VM20 - Martius Flap Reconstruction for an Obstetric Induced Rectovaginal Fistula

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Purpose/Background: The surgical approach to rectovaginal fistulas is complex and dependent on patient anatomy and etiology of fistula development. It is postulated that obstetric-induced rectovaginal fistulas are due to prolonged vaginal delivery which may cause pressure necrosis of the rectovaginal septum. The Martius flap was first described in 1928 and involves harvesting a pedicled labial fat pad which is rotated as a flap into the rectovaginal septum after primary takedown and repair of the fistula.

Methods/Interventions: We present an otherwise healthy 35-year-old female patient who presented with stool and flatus per vagina for 6 years. Pertinent obstetric history included a prolonged vacuum forceps assisted vaginal delivery. She underwent rectal examination under anesthesia and flexible sigmoidoscopy which demonstrated a low-lying anterior midline rectovaginal fistula; she also had a thin perineal body and normal rectal mucosa. Given the thin perineal body and anterior nature of her fistula she was recommended to undergo a Martius flap reconstruction.

Results/Outcomes: After general anesthesia was achieved in the operating room, she was positioned in lithotomy. A longitudinal incision was made over the left labia majora and carried down to the labial fat pad. This fat pad was carefully dissected, starting laterally, then working superomedially in order to preserve the inferomedial pedicle. Silk stay sutures were used to aid in retraction. The preserved pedicle arises from the perineal branch, off of the internal pudendal artery. Next, a transverse incision was made over the perineal body. This was carried deeper until the fistula came into view; the fistula was isolated and divided. Each side of the fistula was closed using 3-0 PDS in an interrupted fashion. A fistula probe was used to confirm successful ligation of the tract. A subcutaneous tunnel was developed from harvest site to the rectovaginal septum to accommodate the pedicled flap. Once positioned, the flap was gently secured into place with 3-0 Vicryl suture. Both incisions were closed in multiple layers using Vicryl followed by Monocryl. The patient tolerated the procedure well and was discharged home the same day. To date, she has been followed for 5 months postoperatively with no evidence of recurrent symptoms.

Conclusion/Discussion: The Martius flap remains a safe and optimal surgical repair option for women with a rectovaginal fistula with a thin perineal body. Success rates range from 60 to 100%. Given the smaller size of the flap, this usually does not cause any deformity or bulky sensation in the rectovaginal septum, which may occur with use of a Gracilis flap. The Martius flap provides a buttress to prevent recurrence and yields excellent cosmesis.