Background: Gracilis muscle interposition (GMI) is a good option for repair of multiple recurrent rectovaginal fistula (RVF).

Methods: This video illustrates the operation proximal and distal.

Results: The patient is placed in the Lloyd-Davies position. Thigh incisions are made after which the muscle is dissected to the level of the proximal neuromuscular pedicle. The tendon is distally divided and the distal muscle is then delivered to the proximal incision and tunneled into an ipsilateral stab wound through which it is sutured to the skin. After wound closure, the patient is carefully repositioned into the prone jackknife position; an incision is made through the perineal body and deepened. The edges of the fistula are resected and both rectal and vaginal sides are closed as advancement flaps. The muscle is then fixed to the apex of the dissection with interrupted sutures. Patients ambulate after 3 days of bed rest in an adduction splint. Intravenous antibiotics are administered for 72 hours followed by 7 days of oral antibiotics. This patient sustained a postpartum RVF and, after 13 failed operative procedures, underwent GMI. Her hospital course was unremarkable, and exam under anesthesia as well as vaginogram and enema confirmed fistula closure. Three months later, the patient underwent ileostomy closure.

Conclusions: GMI is a feasible approach to treat complex multiple recurrent RVF.