Gracilis muscle flap reconstruction as a surgical alternative in anorectal pathology: a report of three cases at ISSEMYM Medical Center

Abstract

Recurrent anovaginal and rectovesical fistulas, and recurrent rectal prolapse, remain challenging for colorectal and reconstructive surgeons because of high recurrence rates, fibrosis from prior surgery, impaired sphincter function, and poor local tissue quality. The pedicled gracilis muscle flap is a versatile option, used as an interposition flap for complex fistulas or as static graciloplasty to support the sphincter complex and pelvic floor in selected prolapse cases. We describe the characteristics, management, and early outcomes of three patients who underwent gracilis reconstruction at ISSEMYM Medical Center between 2025 and 2026: two with complex fistulas and one with recurrent rectal prolapse. The first, with a history of radical prostatectomy, developed a persistent rectovesical fistula treated by fistula takedown and gracilis interposition after failed primary repair. The second, a 59-year-old woman with a recurrent low rectovaginal fistula, underwent resection of fibrotic tissue and gracilis interposition after failed fistulectomy and sphincter repair, later showing persistent recurrence. The third, an 81-year-old woman with recurrent rectal prolapse after prior rectopexy, underwent static graciloplasty with a Thiersch ring; her course was complicated by wound dehiscence, intestinal obstruction requiring colostomy, and hospital-acquired pneumonia, but she achieved a favorable outcome with no recurrence. The pedicled gracilis flap is a safe, reproducible option for complex fistulas and static graciloplasty in recurrent rectal prolapse, particularly after failed conventional treatment. It delivers well-vascularized tissue, reinforces tissue barriers, and supports the sphincter complex, though success depends on lesion etiology, fibrosis, prior surgeries, tissue quality, and patient selection.