum, identify and divide the fistula tract.
  • Perineal phase — circumferential perineal incision; en bloc excision of rectum, anal canal, and sphincter complex; primary repair of the vaginal defect; in irradiated fields, consider myocutaneous flap closure of the perineal wound.[13][14]
  • Stoma — permanent end sigmoid colostomy in the LLQ.
  • Perineal-wound closure — primary closure standard; in irradiated / multi-reoperated fields, rectus abdominis (VRAM), gracilis, or gluteal turnover flap reduce wound complications.[13][14]

Complications:

Perineal wound complications dominate, especially in the RVF population (prior radiation, multiple operations):

  • Wound complication rate: 15% without prior radiation → 30–38% with neoadjuvant radiation.[13]
  • Persistent > 1 yr in ~10% of patients.[14]
  • Risk factors for dehiscence: ASA ≥ 4 (OR 2.2), smoking (OR 2.2), COPD (OR 1.7), BMI ≥ 35 (OR 1.9), anticipated flap closure (OR 2.9).[15]
  • Risk factors for deep SSI: African American race (OR 1.5), ASA ≥ 4 (OR 3.2), BMI ≥ 35 (OR 1.7), weight loss (OR 2.0).[15]

Other: urogenital dysfunction (bladder denervation, sexual dysfunction), perineal hernia (1.8–2.0%)[13], stoma-related complications (parastomal hernia, prolapse, retraction), persistent perineal sinus.

Quality of life and shared decision-making:

  • Proctectomy + permanent stoma yields better symptom relief than diversion alone — Zhong 2017: less tenesmus and anal discharge at 6 and 12 mo for proctectomy + diverting stoma (n = 10) vs colostomy alone (n = 16) in radiation RVF.[1][16]
  • Diversion alone leaves the diseased rectum in situ — ongoing tenesmus, mucous discharge, bleeding, and pain — symptoms eliminated by proctectomy.[11][16]
  • HRQoL — Dutch prospective cohort (n = 1,170): APR patients reported reduced HRQoL vs no-stoma; however, patients with major LARS after sphincter-preserving surgery reported similar HRQoL to those with a permanent stoma — a well-functioning stoma may be preferable to a poorly functioning neoanus.[17]
  • The AGA acknowledges that some women may accept residual fistula drainage over proctectomy + ostomy to optimize overall QoL — shared decision-making is essential.[12]

Etiology-specific considerations:

  • Radiation RVF — Zelga 2017 (n = 50): 96% could only undergo fecal diversion (not definitive repair); fistula healed in only 12%. Healing factors: distance > 7 cm from anal verge (OR 18) and loop ileostomy vs colostomy. Prolonged radiotherapy > 6 wk negatively correlated.[18] When diversion fails and the rectum is unsalvageable, APR is the definitive option. Resectional surgery in radiation proctopathy: morbidity 0–100%, mortality 0–14% — vs 0–44% / 0–11% for diversion alone.[19]
  • Crohn's RVF — Sapci 2023 tertiary referral (n = 80): only 20 underwent surgery to close the fistula; 70% healing, but 40% had ≥ 2 prior surgeries.[20] Up to 40% of perianal Crohn's ultimately require proctectomy.[21]

Role of Fecal Diversion​

  • Initial diversion is generally recommended as the first step for anastomotic-related RVF — ~37% heal with diversion alone.[1]
  • Concomitant diverting stoma independently predicts success — Corte 2015 multivariate OR 3.5 (P = 0.009).[2]
  • Most transabdominal repairs are performed with a temporary diverting ileostomy, reversed after confirmed fistula healing.

Outcomes Summary​

TechniqueSuccessKey complications
Resection + coloanal anastomosis81–91%[1][2][3]Anastomotic leak 17%, LARS 42%
Sleeve excision / pull-through75–79%[1]Early complications 51%, late 32%
Laparoscopic omentoplasty95–100%[4][8][9]Omental necrosis (rare), abscess
DCAA / Turnbull-Cutait81–86%[6][7]Leak 17%, major morbidity 23%
APRDefinitive (no recurrence)Permanent stoma

Independent predictors of success (Corte 2015, multivariate):[2]

  • Major procedure (OR 6.4)
  • Diverting stoma (OR 3.5)
  • Early surgery (OR 2.3)

Etiology: traumatic (iatrogenic / obstetric) fistulas have higher final-follow-up healing (92%) than inflammatory fistulas (46%).[3]

Key Considerations​

  • Preoperative optimization — resolution of active infection / inflammation, nutritional optimization; in Crohn's, endoscopic healing of rectal mucosa before repair[5]
  • Tissue interposition — omentum, gracilis, or Martius flap to introduce vascularized tissue in irradiated or scarred fields[4][8][9]
  • Functional outcomes — LARS affects a substantial proportion after proctectomy-based repairs; counsel preoperatively[6]
  • MIS — laparoscopic approaches to omentoplasty and resection achieve outcomes comparable to open[4][8]

References​

1. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473

2. Corte H, Maggiori L, Treton X, et al. "Rectovaginal fistula: what is the optimal strategy? An analysis of 79 patients undergoing 286 procedures." Ann Surg. 2015;262(5):855–860. doi:10.1097/SLA.0000000000001461

3. Söderqvist EV, Cashin PH, Graf W. "Surgical treatment of rectovaginal fistula — predictors of outcome and effects on quality of life." Int J Colorectal Dis. 2022;37(7):1699–1707. doi:10.1007/s00384-022-04206-7

4. van der Hagen SJ, Soeters PB, Baeten CG, van Gemert WG. "Laparoscopic fistula excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40 patients." Int J Colorectal Dis. 2011;26(11):1463–1467. doi:10.1007/s00384-011-1259-8

5. American Gastroenterological Association. "Medical position statement: perianal Crohn's disease." Gastroenterology. 2003;125(5):1503–1507. doi:10.1016/j.gastro.2003.08.024

6. Collard MK, Tuech JJ, Fernandez B, et al. "Delayed coloanal anastomosis for rectovaginal fistulas: insights from a multicenter cohort (GRECCAR)." Surgery. 2025;188:109767. doi:10.1016/j.surg.2025.109767

7. Blondeau M, Labiad C, Melka D, et al. "Postoperative rectovaginal fistula: can colonic pull-through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutive cases." Colorectal Dis. 2022;24(8):1000–1006. doi:10.1111/codi.16124

8. de Bruijn H, Maeda Y, Murphy J, Warusavitarne J, Vaizey CJ. "Combined laparoscopic and perineal approach to omental interposition repair of complex rectovaginal fistula." Dis Colon Rectum. 2018;61(1):140–143. doi:10.1097/DCR.0000000000000980

9. Schloericke E, Hoffmann M, Zimmermann M, et al. "Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas." Colorectal Dis. 2012;14(5):604–610. doi:10.1111/j.1463-1318.2011.02719.x

10. Lichtenstein GR, Loftus EV, Afzali A, et al. "ACG clinical guideline: management of Crohn's disease in adults." Am J Gastroenterol. 2025;120(6):1225–1264. doi:10.14309/ajg.0000000000003465

11. Anseline PF, Lavery IC, Fazio VW, Jagelman DG, Weakley FL. "Radiation injury of the rectum: evaluation of surgical treatment." Ann Surg. 1981;194(6):716–724. doi:10.1097/00000658-198112000-00010

12. American Gastroenterological Association. "Medical position statement: perianal Crohn's disease." Gastroenterology. 2003;125(5):1503–1507. doi:10.1016/j.gastro.2003.08.024

13. You YN, Hardiman KM, Bafford A, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of rectal cancer." Dis Colon Rectum. 2020;63(9):1191–1222. doi:10.1097/DCR.0000000000001762

14. Kreisel SI, Sharabiany S, Tuynman J, et al. "Perineal wound closure using gluteal turnover flap after abdominoperineal resection for rectal cancer: the BIOPEX-2 randomized clinical trial." JAMA Surg. 2025;160(4):378–385. doi:10.1001/jamasurg.2024.6818

15. Althumairi AA, Canner JK, Gearhart SL, et al. "Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database." Colorectal Dis. 2016;18(7):O260–O266. doi:10.1111/codi.13384

16. Zhong Q, Yuan Z, Ma T, et al. "Restorative resection of radiation rectovaginal fistula can better relieve anorectal symptoms than colostomy only." World J Surg Oncol. 2017;15(1):37. doi:10.1186/s12957-017-1100-0

17. van Kooten RT, Algie JPA, Tollenaar RAEM, et al. "The impact on health-related quality of a stoma or poor functional outcomes after rectal cancer surgery in Dutch patients: a prospective cohort study." Eur J Surg Oncol. 2023;49(9):106914. doi:10.1016/j.ejso.2023.04.013

18. Zelga P, Tchórzewski M, Zelga M, Sobotkowski J, Dziki A. "Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies — new patients, old problem?" Langenbecks Arch Surg. 2017;402(7):1079–1088. doi:10.1007/s00423-016-1539-4

19. McCrone LF, Neary PM, Larkin J, McCormick P, Mehigan B. "The surgical management of radiation proctopathy." Int J Colorectal Dis. 2017;32(8):1099–1108. doi:10.1007/s00384-017-2803-y

20. Sapci I, Zutshi M, Akeel N, Hull T. "What are the outcomes in patients referred to a tertiary referral centre for Crohn's rectovaginal fistula surgery?" Colorectal Dis. 2023;25(8):1653–1657. doi:10.1111/codi.16660

21. Lightner AL, Holubar SD. "Surgical treatment of inflammatory bowel disease." In: Yamada's Textbook of Gastroenterology. 7th ed. Wiley; 2022:Chapter 65.