Treatment of rectovaginal postanastomotic fistula with a transanal endoscopic operation – a video vignette

The reported incidence of postsurgical rectovaginal fistula is very low, with no overall systematic approach to treatment. We report the case of a rectovaginal fistula after resection of the rectum with total mesorectal excision. The 55‐year‐old patient had undergone neoadjuvant chemoradiotherapy prior to surgery 1-6. Three months postoperatively the patient developed a rectovaginal fistula at the level of the anastomosis some 10 cm from the anocutaneous margin. Initially, the Ovesco Over‐The‐Scope Clip system was used for managing the fistula, but the fistula returned after a month. We then decided to use a transanal endoscopic operation (TEO) system to perform a direct sutured repair of the fistula. With the patient in the prone position, the fistula, measuring some 5 mm, was identified. The first part of the procedure consisted of freshening the margin of the fistula (Video S1). Following this, a continuous sutured closure was performed with a resorbable self‐locking monofilament suture. Finally, a second layer was used to reinforce the repair using another monofilament, slowly resorbable, suture. After 6 months there has been no recurrence of the fistula. Postoperative rectovaginal fistulas may be a complication of surgery for rectal cancer and, if they do occur, may be further complicated if preoperative radiotherapy has been employed. An individualized approach may be necessary to achieve successful closure. The TEO system can be a valuable aid but must be used by experienced surgeons.