Full laparoscopic modified-VRAM (Vertical Rectus Abdominis Muscle): technical notes of a new minimally invasive approach for the treatment of recto-vaginal fistula.

Introduction: Rectovaginal fistulae resulting from rectal surgery for cancer, especially in the irradiated field, represent a difficult situation for colorectal surgeons. To avoid radical and mutilating solutions and to limit morbidity, several therapeutic approaches have been described, but no consensus has yet been established. Omental and pedicled muscular flaps interpositioned between the rectum and vagina offer good outcomes; nevertheless, the cosmetic result is poor and the short- and long-term morbidity is high, and resection of the previous anastomosis and redo is often required. Technique: Surgery is represented by usual laparoscopy using five 5 mm ports; the first step consists of the dissection of the rectovaginal space down to the pelvic floor; afterwards, a modified Vertical Rectus Abdominis pedicled flap (m-VRAM) can be easily harvested full laparoscopically and simply interposed in the rectovaginal space. No additional skin or fascial incisions and no repeat anastomosis were needed. No recurrence, stenosis, or other short- or long-term complications were noted. Conclusion: Our technique is minimally invasive and offers a valid alternative for the treatment of rectovaginal fistulae with low morbidity and no additional incision.