Low Rectovaginal and anovaginal fistula repair using a gracilis muscle flap at Groote Schuur Hospital

Motlaleselelo, Pako

Low Rectovaginal and anovaginal fistula repair using a gracilis muscle flap at Groote Schuur Hospital

Thesis / Dissertation

2026

Publisher

University of Cape Town

Department

Division of General Surgery

Faculty

Faculty of Health Sciences

Abstract

Introduction RVF is a severely debilitating condition with a significant impact on the patient's physical, social, and psychological well-being yet treatment is challenging fraught with high recurrence rates and absence of standardized treatment algorithms. Surgery remains the cornerstone of management despite the absence of a single surgical treatment considered to treat all RVF adequately. Gracilis flap has been used as an attractive option with high success and low complication rates. The body of literature regarding the application of the gracilis flap for addressing rectovaginal fistulas consists of fewer than 40 minor retrospective case series. Furthermore, there is a lack of local data assessing the effectiveness and usefulness of gracilis flaps for addressing RVF in patients from South Africa. Methods In this study, we are aiming to describe our experience in terms of safety and efficacy. After obtaining human research ethics committee approval, a retrospective review of all patients who underwent repair of rectovaginal or anovaginal fistula using gracilis muscle flap between January 2016 and December 2022 was undertaken. Data on patients' demographics, clinical presentation, fistula characteristics, and operative and surgical outcomes were obtained. Clinic follow-up notes were used to look at three months of recurrence after the gracilis flap repair and also three months after stoma closure. Results Over a period of 7 years from 2016 to 2022, six patients underwent retrograde gracilis muscle transposition flap. Patients' age ranged from 19 to 64 years. The main presenting symptoms were passing stool per-vagina. The underlying etiology was an obstetric injury in three patients (50%), foreign body in one patient, post-surgery for rectocele repair in one patient, and the last one of unknown etiology in HIV patient (Table 1). Three patients were found to have RVF with sphincter injury; one was repaired before she was referred to the pelvic floor clinic (patient 4) and the other two referred with concomitant sphincter injury with and without incontinence in patients 5 and 6 respectively. Patient 5 had simultaneous RVF gracilis flap and sphincter injury repair. Patient 6 had a staged procedure, where sphincter repair followed by sacral nerve stimulator was performed before the RVF gracilis 4 flap repair. All patients had previous repair once or twice with either simple repair or advancement flap repair (Table 2). All patients had a covering sigmoid loop colostomy either before or in the same setting with the RVF repair. In this series, the three months success rate was 100%, but both short- and long-term complications were reported in three patients, 50%. The short-term complications were SSI and gracilis flap incomplete necrosis that required debridement under general anaesthesia. Also, two patients developed a parastomal hernia. The mean time from RVF repair to loop colostomy closure was (12.1 months) ranged from 4 to 20 months. Two of the three patients who had stoma closure within one year, had an early closure because they developed a symptomatic parastomal hernia. There were no RVF recurrences reported up to three months after stoma closure (Table 3). Conclusion We concluded that the use of Gracilis flap resulted in very low rates of recurrences but stoma closure rates of 50% at one year thus proving a safe and effective treatment option in patients with complicated rectovaginal fistulas, in addition gracilis flap is an ideal option in patients who have had previous failed attempts at repair.