Figure 1. Initial surgical exposure and skin incision. (A) Intraoperative photograph showing the initial surgical field immediately after skin incision for rectovaginal fistula repair. The anus is positioned superiorly and the vagina inferiorly in the image. An 8-French Nelaton catheter is inserted through the fistulous tract to serve as a landmark. Note the shortened distance between the anal and vaginal openings due to a perineal body defect. A transverse S-shaped skin incision is placed on the vaginal side to avoid injury to the residual anal sphincter muscle. (B) Schematic diagram illustrating the surgical approach, with the rectum and vagina clearly differentiated.
Figure 2. Fistulous tract exposure and luminal assessment. (A) Surgical field showing advancement of dissection to reach the fistulous tract, which has been opened to visualize the internal lumen. Dissection proceeds toward both vaginal and rectal sides to ensure complete removal of all fistulous tissue without residual tract remnants. (B) Schematic representation of the fistulous tract exposure and the extent of dissection required for complete tract removal.
Figure 3. Fistulous tract excision and debridement of contaminated tissue. (A) Intraoperative view showing extension of fistulous tract excision to the vaginal side. The contaminated vaginal wall surrounding the fistular origin is excised en bloc with the tract. A similar en bloc excision of the contaminated rectal wall is performed on the rectal side. Even fistulas with diameters less than 1 cm may result in defects reaching approximately 5 cm after complete debridement of contaminated tissue. (B) Diagram illustrating the en bloc excision of the fistulous tract with portions of both rectal and vaginal walls, followed by separate suture closure of each luminal defect.
Figure 4. Perineal body assessment and tissue viability testing. (A) Intraoperative demonstration of traction suture placement on bilateral perineal body remnants. The sutures are crossed at the midline to assess tissue integrity and mobility. Adequate perineal body tissue should demonstrate elastic properties allowing mobilization across the midline without incorporating overlying rectal or vaginal walls. (B) Schematic illustration of the traction test to evaluate perineal body viability and elasticity.
Figure 5. Perineal body reconstruction with multilayer suturing. (A) Intraoperative photograph showing multilayer suture repair of the perineal body. Reconstruction is performed in 4-5 distinct layers from the deepest to most superficial planes, using 3-0 absorbable sutures with typically more than 10 interrupted sutures in total across all layers to achieve three-dimensional anatomical restoration of the perineal body. (B) Schematic diagram illustrating the layered reconstruction technique for optimal perineal body restoration.
Figure 6. Final surgical result and wound closure. (A) Completed surgical repair showing subcutaneous interrupted sutures and continuous skin closure with perineal reconstruction. Anal swelling frequently occurs postoperatively, necessitating skin-only relaxing incisions to prevent sphincter muscle injury. The successful perineal body reconstruction results in increased distance between vagina and rectum (restored perineal length), with wound closure performed in a vertical direction. (B) Schematic diagram showing the final anatomical result with restored perineal anatomy and proper anal-vaginal separation.
