Rectovaginal fistula following low circular stapled anastomosis in women with rectal cancer.

Low anastomosis using a circular stapling instrument has become standard for performing a colorectal reconstruction following resection of a rectal cancer. Often these anastomoses are performed deep in the pelvis using a circular stapling instrument without clear visualization of the anastomotic site. In the female patient, unless an adequate stump of rectum is left above the circular staple line, there is danger that the side wall of the posterior aspect of the vagina can be included in the tissue rings (donuts) that are resected by the circular stapling instrument. This leaves the patient at high risk for late development of a rectovaginal fistula by vaginal mucosa being incorporated into the rectal wall. Maintenance of an adequate mucosa beyond the linear staple linen and a vaginal examination prior to firing the circular stapler will prevent this problem. A patient is presented and the technical details for a safe low-low colorectal anastomosis are reviewed.