Rectovaginal fistula after wedge anterior rectal resection for endometriosis: laparoscopic low anterior resection with transvaginal extraction

The objective of this film is to demonstrate the management of a rectovaginal fistula in a woman in her thirties. Three months before, she had benefited from the resection of a nodule of the rectovaginal septum, along with the vaginal resection of the posterior Douglas’ pouch and the anterior resection of the rectum using the wedge technique with circular stapling. The fistula can be well identified in the clinical examination. A laparoscopic low anterior resection with transvaginal extraction is presented.

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Rectovaginal fistula after wedge anterior rectal resection for endometriosis: laparoscopic low anterior resection with transvaginal extraction

Authors

J Leroy, A Wattiez, J Marescaux

Abstract

The objective of this film is to demonstrate the management of a rectovaginal fistula in a woman in her thirties. Three months before, she had benefited from the resection of a nodule of the rectovaginal septum, along with the vaginal resection of the posterior Douglas’ pouch and the anterior resection of the rectum using the wedge technique with circular stapling. The fistula can be well identified in the clinical examination. A laparoscopic low anterior resection with transvaginal extraction is presented.

Mots-clés

Rectovaginal fistula, wedge anterior rectal resection, endometriosis, laparoscopic low anterior resection, transvaginal extraction

Type de vidéo

Vidéo chirurgicale

Durée

35'58''

Publication

2010-11

Popularité

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Sous-titres

E-publication

WeBSurg.com, Nov 2010;10(11).
URL: http://www.websurg.com/doi-vd01en3070.htm

Rectovaginal fistula after wedge anterior rectal resection for endometriosis: laparoscopic low anterior resection with transvaginal extraction

1. Clinical case presentation 00'31''

The objective of this film is to demonstrate the management of a rectovaginal fistula in a woman in her thirties. Three months before, she had benefited from the resection of a nodule of the rectovaginal septum, along with the vaginal resection of the posterior Douglas’ pouch and the anterior resection of the rectum using the wedge technique with circular stapling. The fistula can be well identified in the clinical examination. The exploration of the abdominal cavity shows no adhesions —which is great news. This demonstrates we are dealing with a subperitoneal fistula.

2. Douglas\' pouch opening 01'21''

The first step of the intervention consists in the opening of Douglas’ pouch. This should be done as much in contact as possible to the posterior vaginal wall by using the traction, counter-traction and action technique by means of the monopolar scissors. The opening of the subperitoneal space is carried out cautiously, remaining in contact to the digestive and vaginal posterior structures in order to stay away from the lateral nerve rami.

3. Fistula identification 02'07''

The identification of the orifice is quite easy thanks to traction and atraumatic retraction carried out by means of a peanut swab. The orifice now comes into sight. It consists of the vaginal orifice in contact to the rectal orifice. It is placed slightly caudad, in contact to the fibrous area of the wedge resection. Attention is no longer paid to this fibrous area or the orifice, but to the perirectal tissue, which is freed laterally and posteriorly, remaining close to the rectal wall, since we are not dealing with an oncological resection issue.

4. Lower rectum dissection 03'24''

Attempts are made to find the plane anterior to the lower rectum, underneath the fistulous area, which is strongly fibrous. The posterior vaginal pouch can be seen here. It is opened. The posterior vaginal wall, which is much more compliant, can also be seen underneath the fistulous area. Dissection is pursued laterally to the left in order to find the healthy plane in contact to the rectal wall, much more caudad, under the fistulous area. The perirectal space will be opened laterally. The posterior vaginal wall is detached from the anterior middle rectum as caudad as possible in order to stay in a healthy rectal area. The Endo-GIA linear stapler will be applied there. It is important to resect the fibrous and fistulous area, which is not in good condition for subsequent suture. Denonvilliers’ aponeurosis is clearly seen here. It covers the anterior rectal wall. It is this white-like, slightly fibrous membrane, which is more resistant than the rectal wall. The lateral attachments are freed laterally to the left and to the right. To do so, either the ultrasonic scissors or the Ligasure® vessel-sealing device may be used. This will allow to free the lower rectum and, especially, to place traction on it in order to bring it slightly cephalad, hence allowing for an easier anastomosis on the compliant lower rectum.

5. Sigmoid colon dissection 05'52''

The colon remains to be divided proximally. Once again, the dissection is carried out in contact to the sigmoid colon, which is not diverticular, but rather compliant. This is not an oncological resection, but a resection for a benign disease. Dissection in contact to the colon has one major advantage: it allows to preserve vascularization and innervation of the low and mid rectum by preserving the superior rectal vessels and the superior hypogastric plexuses around it. Dissection is pursued towards the posterior aspect of the rectum, underneath the fistulous area. Either ultrasonic scissors or the Ligasure® vessel-sealing device prove to be very helpful, as they allow for a good hemostasis, thus avoiding an excessive coagulation of the tissues in contact to the Ligasure® —which is by far the preferable instrument here— and protecting them. All attachments of the sigmoid colon and of the upper rectum must be perfectly divided, remaining in contact to the tube, since, as previously said, this resection is carried out for the management of benign lesion. Hence, the resection of the mesorectum is not necessary. The vascularization and innervation of the mesorectum must be preserved. This will allow for a better vascularization and innervation of the tube, of the rectal stump, and of the urinary collateral neurovegetative plexus.

6. Rectum division 08'42''

Once the rectum has been freed anteriorly, laterally and posteriorly, it is divided by means of an Endo-GIA linear stapler, blue cartridge, underneath the fibrous area where the fistula is located. A perfect hemostasis is carried out. This must be perfectly controlled. Attention must also be paid to the closure of the rectal stump, which must be perfect. To do so, Betadine serum is injected. The anastomosis is then prepared.

7. Colon exteriorization 09'18''

The colon is exteriorized through the vaginal orifice.

8. Anvil introduction 09'30''

Later, the anvil of a PCEEA 28 circular stapler is introduced above the level of the stenotic fistulous area by performing a small colotomy. The anvil’s tip is attached by means of a large-sized Polysorb 2 suture. Then, it is pushed proximally. This suture is not divided by the stapling, as it is not trapped by the staples. The intestinal specimen is exteriorized through the vagina. Then, the anvil’s tip is exteriorized through the colonic wall in order to carry out a side-to-end anastomosis. The exteriorization is secured by means of a bag allowing for an appropriate tightness of the anvil’s rod using a non-absorbable thread. The latter will keep the orifice in contact to the anvil’s rod. The specimen is examined. The fistulous area and the stapling are controlled.

9. Vaginal closure 10'59''

Before performing the anastomosis, decision is made to close the vaginal incision laparoscopically, although this could also be done using a vaginal approach. The suture is carried out by means of 2/0 Polysorb absorbable sutures or 2/0 monofilaments. Either extracorporeal or intracorporeal knots may be used. The closure must be performed as cautiously as possible. There is no need for a perfect patency. The number of stitches used depends on the vaginal incision’s size. The vaginal division area can be seen here. It is hemorrhagic, so it is perfectly vascularized, as in most cases. Should the procedure prove difficult, the suture can be carried out using a vaginal approach. Once the vagina has been sutured either using separated stitches or a running suture by means of absorbable threads —preferably monofilament threads—, the hemostasis is controlled again.

10. Anastomosis 12'47''

The circular stapler is introduced in the rectal stump through the anus in order to connect it to the anvil’s rod, a 28 PCEEA DST circular stapler in this case. A side-to-end anastomosis is performed. In order to avoid any contact at the level of the rectal and vaginal suture area and to avoid any new fistula, it is advisable to interpose thicker tissues, namely the omentum, which, after mobilization, is brought to the posterior vaginal septum and the anterior rectal wall in order to carry out an omentoplasty.

11. Omentum fixation into rectovaginal space 13'35''

The omentum is fixed in the rectovaginal space by means of an absorbable suture, which leans on the posterior vaginal wall. This fixation is performed under laparoscopic control. The objective is to increase the space between the posterior vaginal wall and its suture, and between the anterior rectal wall and its suture.