TJ is a 59-year-old with a medical history significant for Crohn's disease, Crest syndrome, fecal incontinence, a rectovaginal fistula, as well as obesity. She underwent the surgical repair of an analvaginal fistula and anal sphincterplasty. Postoperatively, she had extensive wound breakdown with inflammation resulting in the formation of a cloaca. She then underwent a permanent diverting colostomy. She was sexually active preoperatively. Crest syndrome is caused by an autoimmune reaction that causes collagen overproduction. Given its multifactorial nature, in addition to Crohn's disease, the patient was extensively counseled regarding the risk of wound breakdown and cloaca formation again. Crest syndrome led to difficulty with re-approximation and impaired wound healing in this patient. The patient's Crohn's disease has clear issues from the initial fistula formation to her postoperative wound complications. For over 80 years, the Martius flap has been implemented to aid in wound healing and prevention of fistula recurrence. Its diverse application stems from its dual blood supply, both anteriorly and posteriorly. Obstetrical injury is the most common cause of rectovaginal fistula formation. However, other causes, such as those akin to the patient, such as Crohn's disease and prior anorectal surgery, can also affect restoration of normal anatomy and healing. There are multiple closure techniques for cloaca or rectovaginal fistula repair. However, by maintaining attention-free approximation, antibiotics, and diligent wound care, the patient experienced a positive outcome. At the beginning of the procedure, the vaginal mucosa abuts the rectal mucosa with no intervening anal sphincter, perineal body, posterior vagina, or anterior rectum. A inverted U-shaped incision is created, separating the rectum from the vagina, as well as giving us the ability to isolate the anal sphincter to the level of the ischiorectal fossa. Strap dissection is utilized to separate the rectum from the vagina, given the extensive scarring after prior surgery, infection, and breakdown. Once the rectum and vagina are separated, the retracted fragments of the anal sphincter are isolated, dissected free, and brought together as an overlapping anal sphincterplasty. Also re-approximated is the rectal mucosa, submucosa, and rectovaginal septum. Clearly the posterior compartment is well reconstructed. Incisions are made over each vulva to isolate the bulbocavernosis fat pad using sharp dissection. The bulbocavernosis fat pad is left connected to its posterior blood supply and brought underneath the vaginal mucosa to separate the vagina from the rectum at the conclusion of the procedure. The retracted fragments of the perineal body are re-approximated in the midline. The martius flaps are sutured into place, the right being more cranial and the left being more caudal. The vulvar skin is re-approximated with a subcuticular closure. This is the result at the end of the procedure. The patient is seen here two months postoperatively. Clearly her surgical result is optimal given her preoperative anatomy. The anal sphincter tone is excellent, but formal testing will reveal function. The vaginal canal has normal caliber and length. A special thank you to our patient, TJ, who allowed us to chronicle her surgery and recovery for our education. This has been a presentation of Westridge OBGYN urogynecology. For more information, visit www.bestdocsnetwork.com

rectovaginal fistula

cloaca

Martius flap

wound care

surgical results