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Rectovaginal fistula repair using a totally robotic approach
Posted in Lectures on 20 August 2019
Raquel Bravo (Gastrointestinal Surgeon Consultant)
Ana Otero (Gastrointestinal Surgeon Consultant)
Hospital Clínic, Barcelona (Spain)

We present the case of a patient with a rectovaginal fistula in which we use the robotic approach as a minimally invasive technique of choice, with favorable results.

Clinical case

This is a 62-year-old patient, with no medical history, who underwent a transvaginal hysterectomy for uterine fibroids. 48 hours later she went to the emergency department, presenting with discharges of fecaloid material through the vagina. An abdominal CT scan was performed, objectifying a fistula between the rectum and the  vaginal stump .

Given these findings, it was decided to perform a surgical intervention: Resection of the affected rectum + anastomosis + closure of the vaginal stump through a robotic approach.

When accessing the abdominal cavity we can objectify the blocked pelvis with a significant plastron at this level. The fallopian tubes are closely adhered to the sigma and the area of the alleged fistula. We initiate blunt dissection carefully until we access the fistula, where we observe the stitches made between the anterior side of the rectum and the vaginal stump.

Little by little we release the different anatomical structures, cutting the stitches that establish the fistula. The articulated movements of the robot allow in this case for a careful and delicate dissection when working in a small and deep space.

Finally, we identify the vagina and then proceed to release it from the rectum in order to identify a healthy area and perform resection of the affected segment. At all times, the help of the assistant is important. In this case, the vacuum cleaner is used to keep the surgical field clean. At this time we clearly identify the open vagina, having completely separated the anterior side of the rectum from it. Later we will proceed to section the mesocolon and the mesorectum to perform the resection of the segment affected by the fistula. For this we use the hook, opening the peritoneum and looking for the dissection plane first on the right side and then on the left, until a circumferential dissection is performed in search of a healthy rectal wall to perform the distal section.

Again we see how we are working in a small and deep space, having total autonomy with the robot and with the dissection and the different movements being facilitated by the great range of movement of the robotic instruments. Through the hook we can perform the complete section of the mesorectum.

Once the dissection is complete, we proceed to section the rectum by means of an endo stapler operated by the surgical assistant. The next step is to dissect the proximal area of the colon to be able to section it and perform the anastomosis. In this case we will perform a mechanical side to end anastomosis, using a circular endostapler. The mesocolon section is carefully performed with the robotic hook and with the ligasure used by the assistant.

At this time, before performing the section of the colon, we introduce the anvil of the circular endostapler through the vaginal stump. Once we have the anvil in the abdominal cavity, we proceed to introduce it into the proximal colon to perform the anastomosis. At this time it is important to coordinate movements between the surgeon and the assistant to perform this step easily and without damaging the colon that will be part of the anastomosis.

Once the anvil is placed, we proceed to section the colon by means of an endostapler managed by the assistant, thus completing the resection of the fistula area. The specimen is then extracted transvaginally, avoiding assistance incisions.

Finally, before performing the anastomosis, we check the correct vascularization of the colon using indocyanine green and the Firefly robotic system. To complete the surgery, we perform the side-to-end colorectal anastomosis using the circular endostapler, without complications.

As a last step, we reinforce the anastomosis with two stitches to avoid tension and close the vaginal stump with a continuous barbed suture. A drain is also placed in the surgical field, ending the intervention.

Outcomes

The surgery took 125 minutes.

The patient started an oral diet 6 hours after the surgery. 

The postoperative course was correct, and the patient was discharged on the 4th postoperative day.