Fluorescence-guided gracilis muscle flap in the treatment of complex rectovaginal fistula

Aim:

Show step by step the gracilis muscle interposition technique in the treatment of complex rectovaginal fistula with the technological incorporation of fluorescence-guided surgery to assess correct flap perfusion.

Material and method:

A 76-year-old woman with a history of squamous cell carcinoma of the anus was treated with radiotherapy and chemotherapy. Currently disease free. She presents a complex fistula characterized by a diameter greater than 2.5 cm, medium height, and poor quality of the surrounding tissues. A fluorescence-guided tissue transposition technique is performed. With the patient in the lithotomy position, a transperineal approach is performed, with dissection of the rectovaginal space and closure of the affected rectal and vaginal portion. The gracilis muscle is dissected circumferentially through an incision on the inner side of the thigh, preserving its localized vascular supply at the junction of the proximal third with the distal two thirds at the posterior level of the muscle. It is divided above its distal insertion. Finally, it is mobilized to tunnel it subcutaneously to the dissected rectovaginal space, interposing itself between the rectal and vaginal repairs. ICG infusion fluorescence technology is used to assess the correct vascularization of the flap and thus prevent possible causes of necrosis in a fast, safe and simple way. The gracilis muscle is sutured at that level in order to fix it and prevent its retraction.

Conclusions:

The technical goal is to place healthy, well-vascularized muscle tissue in the rectovaginal space after closure. Meticulous identification and preparation of the vascular pedicle is crucial. Assessment of muscle perfusion after full mobilization and before final placement is critical. And fluorescence-guided surgery is a tool that can help us achieve this goal.