A fully transanal endoscopic approach for large post-anastomotic high rectovaginal fistulas: An IDEAL stage 1 technical note.

backgroundHigh rectovaginal fistulas (RVFs) remain a challenging condition, often requiring transabdominal surgery associated with significant morbidity, particularly in patients with hostile abdomens and multiple prior pelvic operations. Minimally invasive, video-assisted and sphincter-preserving alternatives have been described for mid and low RVF but exceptionally reported for high and large defects. TECHNIQUE: We describe a fully transanal endoscopic approach for the repair of large, high post-anastomotic rectovaginal fistulas using the transanal endoscopic operation (TEO®) platform. According to the IDEAL framework, this represents an IDEAL stage 1 procedure aimed at demonstrating technical feasibility and immediate safety. The technique involves six standardized steps, including marking of the defect, precise endoscopic dissection to achieve adequate reciprocal mobilization of the rectal and vaginal walls, followed by tension-free, layered closure of both defects under stable endoscopic vision. A concise instructional video accompanies the manuscript to illustrate the key technical steps.

resultsThe technique was applied in a representative patient with a large high post-anastomotic RVF and a hostile surgical history. The procedure was completed successfully without intraoperative complications. Postoperative imaging and endoscopic evaluation confirmed complete closure of the fistula. The postoperative course was uneventful, and no recurrence was observed after 2 years of follow-up.

conclusionThis technical note demonstrates the feasibility of a fully transanal endoscopic approach for selected large and high rectovaginal fistulas. By avoiding transabdominal access, this organ-preserving technique may represent a valuable option in experienced centres for patients in whom conventional approaches are associated with high morbidity. Further evaluation in larger series is warranted.