In this surgical video, we demonstrate a unique approach to repairing a complex rectovaginal fistula using a non-cross-linked porcine dermal graft. Our patient is a 53-year-old para 3 female who has a 29-year history of a rectovaginal fistula that developed following the birth of her second child. Due to a large complex fistula with a weakened rectovaginal fascia, the patient elected to undergo a repair using a xenograft augmentation. Rectovaginal fistulas are commonly classified as being simple or complex. Criteria for classification of a complex rectovaginal fistula are seen on the slide. Our patient fits this criteria from the large size of her fistula. The xenograft used in this video is an acellular reconstructive tissue matrix designed to support tissue regeneration. It is derived from porcine dermis, which undergoes a complex process that reduces the likelihood of xenogenic rejection. It is thought to promote tissue regeneration and should transition to host tissue. Indications include use as a soft tissue patch to reinforce soft tissue where there is weakness or damage, and for the repair of hernias or body wall defects, which require the use of reinforcing material to obtain the desired surgical outcome. An exam under anesthesia shows a large 2 1⁄2 by 3 cm rectovaginal fistula in the distal 1⁄3 of the rectum proximal to an intact external anal sphincter. The vagina is infiltrated with marcaine with epinephrine in order to help with dissection. The fistula tract is grasped using Alice clamps in a circumferential manner to provide traction. The perineum is cut in the midline using electrocautery. The fistula tract is then excised. The rectal mucosa edges are identified and grasped, and using foromonical sutures the mucosal edges are re-approximated. The mucosa is then imbricated using foromonical suture. The perineal body is re-approximated using 2-O-Vicryl in an interrupted fashion. The vaginal epithelium is dissected off the underlying fascia. An 8 by 6 cm piece of graft material is trimmed in order to cover the dissected area. A 2-O-PDS suture is placed at the apex of the dissection and threaded through the apex of the graft material and tied down. 2-O-PDS sutures are likewise placed in the corners laterally and distally. The graft material is further trimmed, creating a total size of 3 by 4 cm. The distal portion of the graft is transfixed to the newly approximated perineal body. Copious amounts of irrigation are applied to the incision. The patient was discharged home with scheduled stool softeners and a low residue diet. Postoperatively the patient did well and at one year follow up had no recurrence of the fistula and no complaints of pain or abnormal discharge.

surgical video

rectovaginal fistula repair

porcine dermal graft

xenograft augmentation

tissue regeneration