Operative repair for complicated pouch and rectal fistulas is often difficult. We present our experience with ten consecutive patients operated on for complicated pouch and rectal fistulas by transposition of the rectus abdominis muscle. Ten patients with high and complex pouch and rectal fistulas were treated with the interposition of a vascularized rectus abdominis muscle flap. All patients received standard bowel preparation and antibiotics. All were diverted by a temporary ileostomy. Causes of fistulas included Crohn's disease (n = 3), previous rectal surgery (n = 5), anal atresia (n = 1), and sphincter repair (n = 1). Three patients had a third recurrence. The procedure was performed in combination with a plastic surgeon. All fistulas healed. No special postoperative care was required. There were no cosmetic or functional complaints caused by transposition of the rectus abdominis muscle. Transposition of the rectus abdominis muscle is a suitable technique in treatment of fistulas between the rectum or ileal pouch and the vagina or urinary system, with no obvious side effects and excellent clinical outcome.