Rectovaginal fistulas are notoriously difficult and debilitating conditions for both the patient, who has to live with a physically and emotionally distressing condition, and for the surgeon, who faces the challenging task of surgical repair.

Special consideration is taken in patients with IBD-related complex fistulas.

The patient is placed in the Lloyd-Davies position in Allen stirrups. Two incisions are made, one in the proximal left thigh and one in the distal left thigh. Perforating vessels are divided with the 5 mm diameter Harmonic scalpel. The tendon is divided proximal to the knee joint and the entire muscle is retrieved through the proximal incision. The muscle is mobilized to the level of the neurovascular pedicle, tunneled and brought out through a stab wound at the left lateral aspect of the intended perineal incision. The tendon is sutured in place. The thigh wounds are closed. Patient is repositioned in the prone jackknife position on a Kraske roll. A 120 degree anterolateral circumanal incision is made in the anovaginal septum. After healthy supple avascular tissue is encountered cephalad, the fistula is debrided on both sides and closed. Several sutures are used to map the area where the gracilis muscle is to be brought in. The muscle rests from a caudad to cephalad direction. The muscle is secured in place. Closed suction drains are left along the thigh tunnel and perineum. The skin is closed in layers. Patient is transferred into an adduction splint.

Graciloplasty is an effective modality for recurrent or complex fistulas.