Open Sigmoid Resection for colo-vesical Fistula

Clinical History:

• 44 year old man who had severe abdominal pain 3 months earlier.
• He then developed pneumaturia and had fecal material in his urine.
• CT scan is consistent with a colo-vesical fistula.

Technique description:

Lower midline laparotomy (open) with dissection of the sigmoid colon from the bladder and sigmoid resection with double stapled colo-rectal anastomosis

Procedure Steps:

• 1. Clear liquid diet for 24 hours pre op and oral PEG prep solution evening before surgery.
• 2. Pre-operative oral antibiotics (Neomycin and Metronidazole) at 1 pm, 2 pm, and 11 pm day before surgery.
• 3. No oral liquids for at least 2 hours pre-op.
• 4. Admission to hospital 2 hours before scheduled time of surgery.
• 5. IV antibiotics (Ertapenem 1 gram), clipping of abdominal hair, placement in modified lithotomy position, and abdominal skin prep with chlorhexidine.
• 6. Time out to ensure the correct patient, the correct procedure, and availability of necessary equipment.
• 7. Midline laparotomy incision, extended above umbilicus to be able to deal with small umbilical hernia.
• 8. Abdominal exploration and takedown of sigmoid colon adherent to the left dome of the bladder. Very tedious as very inflamed.
• 9. Insertion of Alexis retractor (wound protector) and Bookwalter retractor and packing small bowel into upper abdomen.
• 10. Mobilization of sigmoid colon from lateral sidewall with identification of left ureter.
• 11. Choosing point of proximal transection of the colon and division of mesentery with EnSeal device.
• 12. Division of proximal colon and elevation of the mesentery to pelvic brim.
• 13. Choice of point of distal transection in upper rectum (just below sacral promontory) and fairly tedious dissection of mesorectum to clear the distal bowel for division.
• 14. Placement of TA-45 mm (green load) stapler across upper rectum and firing of stapler with 45 mm Glassman bowel clamp above staple line. Division of distal bowel with knife and removal of specimen.
• 15. Mobilization of descending colon to splenic flexure to allow reach to pelvis.
• 16. Placement of 0-Prolene purse-string suture (whipstitch) in proximal bowel to secure anvil. Placement of anvil from 29 mm powered circular stapler into proximal bowel and tying of purse-string suture.
• 17. Gentle dilation of rectum by serial passage of EEA sizers (25, 29, and 31 mm) to the end of the rectal stump.
• 18. Passage of 29 mm powered circular stapler through anus up to the staple line in the rectal stump.
• 19. Opening circular stapler so that trocar passes just posterior to the transverse staple line.
• 20. Mating the proximal bowel and anvil to the circular stapler.
• 21. Ensuring proper orientation of the proximal bowel and closing the stapler slowly into firing range.
• 22. After waiting 30 seconds for tissue compression, firing of powered circular stapler with audible and instrument feedback that the firing sequence had been successful.
• 23. Opening circular stapler 2 full turns and removal from the rectum
• 24. Inspection of the stapler to ensure that intact proximal and distal anastomotic rings are present
• 25. Insertion of rigid proctoscope into rectum and gentle insufflation of rectum with saline in pelvis and proximal bowel occluded with the fingers. Good filling of rectum and no evidence of air leak.
• 26. Ensuring that there has been adequate mobilization of descending colon to allow tension free anastomosis.
• 27. Creation of omental pedicle graft from right side of omentum using LigaSure device to allow omental pedicle to lie between anastomosis and the bladder defect. Placement of pedicle into pelvis.
• 28. No repair of bladder defect since it is quite small.
• 29. Change of gloves, gowns, and instruments as part of our protocol to minimize risk of SSI.
• 30. Dissection of umbilical hernia sac from abdominal wall and excision of sac.
• 31. Placement of 1 sheet of SepraFilm beneath incision as an adhesion barrier.
• 32. Closure of midline fascia with continuous #1 PDS suture (start at top and bottom of wound and tie in the middle).
• 33. Irrigation of subcutaneous tissue and closure of skin with staples. No subcutaneous sutures!
• 34. Placement of dressing.

Learning Points:

• 1. The symptom of pneumaturia (air in the urine) is highly suggestive of a fistula from the bowel to the bladder.
• 2. It is best to wait from 6-12 weeks after onset of the symptoms before the surgical procedure.
• 3. A colonoscopy should be performed before the planned surgical resection to rule out a neoplastic cause for the fistula.
• 4. The surgery is performed by open technique because of the dense attachments between the colon and the bladder and the careful dissection necessary to separate the two organs.
• 5. A midline incision is chosen because of ease and speed of performing and closing the incision and the ease of extending the incision if necessary.
• 6. After making the incision the fistula is taken down by careful and tedious blunt and sharp dissection. In performing the dissection, we try to err on the colon side since that will be part of our resection. Typically, the opening into the bladder is quite small as in this case. Also, it is usually not necessary to perform any resection of the bladder for this benign condition.
• 7. Careful lateral to medial mobilization of the sigmoid colon along the avascular plane usually will take you down to the left ureter which must be identified and preserved..
• 8. The proximal extent of the resection should be to soft pliable bowel without any diverticula at the site of the anastomosis. It is not necessary to try to resect all of the diverticula.
• 9. The sigmoid mesentery can be taken either with clamp and tie technique or with the energy device (in this case, the EnSeal).
• 10. The bowel is mobilized posteriorly to the point of distal resection. It is critical that the distal margin be to the upper rectum. If the anastomosis is performed to the sigmoid instead of the rectum there is a 2-4 times greater risk of recurrence of the diverticulitis.
• 11. After carefully clearing the mesorectum from the bowel, it is stapled with a linear stapler. We use a green staple load because of the thickness of the rectum.
• 12. Prior to placing the purse-string suture to secure the anvil of the stapler, we ensure adequate length of bowel to allow a tension free anastomosis. It was necessary to mobilize the descending colon to the level of the splenic flexure. It was also necessary to extend the incision to facilitate splenic flexure mobilization.
• 13. The purse-string suture is really a whipstitch. We use 0-Prolene suture to avoid breaking the suture when we tie it around the anvil.
• 14. Prior to inserting the stapler from the anus, we insert the EEA sizers (dilators). We insert the 25, 29 and 31 mm sizers which makes insertion of the stapler easier and more likely to reach the end of the rectal stump. We used the powered 29 mm stapler. When the stapler is opened, I try to bring the spike just posterior to the staple line. After the anvil is mated and proper orientation ensured, the stapler is closed to the mid portion of the firing range. We wait at least 30 seconds before firing to allow tissue compression. If the anvil is properly connected and the stapler has been closed into the firing range, the device will allow you to fire. The powered stapler performs the firing sequence ensuring complete firing of staples and deployment of the knife blade.
• 15. After firing, the stapler is opened two full turns and removed. This is a change from the recommendations for the non-powered stapler. The handle of the stapler is then swung from side to side to facilitate removal.
• 16. After removing the stapler, the anastomotic rings are checked for completeness. We also perform an air test by filling the pelvis with saline and inserting a proctoscope to insufflate the rectum and anastomosis.
• 17. We now create an omental pedicle to place between the anastomosis and the site of the bladder perforation. The EnSeal energy device is used to mobilize the omentum from the right side of the transverse colon. In this case, the pedicle was quite ample in size and did not need to be sutured in place,
• 18. We are now ready for closure and change gowns, gloves, and instruments as part of our protocol to reduce surgical site infections.
• 19. Before closing the incision we insure that the counts are correct. SepraFilm (an adhesion barrier) beneath the incision to decrease adhesion formation to the undersurface of the midline incision.
• 20. The fascia is closed with two sutures of #1 PDS (an absorbable monofilament suture) starting at the top and bottom of the wound and tying the sutures together in the middle. The stitches are 1 cm apart and 1 cm back from the fascial edges.
• 21. After irrigation of subcutaneous tissue, the skin is closed with skin staples.
• 22. The bladder is not closed during the procedure. The Foley catheter is left in place for 7 days after the surgery.
• 23. The patient was discharged on post-operative day 4 and has had no complications.