The surgical management of rectovaginal fistulas remains difficult, as they tend to be recurrent and vary widely in location and complexity. We present a case of a 63-year-old woman with a low-lying rectovaginal fistula who initially underwent chemoradiation and a Low Anterior Resection for a low-lying rectal cancer. Her course was uneventful until two years post-operatively, at which time her anastomotic staple line became stenotic with associated bleeding. This was initially addressed by Gastroenterology who executed a dilation and achieved hemostasis with Argon Plasma Coagulation. This remedied the stenosis, however, it was complicated by the formation of a rectovaginal fistula. Due to the low-lying location and its presence in an irradiated field, a transvaginal approach with an interposed gracilis flap was elected for repair.
Stoma prolapse is an increase in the size of the stoma secondary to intussusception of the proximal bowel segment. Strangulation and ischemia of the prolapsed segment have been reported as complications.
This is the case of a 58-year-old man with multiple comorbidities who was diagnosed with an adenocarcinoma of the ascending colon with hepatic metastasis. He was considered unable to start conversion chemotherapy because of his cardiovascular comorbidities and was therefore under paliative chemotherapy.
Patient came into emergency room with an acute bowel obstruction and underwent a loop ileostomy as a diversion procedure. Following up the procedure, the patient developed an acute on chronic kidney failure because of dehydration from high output ileostomy. In the postoperative day 17, patient presented with an acutely incarcerated prolapsed afferent limb of the loop ileostomy. Attempts at reduction were unsuccessful.
Herein we present a simple, safe, and fast approach for correcting a prolapsed loop or terminal stoma using a step-wise application of linear staplers.
When laparotomy and/or stoma reversal is not appropriate, local revision of stoma prolapse provides a low-risk and high-benefit alternative solution.
A rectovaginal fistula (RVF) is an epithelial lined tract between the rectum and vagina. This can result in recurrent urinary tract or vaginal infections, but also creates a significant psychosocial burden for the patient. Unfortunately, due to the individual complexities of these patients, they are difficult to manage despite the numerous surgical options presently described.1
Generally RVFs are classified as low, middle or high, due to the location of the rectal and vaginal opening. Due to this, both low and middle RVFs may be approached via anal, perineal or vaginal routes. Where as high RVFs, which have their vaginal opening near the cervix, generally require an abdominal approach for repair.2
Traditionally for high RVFs patients underwent open surgery; however, minimally invasive surgery has recently been widely accepted as the preferred approach. Although surgeons are becoming more facile with these approaches, both pelvic surgery and a reoperative abdomen still impose significant technical difficulties.3,4 Here, we present the video of a female with a complex surgical history including a hysterectomy, bilateral salpingo-oopherectomy, creation and reversal of a Hartmann’s colostomy as well as a loop ileostomy due to a locally advanced recto-sigmoid cancer, who subsequently developed a rectovaginal fistula and was managed minimally invasively with a multidisciplinary novel approach through a posterior vaginectomy; an approach that utilized the enhanced magnification of the Robot, which improved visualization and allowed access into an uninflamed, virgin plane, resulting in minimal loss of vaginal length.
Milind D. Kachare, M.D.
Osvaldo Zumba, M.D.
Lorna Rodriguez-Rodriguez, M.D., Ph.D.
Nell Maloney-Patel, M.D.
Rutgers Robert Wood Johnson Medical School, Hackensack University Medical Center, City of Hope National Medical Center
Contributors: Justin A. Maykel MD
The following video demonstrates a laparoscopic transanal total mesorectal excision (taTME) for the treatment of a locally advanced mid-rectal tumor. Eight weeks following neoadjuvant chemotherapy and radiation she was brought to the operating room for radical resection.
Referred by Jeffrey B. Matthews
Contributors: Marco G. Patti
Laparoscopic Heller Myotomy and Anterior Partial Fundoplication
Contributors: Marco P. Fisichella
Laparoscopic Heller myotomy and Dor fundoplication for a patient with type 2 achalasia.
We present a case of a 21-year-old male with a one-day history of right lower quadrant pain and CT scan findings suspicious for a perforated Meckel’s Diverticulum who underwent a robotic assisted small bowel resection with an intracorporeal anastomosis.
Milind D. Kachare, M.D.
Nisha Dhir, M.D., FACS
University Medical Center of Princeton at Plainsboro, Rutgers – Robert Wood Johnson Medical School
Contributors: Dr. Jimmy Lin, Dr. Juana Hutchinson-Colas, Dr. Nell Maloney-Patel
Rectovaginal fistulas can occur for a number of reasons, including obstetric trauma, iatrogenic, radiation damage and Crohn’s disease. Symptoms range from asymptomatic to uncontrollable passage of gas or feces from the vagina leading to poor quality of life for some patients. For those patients whom surgery is indicated, there are several different approaches depending on the fistula etiology and previous attempts at repair. These range from simple fistulectomy to transabdominal repair with tissue interposition to Martius flap interposition. Our patient in the video had previously underwent multiple various repairs which failed to provide adequate resolution of her fistula and therefore presented for a Modified Martius flap repair. The benefit of such a repair is to provide neovascularity at the site of repair with minimal cosmetic effect.
It is well-accepted that recurrent or complicated diverticulitis is an indication for surgical resection. Minimally invasive techniques, like the daVinci robot, have been developed to enable better visualization of the pelvis with articulating instruments. However, many times, the minimally invasive approach is deferred for cases of severe disease and adhesions. This video demonstrates the dissection of a significantly diseased sigmoid colon during a robotic-assisted low anterior resection. As you can see, with surgeon experience and patience, even complicated cases can be done successfully using the robot.
The patient is a 65-year-old male with a history of multiple episodes of diverticulitis. The most recent episode was complicated by a pericolonic abscess, which was treated non-operatively with drainage and antibiotics. He presents 2 months later for an elective resection.
Laparoscopic conversion of sleeve gastrectomy to roux-en-y gastric bypass