Sleeve advancement anorectoplasty for complicated anorectal/vaginal fistula

Transanal flap-advancement procedures for complicated anorectal or rectovaginal fistula may include vertically incised flaps, horizontal flaps, and tubal flaps. Anatomic and pathologic considerations affecting choice of the three major techniques are examined in the context of their historical development over the last century. Application of the tubal (or sleeve) advancement principle is described in a woman whose combined rectovaginal and cryptogenic fistulas encompassed more than one-third of her anal circumference, necessitating surgical modifications beyond those afforded by previously documented techniques. Obliteration of disease and preservation of sphincteric competence were the achieved objectives of the procedure. Rationale for the procedure and technical details of the sleeve advancement anorectoplasty are described, mindful of the surgical antecedents of this therapeutic option.