Laparoscopic robotic-assisted treatment of vesicouterine fistula

This video presents the case of a female patient with a benign vesicouterine fistula. Conservative treatment was unsuccessful.

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Laparoscopic robotic-assisted treatment of vesicouterine fistula

Authors

Abstract

This video presents the case of a female patient with a benign vesicouterine fistula. Conservative treatment was unsuccessful.

Classification

basic techniques, robotic

Keywords

laparoscopy, robotic-assisted, (DaVinci) treatment of vesicouterine fistula, urology

Media type

Surgical video

Duration

07'56''

Publication

2008-09

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E-publication

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2416.htm

Laparoscopic robotic-assisted treatment of vesicouterine fistula

1. Clinical case presentation 00'15''

This 35-year-old patient presented with a vesicouterine fistula secondary to a difficult delivery. Conservative treatment with extended vesical drainage was unsuccessful. Cystoscopically, the vesical fistula was widely opened and the vesical fluid was flowing through the cervix. The patient is in a dorsal decubitus Trendelenburg position. The robot is rolled in between the legs of the patient.

2. Pelvic exploration and fistula dissection 00'46''

The pelvis is explored using the bipolar forceps in the left hand and the electrocautery hook in the right hand. The incision begins in the vesicouterine cul-de-sac. The articulated bipolar forceps allows freeing the peritoneum to facilitate its incision. Dissection goes on in the vesicouterine plane down to the fistula, which is then opened. Dissection goes on to the right of the vesicouterine plane using electrocautery in the right hand and the bipolar forceps in the left hand, which allows presenting and pushing aside the tissues. Dissection goes on to the left.

3. Vesicouterine space dissection 01'44''

The vesical part of the fistula is then dissected, allowing to free the posterior aspect of the bladder. The bipolar forceps allows to pull upwards the bladder and to free up the intervesicouterine space. Dissection of the intervesicouterine space is carried on towards the upper part of the vagina. The left part of the bladder is then freed in the same way. In order to limit any tension on the suture, the upper aspect of the bladder is also freed. Pulling the bladder with the bipolar forceps helps to dissect the anterior aspect of the bladder.

4. Vesical closure 02'55''

First, 4/0 Vicryl thread is brought by the assistant into the abdomen. You can notice how the needle is easily positioned in the needle holder. The first stitch is positioned forehand on the anterior and then the posterior right angle of the fistula. The first knot is tied without any problem. Articulated instruments make these movements much easier than in standard laparoscopy. Closure of the mucosa goes on with a running suture. The first plane finishes at the left angle. The threads are cut by the assistant who introduces his scissors through an accessory port. A second running suture allows the closure of the vesical muscle. The articulated DaVinci instruments make it possible to tie knots even with very short scrap of thread. Closure of the bladder is now completed.

5. Cervical closure 04'20''

A part of the Foley catheter is introduced into the cervix and is easily manipulated thanks to the articulated instruments. Its upper part is introduced into the uterine cavity. This catheter will be used as a guide in order to limit the risk of cervix stenosis during the suture. The first 4/0 Vicryl stitch is placed at the middle part of the fistula on the uterine side. The thread is left waiting. Several discontinued stitches are then placed in the same way. The different stitches are introduced by the assistant. The last stitch is placed on the left side of the uterine fistula. Positioning of the stitches is very easy, even better than in open surgery where the suturing is performed with an at least 20cm long rigid needle holder. With the articulated robotic instruments, the surgeon feels as if he was manipulating the needle between his thumb and index finger. Knots are tied one after the other ; there is no feedback with the robotic instruments but this is visually reconstructed. Camera movements and zooming in and out are under the surgeon’s control. Fat is pediculated from the epigastric pedicle. Hemostasis is performed either with monopolar or bipolar coagulation. The pediculated fat is brought in the vesicouterine space. The fat is then fixed on the left part of the bladder and on the anterior aspect of the uterus using a 4/0 Vicryl stitch. This fat pedicle is spread out between the vesical and uterine sutures.

6. Peritoneal closure 07'20''

We now begin the peritoneal suture with a 3/0 Vicryl. Hemostasis has been checked after lowering the CO2 pressure. No drainage is needed. Peritonization is completed. You can notice the unwanted movements of the scissors and compare them to the stability of the robotic instrument tips. Four trocars were used, two 10mm for the robotic instruments, one 12mm at the umbilicus for the optic and another 12mm trocar for the assistant in the left flank.