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Pure transanal laparoscopic repair of early rectovaginal fistula

G Dapri, MD, PhD, FACS, FASMBS, Hon FPALES, Hon SPCMIN, Hon BSS, Hon CBCD, Hon CBC M Degueldre, MD, PhD
Epublication WebSurg.com, Mar 2017;17(03). URL: http://websurg.com/doi/vd01en4843

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Background: Rectovaginal fistula is an abnormal connection between the rectum and the vagina, with leakage of rectal contents through the vagina. Different surgeries have been attempted such as direct repair, plug placement, advancement flap, muscle interposition, colostomy, proctectomy or delayed pull-through colo-anal anastomosis. Recently, transanal minimally invasive surgery has been described amongst the surgical options.
Video: The authors present a pure transanal laparoscopic repair of early rectovaginal fistula in a 74-year-old lady, submitted 3 weeks before to a laparoscopic anterior resection of the rectum with ‘en bloc’ hysterectomy for rectal adenocarcinoma (pT4aN0M0). A protective ileostomy was performed at the time of rectal surgery, and the postoperative course was uneventful. After having positioned the patient in a gynecologic position, a new reusable transanal platform according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany) was adopted. The exploration of the lower rectum put in evidence a 2cm rectovaginal fistula, located at a 3 o’clock position and at a 12cm distance from the anal margin. Absorbable figure-of-8 sutures using Vicryl 2/0 were performed to close the defect. Thanks to the curves of the instruments, the surgeon worked under ergonomic positions, without clashing of the instruments’ tips and any conflict of the surgeon’s hands. At the end of the procedure, injection of methylene blue through the vagina did not show any passage of the product into the lower rectum.
Results: The operative time was 120 minutes and intraoperative bleeding was insignificant. The postoperative course was uneventful, and patient discharge was allowed after 6 days. Due to the reusable nature of all the material implemented, no supplementary cost was necessary. The gastrograffin enema after 2 months showed a complete healing of the fistula. As a result, the protective ileostomy was closed.
Conclusion: Rectovaginal fistula can be repaired through a pure transanal laparoscopy, which prevents complicated and demolition surgeries usually performed through the abdomen.