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da Vinci Assisted Take Down of a Rectovaginal Fistula Through a Posterior Vaginectomy

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.

Contributors:

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

da Vinci Assisted Take Down of a Rectovaginal Fistula Through a Posterior Vaginectomy
The patient had 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.
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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. 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. 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.
Main advantage was the enhanced magnification of the Robot, which improved visualization and allowed access into an uninflamed, virgin plane, resulting in minimal loss of vaginal length.
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Authors declare no Conflicts of Interests for this article.
Authors declare no Acknowledgements for this article.
1. Kniery KR, Johnson EK, Steele SR. Operative considerations for rectovaginal fistulas. World Journal of Gastrointestinal Surgery 2015;7:133-7. 2. Jasso KAS, Vega FAM, Vallejos JM, Hernández, MAC. Surgical repair of complex rectovaginal fistulas: Report of two cases. Journal of Pediatric Surgery Case Reports 2017;22:31-4. 3. Puntambekar S, Rayate N, Agarwal G, Joshi S, Rajmanickam S. Robotic rectovaginal fistula repair. Journal of Robotic Surgery 2011;6:251-3. 4. Feigel A, Sylla P. Role of Minimally Invasive Surgery in the Reoperative Abdomen or Pelvis. Clinics in Colon and Rectal Surgery 2016;29:168-80.

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