IPEG 2020 TOP ABSTRACT: Utilizing laparoscopy in rectovaginal fistula repair
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More about congenital rectovaginal fistula
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What the experts said
Congenital rectovaginal fistula is a rare type of anorectal malformation.
The location of the fistula determines operative approach.
High fistulas may need abdominal mobilization and posterior sagittal incisions.
Low fistulas may be repaired from a posterior sagittal approach only, but the incision must be large enough to accommodate rectal mobilization and separation from the posterior vaginal wall.
Traditional low fistula repair generally requires division and reconstruction of the perineal body.
Laparoscopy has been used in the rectal mobilization of anorectal malformations, but its use in repair of rectovaginal fistulas is not broadly reported.
Preoperative contrast imaging demonstrated a long and narrow fistula connecting the rectum to the mid vagina.
Cystoscopy and vaginoscopy demonstrated a rectovaginal fistula near the distal vagina, approximately 1 centimeter from the introitis.
Because of the length of the fistula, the decision was made to utilize laparoscopy to identify the rectum intraabdominally and assist with rectal mobilization.
Rectal dissection is initiated with electrocautery, staying close to the rectal wall while preserving intramural blood supply.
A good portion of the dissection is performed sharply to minimize thermal injury.
Properly identifying the rectovaginal plane is a critical component of this operation and requires patience and care.
Approaching the common rectovaginal wall from above facilitates finding the proper plane of dissection.
Tension on the rectum helps open the angle between the fistula and the vagina, which assists sharp dissection of the common wall.
Dissection is carried out fully along the lateral aspects of the fistula before taking down the common wall.
A limited incision is made, sparing the perineal body.
After rectal separation, the vaginal defect is repaired with interrupted vicryl sutures and buttressed with a layer of fat.
Due to the mobility obtained by the laparoscopic dissection, the rectum is quite mobile, and the incision does not need to be extended to finish the rectal dissection.
The patient was started on clear liquids on postoperative day 3.
The patient was discharged home on postoperative day 6.
At approximately 1 month postoperatively, the patient was dilating twice per day and stooling spontaneously between dilations.
Laparoscopy can be a useful tool for mobilizing the rectum in rectovaginal fistula repair.
Laparoscopy enables a more limited perineal incision and negates the need to disrupt the perineal body.