Minimally invasive transanal repair (MITAR) for rectovaginal fistulas: a novel technique

A rectovaginal fistula (RVF) is an abnormal epithelialized connection between the rectum and vagina. Surgical repair is the treatment of choice but is challenging, particularly for fistulas in the middle and lower rectum, where conventional transabdominal or transperineal procedures offer limited access. This study describes a novel minimally invasive transanal repair (MITAR) technique for mid- and lower rectovaginal fistulas. RVF develop following vaginoplasty for a rudimentary vagina, low colorectal anastomosis for rectal carcinoma, and rectocele repair. All had preexisting protective diversion stomas. Patients were operated on under general anesthesia in the prone position. The transanal access port (Gel POINT path platform) was introduced, and the pneumorectum was maintained at 12–14 mmHg. The rectal and vaginal walls were separated at the fistula site and mobilized circumferentially along the rectovaginal septum for at least 1 cm. The mobilized vaginal and rectal walls were closed transversely one after the other through the transanal route. The diversion stoma was subsequently closed. MITAR was completed successfully in all three patients. The technique provides direct access to the fistula site. A magnified and excellent endoscopic view helped with precise and meticulous dissection. Patient recovery was uneventful. At a mean follow-up of 29 months, there was no recurrence. MITAR is a safe, feasible, and effective approach for the repair of middle and low rectovaginal fistulas. This minimally invasive technique offers excellent visualization, precision, and tension-free closure of the fistula. This technique can be considered an alternative to existing techniques for RVF repair.