This video shows the technique of an overlapping sphincteroplasty and endorectal advancement flap for rectovaginal fistula associated with an obstetric injury. The patient is a 29 year old white female who sustained an anal sphincter laceration following vacuum extraction of an 8lb baby 6 months prior to consultation. She subsequently developed stool and gas leakage into the vagina as well as fecal incontinence with a Cleveland Clinic Florida Fecal incontinence score of 12/20. On physical exam, the rectovaginal septum was thin and an obvious rectovaginal fistula was present at the dentate line.

A curvilinear incision is made in the perineum between the vagina and anus. Dissection is deepened into this space up to the level of the levators. A levatorplasty is performed by suturing together portions of the puborectalis anterior to the rectum. Portions of the posterior vaginal wall are imbricated over the tract but the vaginal opening of the tract is left open for drainage. The internal anal spincter is imbricated. Finally, the ends of the external anal sphincter are overlapped and secured with mattress sutures placed circumferentially around the edges. The portion of anoderm containing the fistula is removed by transaction of the distal most aspect of the flap which is then advanced and the skin edges partially closed.