Transperineal approach for the repair of a low H-type rectovestibular fistula: a case report

Introduction: H–type rectovestibular fistula with a normal anus is a rare entity in the spectrum of anorectal malformations. There have been only a few reports describing a very low positioned H-type fistula with several operative techniques described. Case presentation: A female patient that was followed since birth due to passing stool through the introitus. On physical exam the anal and urethral openings appeared normal. She had a small opening at the vestibule of the vagina suspicious for an H-type recto-vestibular fistula. At the age of 1 month, she was taken to the operating room for a diverting colostomy. The presence of an H-type fistula was confirmed by demonstration of bubbles emanating from the anal canal after instillation of hydrogen peroxide through the vestibular fistula opening. A small umbilical catheter was inserted through the fistula for better visualization. At 4 months of age, the definitive surgical repair was done via a transperineal approach, using the perineal sphincter muscle and fat tissue as an interposition flap that served as a barrier between the vaginal and rectal walls. The technique provided excellent visualization of the dissection plane between the rectum and vagina. The patient recovered uneventfully. The colostomy was closed at the age of 7 months. She has had no recurrence at two years of follow-up. Conclusion: The transperineal approach with addition of fatty tissue interposition seems to be an effective option for the management of low H-type rectovestibular fistulas.