Rectovaginal fistula is a challenging pathology due to its difficult resolution and high recurrence rate. The treatment failure is associated with endorectal ultrasound alterations, previous surgeries, Crohn´s disease, previous pelvic radiation, and recurrent fistula. Marthuis Flap is an option in those cases.
This video shows the surgical steps followed for the rectovaginal  repair using a combined transperineal and rectal approach by interposing a Marthuis Flap.

The case presented here was a 41-year-old female patient who consulted due to loss of fecal matter through the vagina. As a history, she refers an hemorrhoid surgery after which the symptoms began and two unsuccessful surgical repair of the rectovaginal fistula. The first surgery was an endorectal approach and the second one a perineal and rectal approach. 
Physical examination revealed a normotonic sphincter and a rectovaginal fistula in the lower third of the vagina. 360° 3D endorectal ultrasound showed on  the left anterolateral a fistulous tract between the rectum and the lower third of the vagina.
A combined transperineal and rectal approach was performed with the use of the Marthius flap.
The aim of this presentation is to introduce the case describe above and show the surgical repair (video) of a recurrent rectovaginal fistula using the Martius procedure.

Under general anesthesia, the patient was placed in a lithotomy position, and after broadspectrum antibiotic was provided. A transperineal transverse approach was performed. Careful blunt and sharp dissection was used to separate the vaginal mucosa from the fistula. The vaginal orifice was closed with vycril after resection of fibrosis from the edges. Incision on labia majora. Pediculed flap dissection. Transposition to the perineum without tension. Perineal and labia closure. A rubber sheet is placed. Advancement of rectal mucosa flap for endoanal closure. The patient was discharged after 24 hours of hospitalization without immediate complications.
Upon clinical evaluation at 2 months follow-up, the fistula's symptoms had resolved. The perineal and rectal scars were correctly closed with no visible defect at the rectoscopy.

Rectovaginal fistula has a high recurrence rate. Performing a Marthuis flap is a feasible adjuvant technique for recto vaginal fistula with excellent postoperative outcomes.

Continence 12S (2024) 101636
DOI: 10.1016/j.cont.2024.101636