Laparoscopic treatment of a rectovaginal fistula following the resection of a rectovaginal endometriotic nodule

For thousands of years, women simply tolerated the distressing symptoms generated by rectovaginal fistulas (RVFs). This is no longer necessary because most RVFs can be surgically corrected via a number of approaches. The most common etiology of RVFs is obstetric injury, followed by radiation injury, inflammatory bowel disease, operative trauma, infectious etiologies, and neoplasm. We here show the operative management of a RVF that complicated a laparoscopic gynecological procedure.

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Laparoscopic treatment of a rectovaginal fistula following the resection of a rectovaginal endometriotic nodule

Authors

J Leroy, O Garbin, J Marescaux

Abstract

For thousands of years, women simply tolerated the distressing symptoms generated by rectovaginal fistulas (RVFs). This is no longer necessary because most RVFs can be surgically corrected via a number of approaches. The most common etiology of RVFs is obstetric injury, followed by radiation injury, inflammatory bowel disease, operative trauma, infectious etiologies, and neoplasm.
We here show the operative management of a RVF that complicated a laparoscopic gynecological procedure.

Classification

clinical cases

Keywords

Laparoscopic treatment, rectovaginal fistula after endometrial resection, RVF

Media type

Surgical video

Duration

05'00''

Publication

2009-02

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E-publication

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2489.htm

Laparoscopic treatment of a rectovaginal fistula following the resection of a rectovaginal endometriotic nodule

1. Clinical case presentation 00'19''

The objective of the video is to show the significance of a laparoscopic control of the abdominal cavity, with possible treatment, following an early postoperative rectovaginal fistula. The patient underwent a laparoscopic endometriotic nodule resection. On the 10th postoperative day, she presented with an exteriorized rectovaginal fistula along with stools coming out of the vagina. She has no generalized infectious syndrome. The laparoscopic approach is performed by re-using the trocar sites that had been used 10 days beforehand. We observe that there is no diffused peritonitis but that there is a localized peritonitis at the level of the dissection.

2. Vaginal and rectal orifice identification 01'08''

A gentle dissection allows to rapidly find the vaginal orifice where the suture has come completely undone, followed by the identification of the rectal orifice that has not had sutures fitted: a submucosal screening with nodule excision had been performed.

3. Suture of vaginal orifice 01'40''

After cleaning the abscess’s cavity, we re-stitched the vaginal suture using absorbable PDS suturing material with extracorporeal knots. This was performed with the EndoSuture System® that allows to easily carry out the suturing. The stitches are quite loose so as to just bring together the edges of the vaginal suture; the stitches are interrupted and non-airtight, which should eventually favour oozing via this vaginal suture. At the end of the procedure, the suture will be checked via the vaginal route.

4. Suture of rectal orifice 02'39''

Once the vaginal suturing has been completed, we begin on the anterior rectal orifice. It measures around 1cm, and we perform an extramucosal suture with absorbable PDS monofilament sutures. The knots are performed extracorporeally and conventionally using the EndoSuture System®, which eases stitches in the lower parts of the pelvis. The suture is then checked by performing a Betadine test in order to check that there is no leakage around the sutured area. We then decide to perform an omentoplasty by dividing the greater omentum from its colonic insertion point.

5. Omentoplasty 03'32''

We start on the right by dividing the right omental vessels, and by preserving the left vascular pedicle. The omentoplasty is performed by attaching the extremity of the lowered greater omentum below the sutured zones: we interpose the greater omentum between the uterus, the vagina, and the anterior rectal wall. The procedure is concluded by a protective ileostomy of the sutured area. To do this, we select a segment of the terminal bowel, approximately 20cm from the ileocaecal valve and we build an ileostomy.

6. Protective ileostomy 04'35''

The ileostomy is prepared in a conventional way, by performing an evagination of the proximal small intestine with intussusception that will allow for an easy functioning of the system during the end of the healing process. Two months later, a control CT-scan performed on the distal end of the ileostomy does not reveal any fistulas. We therefore decide to close the ileostomy and proceed with a laparoscopic control using a 30 degree scope introduced through the freed ileostomy orifice. There are no abdominal adhesions and the omentum is fixed at the level of the rectovaginal wall. There are no adhesions on the adnexa in this patient that has had a left salpingectomy. To the right, the uterine tube is perfectly free. We discover an endometriotic nodule in the vesicouterine pouch that we electro-coagulate.