Martius Flap for Persistent, Complex Rectovaginal Fistula.

520 DISEASES OF THE COLON & RECTUM VOLUME 61: 4 (2018) Rectovaginal fistulas constitute less than 5% of all anorectal fistulas. However, symptoms cause significant sexual and social distress. Symptoms include passage of air, stool, or purulent discharge from the vagina; recurrent urinary tract infections; and recurrent vaginal infections. Most rectovaginal fistulas are secondary to obstetric trauma. The remainder results from pelvic surgery, IBD (especially Crohn’s disease), malignancy, and radiation therapy. Many surgical options exist including primary local repair, plug, advancement flaps, muscle flaps (gracilis flap, Martius flap), transadominal ligation, and mesh repair. The type of repair and approach depend on location, etiology, morphology of fistula, and history of prior repair. Low fistulas may be repaired via anal, perineal, or vaginal approaches. High fistulas typically are repaired via an abdominal approach. Fecal diversion is not necessary, but may be considered after multiple failures. Endoanal suturing and advancement flaps are usually the first step; however, if those fail, other techniques are utilized. The Martius flap was first described as a technique to repair cystovaginal and urethrovaginal fistulas. This technique has since been adopted to repair low rectovaginal fistulas. It is indicated for complex or recurrent fistulas and has a success rate of 65% to 100%. The flap is a pedicled muscular graft derived from the bulbocavernosus muscle (also known as the bulbospongiosus muscle) and labial fat pad. The perineal branch of the pudendal artery supplies this graft entering the muscle from an inferoposterior position. After a vaginal flap is created to separate the rectovaginal septum above the defect, the graft is released via an incision over the labia majora. Dissection starts superiorly to prevent damage to the blood supply, which enters inferiorly. The flap is then tunneled through the subcutaneous tissues to the vaginal side and covers the rectal closure that provides healthy tissue separating the rectal and vaginal walls. See Video Abstract at http:// links.lww.com/DCR/A511.

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