Double-sided folded internal pudendal artery perforator flap for the repair of a recurrent rectovaginal fistula

A 53-year-old woman underwent 3 fistulectomies performed by a colorectal surgeon due to a recurrent rectovaginal fistula (RVF), which developed 2 years after complicated labor dystocia with an episiotomy. Nonetheless, the fistula recurred, and the patient was referred to the Department of Plastic and Reconstructive Surgery, where a plan was made to use a double-sided folded internal pudendal artery perforator (IPAP) flap to repair the recurrent RVF ([Fig. 1A]). Prior to this operation, a laparoscopic diverting loop ileostomy was performed by a colorectal surgeon.

Fig. 1. Double-sided folded internal pudendal artery perforator flap operation. A recurrent RVF with a diameter of about 40 mm, located approximately 7 cm upward from the anus, was present (A). A folded IPAP flap was designed in an area 3 cm from the perineum and 9 cm cranially. “X” indicates the location of the perforator vessel, as confirmed by Doppler ultrasonography. A de-epithelialized area was located between “R” and “V,” and was folded (B). Immediate postoperative photograph shows that both the vaginal and rectal opening of the fistula were covered with a well-vascularized skin paddel (C). RVF, rectovaginal fistula; IPAP, internal pudendal artery perforator.

After complete debridement of the fistula and the surrounding unhealthy tissue, the exact localization of the flap to be elevated was determined via tracing of the IPAP using Doppler ultrasound ([Fig. 1B]). The flap was partitioned into 2 compartments in a distal to proximal direction from the perforator, and each flap was designated as “R” and “V,” respectively. The “R” and “V” areas were determined considering the size of the rectal opening and the distance between the vulva and the vaginal opening. The proximal part of the “R” flap was de-epithelialized and folded with the subcutaneous fat sides facing each other, and was then transposed between the vagina and rectum to Creplace the damaged rectovaginal septum ([Fig. 2]). As a result, both the vaginal and rectal openings of the fistula were covered with a well-vascularized skin paddle ([Fig. 1C]).

Fig. 2. A schematic illustration of the double-sided folded IPAP flap. Preoperative state of the RVF, which connected the posterior vagina and anterior rectum (A). Flap design and elevation; “R” and “V” indicate the distal and proximal parts of the flap, respectively, and the proximal part of “R” was deepithelialized (B). The flap was folded and fistula debridement was performed; the arrow indicates the direction in which the flap rotated (C). Both the vaginal and rectal openings were covered with the skin paddle of the IPAP flap (D). IPAP, internal pudendal artery perforator; RVF, rectovaginal fistula.

At a 3-month postoperative visit, the fistula was confirmed to be completely closed by a Gastrografin contrast enema ([Fig. 3]), and transrectal ultrasonography performed 1 year postoperatively also showed no evidence of RVF recurrence ([Fig. 4]).

Fig. 3. Three-month postoperative fistulography. No visible contrast leakage or abnormal fistulous tract was observed in the lateral view.

Fig. 4. Transrectal ultrasonography. Preoperative TRUS; yellow arrows indicate the RVF (A), and there was no evidence of RVF recurrence on 1-year postoperative TRUS (B). TRUS, transrectal ultrasonography; RVF, rectovaginal fistula.

RVF is not a common complication of pelvic procedures. However, RVF repair is usually challenging for both patients and surgeons because of its high recurrence rate after primary repair [1]. The inflamed state of the tissue, poor vascular perfusion of the bed, and fibrotic adhesions from prior surgery are thought to be the most important factors contributing to recurrence. Therefore, treatment of recurrent RVF necessitates coverage of both the vaginal and rectal sides of the fistula with healthy, well-vascularized, perfused flaps [2]. Various surgical techniques, such as random pattern flaps, muscle transposition, and even artificial mesh grafts, have been tried for repairing recurrent RVF. However, none of these methods have been accepted as a procedure of choice because of an unsatisfactory recurrence rate and poor cosmetic and functional outcomes [1]. In this case, a technique covering the entire fistula region with a well-vascularized IPAP flap was utilized. The IPAP flap is considered an excellent choice for reconstruction of the pelvic region because it can be used without causing any notable functional deformities. Furthermore, it has a dominant vascular pedicle that can be used for perineal transposition with adequate length. All these factors contribute to the use of the IPAP flap in pelvic reconstructive surgery [3]. However, adaptation of the folded IPAP flap to cover both the vaginal and rectal sides at the same time in the treatment of a recurrent RVF has not been previously reported, and the outcome was satisfactory. In conclusion, the use of a double-sided folded IPAP flap can be considered a reliable and feasible procedure to cover both the vaginal and rectal sides of an RVF with a well-vascularized, perfused skin paddle.

Patient Consent

The patient provided written informed consent for the publication and the use of their images.

The authors would like to thank Dong-Su Jang, a medical illustrator in the Medical Research Support section of Yonsei University College of Medicine, Seoul, Korea, for assistance with the illustration.

Publication History

Received: 07 February 2017

Accepted: 19 September 2017

Article published online:
03 April 2022

• References

• 1 Kaoutzanis C, Pannucci CJ, Sherick D. Use of gracilis muscle as a "walking" flap for repair of a rectovaginal fistula. J Plast Reconstr Aesthet Surg 2013; 66: e197-200
• 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: 855-60
• 3 Hashimoto I, Abe Y, Nakanishi H. The internal pudendal artery perforator flap: free-style pedicle perforator flaps for vulva, vagina, and buttock reconstruction. Plast Reconstr Surg 2014; 133: 924-33