Figure 1 shows several rectovaginal fistulae with a honeycomb appearance. An incision that encompasses the entire fistulae should be made in the posterior vaginal wall mucosa.

The fistula tract has been removed down to the rectal mucosa. The margins of the vagina that remain are elevated and mobilized with sharp dissection. A perineotomy incision is made through the vagina, the superficial transverse peritonea (STP), the anal sphincter, and anal mucosa.

Figure 3 illustrates the surgical removal of the fistulae, the perineotomy with the transected anal sphincter, the transected superficial transverse peritonea, and the rectovaginal space that has been developed surgically between the vaginal mucosa and the rectum (R).

The rectum is repaired with a far-near-near-far Connell inverting suture that inverts the mucosa into the lumen of the rectum. Care is taken that the knot is tied in the rectum to prevent the knot from becoming a wick for bacteria in this area.

The rectum is repaired down to the anal mucosa; the sutures are then cut. 1-5.

Figure 6 shows the anterior rectal wall with far-near-near-far sutures in place. The excess suture outside the knot can be cut. This differs from the traditional technique where woven suture products were used, since the sutures had to be left long so they could be removed from the wound on the seventh postoperative day. After the rectal mucosa has been sutured, a decision must be made to bring in an exterior source of blood supply, such as the bulbocavernosus muscles with their vestibular fat pad. If that is to be performed, it should be performed at this point, and the bulbocavernosus muscle with its fat pad should be sutured over the rectal suture line before beginning the posterior repair with plication of the levator muscle in the midline.

After the rectal mucosa has been sutured closed, the finger of the left hand is placed on top of the rectal suture line. This invagination produces prominence of the levator ani muscles. Delayed synthetic absorbable suture is placed in the levator muscles to plicate them on top of the rectal suture line.

The levator plication has taken place over the rectal suture line. The stumps of the superficial transverse peritonea muscle must be identified, especially with their fascia sheaths. The anal sphincter muscle should be identified, and care should be taken to identify its fascia sheath. Sutures are placed through the fascia sheath and muscle. Generally, four sutures are used in a points-of-the-compass pattern.

Figure 9 shows the rectal mucosa sutured. The levator ani muscles have been plicated over the rectal mucosa, the anal sphincter is plicated in the midline, and now the stumps of the superficial transverse peritonea (STP) muscle are identified, and sutures are placed in the fascia of this muscle in a points-of-the-compass pattern.

The vaginal mucosa is closed with a running synthetic absorbable suture. Note that the knot is tied at the top of the vagina, and one strand of the knot is left long, coming on top of the levator repair underneath the vaginal mucosa. This strand of suture, when tied, will further plicate the top of the vagina posteriorly on top of the rectum, creating the so-called hockey-stick pattern of the vaginal canal.

The suture has been extended out over to the skin of the peritoneal body. Note that the long end is tied to the end of the running suture. When this is performed, the upper vagina is pulled posteriorly onto the rectum.

A finger could be inserted in the vagina, and a finger should be inserted in the rectum. These fingers should make a 90 dgree angle. Postoperatively, the patient is placed on running daily doses of mineral oil and a low-residue diet. We would prefer the patient have loose watery stools every day for 2 weeks. After each watery stool, she should be cleaned with a septic solution.