Rectovaginal fistulas can be simple or complex. For simple RVF, sliding advancement flaps are the most popular surgical options for repair, performed either rectally or vaginally. In patients with an associated anal sphincter defect, the advancement flap is usually combined with an overlapping sphincteroplasty. However, for complex RVF, the surrounding tissue is often abnormal, requiring excision to reach healthy tissue. Alternatively, well vascularized tissue can be interposed between the rectum and vagina. Many tissue interposition techniques have been described using grafts of omentum, gracilis, sartorius, gluteus maximus, or rectus abdominus. Their purpose is to avoid direct apposition of two suture lines and to introduce healthy, well vascularized tissue into the area. In this video we describe the technique of gracilis muscle harvesting and interposition for complex RVF.