Repair of low rectovaginal fistula

Direct appositional (no flap) closure of deep anal fistula

“…Whereas most advocate a three to four centimetre U shaped flap, some construct five to seven centimetre ones. Again while most incorporate a skim of underlying muscularis, in three series [10,11,13] the flap was raised in the submucosal plane, and in three others it was created full thickness [2][3,8], and in one small series too, no cephalad incisions were made at all [19] and in another [3] the longitudinal incisions defined the muscular part of the flap only, the overlying mucosa being kept intact. Furthermore, although all series contain some case of Crohn's disease, in one [25] it afflicted all 31 patients, and finally while most include some patients referred after failed treatment elsewhere the proportion differs greatly from one series to another.…”

“…The flaps described in reports since, however, vary both in length and thickness. Some are dissected in the intersphincteric plane [2–5] (in one series of fistula repair in patients with Crohn's disease the entire rectal circumference was dissected and advanced [6]) or in the submucosal [7–29], though in the latter case many publications refer to the incorporation of a skim of underlying muscularis propria. Because, furthermore, both flap length advocacy, series size, exclusion criteria (Crohn's disease and obstetric fistula), proportion of repeat procedures, and follow‐up data (some providing none) vary from publication to publication, interpretation is uncertain.…”