Laparoscopic approach for a colovesical fistula

This video demonstrates a laparoscopic sigmoid colectomy in a patient with diverticulosis and chronic colo-vesical fistula. The surgeon uses a combination of lateral and medial approach to mobilize the mesocolon and divide the vessels close to the bowel. The fistula tract is divided to free up the colon in order to resect the affected segment. The surgeon in this case decides to resect the fistula tract completely and repair the bladder primarily. This is not always necessary. This video is a good demonstration of the surgical approach to complicated diverticular disease with resection of colovesical fistula and repair of bladder.

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Laparoscopic approach for a colovesical fistula

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates a laparoscopic sigmoid colectomy in a patient with diverticulosis and chronic colo-vesical fistula. The surgeon uses a combination of lateral and medial approach to mobilize the mesocolon and divide the vessels close to the bowel. The fistula tract is divided to free up the colon in order to resect the affected segment. The surgeon in this case decides to resect the fistula tract completely and repair the bladder primarily. This is not always necessary.
This video is a good demonstration of the surgical approach to complicated diverticular disease with resection of colovesical fistula and repair of bladder.

Classification

complex cases

Keywords

Sigmoid colectomy, colovesical fistula, bladder repair, diverticulosis

Media type

Surgical video

Duration

13'30''

Publication

2006-02

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E-publication

WeBSurg.com, Feb 2006;6(02).
URL: http://www.websurg.com/doi-vd01en1927.htm

Laparoscopic approach for a colovesical fistula

1. Patient history 00'15''

2. Trocar placement 00'27''

The port sites are shown here. We now have an inside view. The sigmoid loop is demonstrated along with its vascular structures. Our usual technique is to start with a medial approach. However, occasionally, such as in this case, we start with a lateral approach.

3. Lateral mobilization 00'53''

This is because laterally here the planes are easier to define, and therefore by starting here, we can more correctly define the way to proceed with the dissection. We use traction and counter-traction in order to open up the plane. Just coming into the picture now, there is a left renal cyst which is tenting up the peritoneum that runs over it. We now turn our attention to the medial dissection.

4. Medial approach 01'41''

This is performed close to the bowel wall as this is benign disease rather than far away from the bowel wall that would be done at the base of the mesentery where this is malignant disease. The Ligasure device is used in order to coagulate and divide the vessels. The device can also be used for gentle retraction in order to open up the space, and very soon we will see that the mesentery has been divided, and we join the lateral dissection.

5. Vascular control 02'47''

The dissection now continues down into the pelvis. The planes here are often very thickened in this inflammatory condition and careful dissection must be performed.

6. Division of sigmoid colon with stapler 02'59''

In order to help us find the plane and continue dissection, we divide the sigmoid at an early stage. We use a linear stapler and a blue cartridge. The Ligasure is now going to be used like a finger in open surgery to help and in order to try to open up the plane. This can be done with gentle traction and counter-traction and also the use of the Ligasure just to pinch off the tissue around the area of the fistula that is between the bladder and the sigmoid colon.

7. Division of colovesical fistula 03'45''

Once we have helped to find the plane using this, we can then turn our attention to the use of monopolar diathermy once again. The tissues are very inflamed here and thickened, and hence some bleeding is inevitable. Dissection is always aided by traction and counter-traction. This is particularly important as we come to the area where the fistula is opening. By using good traction and counter-traction, we can use the monopolar diathermy to open up the plane. The sigmoid colon is now almost completely released from the lateral side wall, and soon we will turn our attention to the mesentery once more. The Ligasure is particularly good for dividing the mesentery as it both coagulates and then following coagulation divides the tissue. The sigmoid is brought up out of the pelvis and the final part of the mesentery is divided using the Ligasure device. The next step of the procedure is to divide the bowel at the rectosigmoid junction.

8. Division of rectosigmoid junction 06'20''

This is done once again using a linear stapler, this time a roticulating stapler, and we use the blue cartridge and as per usual more than one firing is required in order to get right across the bowel. Our attention now turns to the opening at the dome of the bladder. The principle here is to cut away a disc of tissue including the fistula itself.

9. Suturing of the bladder 07'04''

This would result in being a healthy tissue in order that this can be closed and the closure remains watertight. The tissue is very inflamed and thickened and a combination of monopolar diathermy and scissors is required in order to incise into it. A disc of tissue including the fistula has now been excised and we can place the laparoscope inside of the bladder and check the position of the ureteric orifices. This is essential to visualize these so that we do not cause any damage or possibly place a stitch too close to the ureteric orifice which may endanger it or indeed occlude it. The dome of the bladder is then closed using interrupted sutures. In this case, we have used an extracorporeal knotting system to place the knots. Once this has been completed, the sutures can be checked to ensure that this is a watertight closure with the use of a methylene blue dye test through the urethral catheter.

10. Extraction of specimen 09'54''

In order to extract the specimen, we enlarge the suprapubic port. It is now the time to make the anastomosis. The proximal bowel is checked to ensure that there is a good length so that a tension-free anastomosis can be performed. It is then retrieved through the wound and the end of the bowel is prepared as can be seen here. The next step is to place the purse-string suture and we do this using a purse-string device. One the anvil has been introduced it is noticed that there is a small diverticulum adjacent to where the staple line will be. Therefore, this is sutured and incorporated close to the anvil in order to ensure that it is within the doughnut rather than the staple line. The proximal bowel is then re-introduced into the abdomen and the abdomen is reinsufflated.

11. Colorectal anastomosis 12'04''

The stapler is introduced into the rectum and as can be seen, there is adipose tissue anteriorly. Therefore the peritoneum is divided so that the stapler can be introduced right to the very end of the rectal stump. The anastomosis is now performed in a standard fashion ensuring that the proximal bowel does not have a twist, that it is well vascularized, and that there is no tension. The doughnuts can be seen here and they are both intact. A final check is made of the anastomosis and the pelvis is washed out.