The Role of Graciloplasty in the Treatment of Obstetric Anal Sphincter Injury with Subsequent Fecal Incontinence and Recurrent Low Recto-Vaginal Fistula: A Case Report

Abstract

Background and Clinical Significance: Recto-vaginal fistulae (RVF) and fecal incontinence (FI) pose significant challenges for colorectal surgeons. Various therapeutic options have been proposed for each condition over time. Despite its procedural complexity and the risk of complications, graciloplasty remains a viable therapeutic option for both conditions, with favorable long-term results. To our knowledge, this is the first report of a case where the need to treat both conditions concurrently arose. Case Presentation: We report the case of a 54-year-old woman with severe FI and repeatedly operated on recurrent recto-vaginal fistula. The patient underwent graciloplasty to provide healthy tissue with an adequate vascular supply to both enhance the healing process of the fistula and reshape the anal canal with a circular muscular structure. Following the procedure, the patient experienced prompt symptom resolution and good clinical and functional recovery at a 1-year follow-up evaluation. Conclusions: This case report highlights the safety and effectiveness of an overlooked procedure for the treatment of large sphincter defects and concurrent recto-vaginal or recto-vaginal tears.

Keywords: ano-vaginal fistula; case report; fecal incontinence; graciloplasty; obstetric anal sphincter injury; recto-vaginal fistula.

Figure 1

EAUS for the assessment of the anal sphincter complex. (a) Internal anal sphincter anterior defect of 154°; (b) external anal sphincter anterior defect of 145°.

Figure 2

Ano-vaginal fistulous tract identification.

Figure 3

Dissection of the right gracilis muscle. (a) Skin incision; (b) harvest of the distal tendon of the muscle.

Figure 4

(a) Skin incisions in the perianal region; (b) Creation of a circumferential tunnel around the anus via blunt digital dissection; (c) transposition of the right gracilis muscle; (d) wrapping of the muscle around the anus.