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.
Mirizzi syndrome, the mechanical obstruction of the common hepatic duct secondary to extrinsic compression of stones impacted in the gallbladder neck or the cystic duct, is a rare complication of cholelithiasis (0.2% to 1.5% of patients). Up to 50% of patients are diagnosed intra-operatively.
We describe technical tips of laparoscopic treatement of Mirizzi Syndrome, including laparoscopic cholecystectomy, common bile duct exploration and stone extraction. Often it is best to fashion the ductotomy over the palpable stone. T tube cholangiogram is also invaluable.
In conclusion, laparoscopic treatment may be used for Mirizzi Syndrome.
Contributor:Dr. Manish Parikh
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.
A laparoscopic approach was used to evaluate and manage hemoperitoneum that occurred in a 50 year-old woman who had undergone recent sleeve gastrectomy complicated by pulmonary embolism and hemoperitoneum. This case illustrates an important complication of laparoscopic sleeve gastrectomy, the usefulness of laparoscopy for managing complications of bariatric surgery, and the challenge of laparoscopy in an peritoneum filled with a significant quantity of blood.
Authors: Donald Q Brubaker, BA – West Virginia University. Nova Szoka, MD – West Virginia University.
71 yrs old male s/p robotic low anterior resection with primary coloproctostomy and diverting loop ileostomy for bulky, locally advanced rectal cancer. Robotic approach for loop ileostomy closure was planned due to obese body habitus. We utilized DaVinci Xi robotic platform. The set up consisted in 4-port placement, with ports # 2, 3 and 4 positioned starting in the left upper abdominal quadrant along MCL and port # 1 in suprapubic area. After docking and insertion of robotic instruments, the RLQ ileostomy was visualized. Appropriate orientation of efferent and afferent limbs was confirmed. Two enterotomies were created with electrocautery at the antimesenteric border of each limb, approximately 10 cm from the fascia. Head and anvil components of a robotic 60 mm stapler were then inserted in each enterotomy and the stapler fired in order to create a common channel between the lumens. After stay suture with 3-0 Vicryl was placed at the crotch of the anastomosis, common enterotomy defect was approximated with running 3-0 V-Lock suture in two layers. The matured portions of the loop ileostomy were then divided right below the fascia level with robotic 60 mm stapler after gentle dissection of the mesenteric border of each limb, while the mesentery was divided with robotic vessel sealer. The robotic system was then undocked and the ports removed. The remaining portion of the loop ileostomy was finally dissected from the abdominal wall at the mucocutaneous junction and the fascia defect approximated in the usual fashion (not included in the video).
Rectal cancer with local invasion presents a particular operative challenge. The standard procedure for locally advanced rectal cancer is a total pelvic exenteration (TPE), which is a highly morbid procedure. For select patients, the literature has demonstrated that bladder-sparing techniques involving en bloc resection of the prostate are safe and oncologically acceptable.1 Additionally, case studies have demonstrated the success of combined approaches using laparoscopic techniques.2,3 However, little has been published concerning the combined robotic-assisted approach of an abdominoperineal resection (APR) and en bloc prostatectomy with vesicourethral anastomosis. Robotic assistance offers several advantages for pelvic surgery, including better visualization using 3D technology and wristed instruments. Furthermore, research has shown the advantages of robotic surgery for rectal cancer resections.4,5
Our video presents a case of T4N0M0 rectal cancer, 1 cm from the dentate line, in a 63 year old male with invasion anteriorly into the prostate. After completing chemotherapy and radiation, a combined approach with a colorectal surgeon and a urologist was done using the daVinci Xi robot (Intuitive Surgical Inc, Sunnyvale, CA). The important steps of the procedure are demonstrated in the attached video. Pathology revealed a 5 cm mucinous adenocarcinoma with treatment effect and negative margins. The patient did well post-operatively with no complications. He was discharged on post-operative day 5.
Robotic-assisted procedures offer the advantage of precision and visualization for pelvic operations. For locally invasive rectal cancer, robotic surgery allows the opportunity to create novel techniques for select patients in order to reduce the number of TPEs.