Fistula repair is surgery to close an abnormal tunnel that forms between two body parts that aren’t supposed to be connected, such as the anal canal and the skin, the bladder and the vagina, or the rectum and the vagina. These tunnels, called fistulas, rarely heal on their own, so surgery is the primary treatment. The specific technique a surgeon uses depends on where the fistula is, how deep it runs, and how much surrounding tissue (particularly muscle) is involved.
How Fistulas Form
A fistula develops when an infection or injury creates a channel from one organ or cavity to another, or to the skin surface. The most common type is an anal fistula, which usually starts as an abscess near the anus. When the abscess drains but doesn’t fully heal, it leaves behind a persistent tract. Other causes include Crohn’s disease, radiation treatment, and surgical complications.
Vesicovaginal fistulas (between the bladder and vagina) and rectovaginal fistulas (between the rectum and vagina) often result from childbirth injuries, particularly traumatic vaginal deliveries. In many parts of the world, prolonged obstructed labor remains a leading cause of these fistulas. Pelvic surgery and radiation therapy can also create them.
Types of Anal Fistula Repair
Surgeons classify anal fistulas based on their relationship to the sphincter muscles that control bowel movements. A fistula that passes through only a small amount of sphincter muscle is considered “simple,” while one that crosses a significant portion of the muscle, or takes a complicated path, is considered “complex.” This distinction drives the choice of procedure.
Fistulotomy
This is the most straightforward approach and the go-to option for simple, low-lying fistulas. The surgeon inserts a thin probe through the tunnel from one opening to the other, then cuts open the entire tract so it can heal from the inside out as a flat, open wound. Because it lays the tract open rather than removing it, fistulotomy leaves a smaller wound that heals faster than other methods. Recurrence rates for simple fistulas sit around 10%, and for more complex fistulas treated this way, recurrence can be even lower.
Fistulectomy
Instead of simply opening the tract, a fistulectomy cores out and removes the entire tunnel. This takes longer in the operating room because the surgeon must carefully dissect the fistula away from surrounding tissue, close the internal opening, and control bleeding. The advantage is that removing the whole tract reduces the chance of missing hidden side branches and provides tissue that can be examined under a microscope. It’s typically reserved for cases where the surgeon needs a clearer picture of what’s going on inside the tract.
Seton Placement
A seton is a thin thread or rubber loop passed through the fistula tract and tied in a loop. It serves two different purposes depending on the type. A draining seton keeps the tract open so infection can drain freely, preventing abscesses from forming while the surrounding tissue settles down. This is often a first step before a more definitive repair. A cutting seton works differently: it’s tied snugly and gradually tightens over weeks, slowly dividing the muscle while scar tissue forms behind it. This controlled, gradual approach prevents the sphincter from springing apart and losing function. Cutting setons are associated with very low recurrence rates, around 7% for complex fistulas.
LIFT Procedure
The Ligation of Intersphincteric Fistula Tract procedure is a sphincter-sparing technique designed for complex fistulas where a standard fistulotomy would risk damaging too much muscle. The surgeon makes a small incision in the groove between the two sphincter muscles, identifies the fistula tract running through that space, ties it off near the internal opening, and removes the portion between the muscles. The gap in the outer sphincter is then stitched closed. Because it works between the muscles rather than cutting through them, the LIFT procedure preserves continence. However, recurrence rates tend to be higher than with fistulotomy or cutting setons, reaching 25 to 50% in some studies.
Advancement Flap
For high or complex fistulas, particularly rectovaginal fistulas caused by childbirth injuries, surgeons can create a flap of healthy tissue from the rectal wall and use it to cover and seal the internal opening. This technique is sometimes combined with sphincter repair when the surrounding muscle has been damaged. It avoids cutting through the sphincter entirely but carries a higher rate of postoperative incontinence (roughly 28%) compared to fistulotomy (about 15%).
Laser and Video-Assisted Options
Newer sphincter-sparing techniques include laser fistula closure, where a laser fiber is threaded through the tract to seal it shut from the inside, and video-assisted anal fistula treatment, which uses a tiny camera to visualize and treat the tract. Laser closure has the advantage of not affecting continence at all, but because the surgeon can’t directly see the full tract, recurrence rates tend to be higher. Both approaches also require specialized, expensive equipment that limits their availability.
Repair of Bladder and Vaginal Fistulas
Vesicovaginal fistulas, the connection between the bladder and vagina, can be repaired through several routes. A transvaginal approach works well for fistulas located low in the vagina. It involves minimal blood loss, less tissue trauma, and avoids opening the bladder. For fistulas higher up, the limited space makes vaginal access difficult, so surgeons typically use a laparoscopic or open abdominal approach that involves opening the bladder to locate and repair the fistula from above.
Rectovaginal fistulas are repaired using similar principles. The surgeon accesses the tract, separates the connected tissues, and closes each side independently, often placing healthy tissue between the two repairs to prevent them from reconnecting.
What Affects Recurrence Risk
Not all fistula repairs succeed on the first attempt, and certain factors make recurrence more likely. Diabetes roughly quadruples the odds of a fistula coming back. A history of anorectal abscesses triples the risk. Complex fistulas that involve more tissue are inherently harder to cure in a single operation. Sphincter-sparing techniques, while better for preserving continence, generally carry higher recurrence rates than procedures that cut through muscle. This is the central tradeoff in fistula surgery: protecting muscle function versus minimizing the chance of the fistula returning.
Risks of Surgery
The most significant concern with anal fistula repair is damage to the sphincter muscles, which can lead to difficulty controlling gas or stool. Overall, about 10.6% of patients who had normal continence before surgery develop some degree of stool leakage afterward, and about 5% develop gas incontinence. The risk varies by procedure. Fistulotomy, despite being the simplest technique, still carries a 15% incontinence rate because it involves cutting directly through muscle. Advancement flaps carry the highest rate at nearly 28%.
Other possible complications include bleeding, infection, and incomplete healing that leads to recurrence. For vesicovaginal and rectovaginal repairs, additional risks include injury to surrounding organs and, rarely, narrowing of the vagina or rectum.
Preparing for Surgery
Preparation typically begins two to three weeks before the procedure with a preoperative clinic visit for blood work, a heart tracing, and a review of your medications. Blood thinners and aspirin usually need to be stopped ahead of time. If you smoke, quitting six to eight weeks before surgery significantly improves healing. Staying physically active in the weeks leading up to surgery, even just daily walks, helps your body recover faster. Depending on the type of repair, you may be asked to do a bowel preparation the day before, which cleans out the colon and means you likely won’t have a bowel movement for the first day or two after surgery.
Recovery After Fistula Repair
Fistula repair is typically an outpatient procedure for anal fistulas, meaning you go home the same day. Vaginal and abdominal repairs for bladder or rectal fistulas may require a short hospital stay. Regardless of the approach, full healing takes longer than most people expect. The wound from a fistulotomy can take several months to close completely, and your surgeon may recommend avoiding strenuous lower-body exercise for much of that time.
During the first two weeks, your daily routine will be noticeably affected. Pain medication, sitz baths (sitting in a few inches of warm water), and gentle wound care with gauze changes are the main elements of early recovery. Keeping stools soft is critical: drinking plenty of water and eating high-fiber meals prevents straining that could disrupt the healing wound. After bowel movements, alcohol-free wet wipes or a quick shower help keep the area clean without irritating it.
Most people can return to desk work within about two weeks, though physically demanding jobs may require a longer absence. Your surgeon will give you a more specific timeline based on the extent of your repair. If a bowel prep was used or if the repair involved the vagina, you may receive additional instructions about when to restart certain medications or activities.