This video presents a perineal repair of a recurrent rectovaginal fistula with sphincteroplasty and levatoroplasty. The patient is a 26 year old female with a history of a fourth degree perineal tear 3 years prior to this presentation. This was repaired primarily at the time of injury but resulted in a rectovaginal fistula with associated fecal incontinence to gas and liquid stools. About six months prior to this presentation, she underwent rectal advancement flap at an outside institution, which failed. Repair of the recurrent fistula via perineal approach is presented. Generous mobilization of the external sphincter was performed, preserving a layer of surrounding, well vascularized tissue. Careful dissection was carried out in the scarred rectovaginal septum, dividing the fistula tract and extending the dissection two centimeters proximally. The levator muscles were exposed and mobilized. The fistula defect was repaired primarily on both the rectal and vaginal sides. A levatoroplasty and sphincteroplasty were performed to bolster the repair and strengthen the perineal body and sphincter complex. The skin was left open for drainage and ultimately healed via secondary intention. Finally, the patient was managed with ten days of a clear liquid diet and total parenteral nutrition as an outpatient, as an effective alterative to fecal diversion.