Rectovaginal nodule excision and measures for prevention of fistula formation

A step by step strategy procedure of rectovaginal nodule excision, including technique of ureterolysis, technique of "shaving" the nodule, closure of vaginal and rectal defects and omentoplasty for fistula prevention. At the end of procedure, a safety test to detect incomplete rectal closure is performed.

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Rectovaginal nodule excision and measures for prevention of fistula formation

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Abstract

A step by step strategy procedure of rectovaginal nodule excision, including technique of ureterolysis, technique of "shaving" the nodule, closure of vaginal and rectal defects and omentoplasty for fistula prevention. At the end of procedure, a safety test to detect incomplete rectal closure is performed.

Keywords

rectovaginal, fistula, ureterolysis, fistula, nodule

Media type

Surgical video

Duration

08'00''

Publication

2007-02

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E-publication

WeBSurg.com, Feb 2007;7(02).
URL: http://www.websurg.com/doi-vd01en1974.htm

Rectovaginal nodule excision and measures for prevention of fistula formation

1. Clinical information 00'09''

Our patient is a 23-year-old lady with severe dyspareunia and chronic pelvic pain. On physical examination, a large rectovaginal nodule was found in the proximal third of the vagina. Preoperative MRI demonstrated invasion into the muscularis layer of the rectosigmoid region.

2. Adhesiolysis 00'31''

At the start of the procedure, we free the adhesions of the sigmoid colon from the left adnexa.

3. Ureterolysis 00'44''

The peritoneal layer over the left ureter is incised and the ureter is fully dissected off until it goes into the ureteric canal. Here we can watch all the tract of the left ureter.

4. Pararectal dissection 01'20''

The lateral rectal fossa is opened first on the left side, and then on the right side. Opening of the lateral rectal fossa gives us access to the area of the rectovaginal nodule. Here you see the peristalsis of the left ureter, and now we’re approaching the nodule area.

5. Dissection of rectovaginal nodule 02'20''

We dissect into the nodule identifying its vaginal and rectal parts.

6. Uterine and ovarian suspension 02'41''

To facilitate our exposure enabling free our assistant the uterus and the left adnexa are suspended to the abdominal wall.

7. Rectovaginal nodule excision 03'17''

The excision of the vaginal part of the nodule necessitates the opening of the vagina to enable the complete excision of the nodule. The vagina is opened by a monopolar hook. And the lower part of the rectovaginal nodule will be identified from above. When the incision is completed, the nodule is extracted fully through the vagina.

8. Excision of rectal part of the nodule 04'56''

Before taking the rectal part, we perform a traction suture facilitating the excision of the nodule area. While following the nodule tract step by step, the rectum will be opened.

9. Closure of rectal defect 06'06''

The rectum is sutured using monocryl 3/0, separate sutures. Then we suture the vagina with separate monocryl 2/0 sutures.

10. Leak test 07'01''

Before ending the procedure, the proximal rectum is clamped. The small pelvis is filled with saline, and air is injected through the rectum to verify its integrity.

11. Omentoplasty 07'24''

The procedure is completed with the placement and fixation of infracolic omentum between the vagina and rectum, avoiding the direct contact between suture lines. Our measures to prevent fistula formation are complete adhesiolysis, exposure, ureterolysis, avoiding direct suture line connections, performing systematic bowel leak test, and meticulous hemostasis.