Laparoscopic stapler repair of high rectovaginal fistula: A case report

doi:10.4236/ojgas.2013.31005

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Open Journal of Gastroenterology, 2013, 3, 35-37 OJGas

http://dx.doi.org/10.4236/ojgas.2013.31005 Published Online February 2013 (http://www.scirp.org/journal/ojgas/)

Laparoscopic stapler repair of high rectovaginal fistula:

A case report

Amit Kumar Parmar, Mittu John Mathew, Prasanna Kumar Reddy*

Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospital, Chennai, India

Email: *[email protected]

Received 3 October 2012; revised 3 November 2012; accepted 11 November 2012

ABSTRACT

For thousands of years, women simply tolerated the

distressing symptoms generated by rectovaginal fis-

tulas (RVFs). This is no longer necessary because

most RVFs can be surgically corrected via a number

of approaches. Most rectovaginal fistulas are acquired;

obstetric injury alone accounts for nearly 88% of the

cases. The high fistulas are repaired by abdominal

approach, while middle or low fistulas are best ap-

proached perineally. There are only few case reports

of laparoscopic RVF repair noted in literature till

date. Laparoscopic repair of RVF is challenging and

requires advanced laparoscopic skill. Laparoscopy is

a better alternative in selected cases of RVF and

yields faster recovery and good patient compliance.

We present a case of high RVF managed laparo-

scopically by using stapler.

Keywords: Laparoscopy; Rectovaginal Fistula; Stapler

1. INTRODUCTION

Obstetric trauma is the most common cause of rectovagi-

nal fistula. Most of the RVFs are managed by conven-

tional open surgery. Abdominal surgeries such as hys-

terectomies, low anterior resections and ileo-anal anas-

tomosis also carry the risk of developing an RVF. RVF

can also develop secondary to radiation, pelvic malig-

nancy, and diverticular disease. Low RVF can be re-

paired through perineal approach but high RVF requires

transabdominal approach. Laparoscopic approach is fea-

sible in high RVF.

2. CASE PRESENTATION

A 36-year-old female patient underwent total abdomi-

nal hysterectomy with bilateral salpingoophorectomy for

endometriosis 6 months back elsewhere. On postopera-

tive day 3, she had severe abdominal pain and distension

for which she was re-explored and found to have a rectal

perforation. Primary closure of perforation and diverting

ileostomy was performed. Post operatively she devel-

oped high RVF which did not healed even after 3 months

of conservative management. She was referred to our

hospital for further management. After doing all routine

investigations and methylene blue leak test, she was

posted for laparoscopic repair of RVF.

3. OPERATIVE TECHNIQUE

Under general anaesthesia in modified lithotomy position,

pneumoperitoneun was created by veress needle through

Palmer’s point. 10 mm supraumblical telescopic port was

placed. 5 mm and 12 mm ports inserted in left and right

iliac fossae respectively. Adhesiolysis was done with

sharp dissection. The rectum was mobilised. A short,

wide fistulous tract was identified Figure 1 and dissected

all around and divided with articulating stapler (Echelon

flex 60, ETHICONTM). Air leak test was performed w h i ch

showed no leak. The omentum was placed between rec-

tum and vagina. Ileostomy was closed. The patient was

discharged on 3rd post operative day. She is symptom

free on 6 mon t hs fo l low up.

Figure 1. Intraoperative view of division of rectovaginal fistula

with articulating stapler.

*Corresponding a uthor.

OPEN ACCESS

A. K. Parmar et al. / Open Journal of Gastroenterology 3 (2013) 35-37

4. DISCUSSION

Rectovaginal fistula is epithelial lined communication

between rectum and vagina. Most common cause of RVF

is obstetric trauma. It can occur as a complication after

variety of rectal, vaginal and pelvic operations including

hysterectomy, low anterior resection, ileal-pouch anal

anastomosis and stapled hemorroidectomy [1]. RVF can

be associated with pelvic malignancy or radiation ther-

apy for malignancy, and inflammatory bowel disease.

RVFs can be classified into low and high varieties. Low

RVF is between the lower third of the rectum and the

lower half of the vagina. A high RVF is between the

middle third of the rectum and the posterior vaginal

fornix. Small-sized fistulas are less than 0.5 cm in di-

ameter, medium-sized fistulas are 0.5 - 2.5 cm, and

large-sized fistulas exceed 2.5 cm [2]. Clinical features

of the rectovaginal fistula are stool and air passage from

the vagina. Other symptoms include recurrent urinary

tract infection and perineal skin inflammation or infec-

tion. Symptoms of chronic inflammat ion and irritation in

these patients have an effect on their social life and psy-

chology and lead to sexual dysfunction. Most fistulas at

the lower rectum are palpable by digital rectal examina-

tion. Contrast radiography is the most dependable meth od

for diagnosing small and high rectovaginal fistulas. High

fistulas may not be readily apparent on physical exami-

nation or vaginal inspection and may even be missed by

endoscopy. Methylene blue enema with a vaginal tam-

pon in place, looking for staining on the tampoon is used

to confirm the diagnosis. Vaginography with a water

soluble contrast medium has a reported sensitivity of

79% to 100% [3-5]. CT and MRI also play a role in the

diagnosis and evaluation of the RVF as they may give

insight into the un derlying cause of the fistula.

Spontaneous healing may occur with adequate medical

treatment such as total parenteral nutrition, antibiotics,

and long-time fasting. However, surgical therapy re-

mains the mainstay for managing complex fistula was

not suitable for conservative management or underwent

prolonged conservative management (without resolution).

Operative access to this type of lesion includes fecal di-

version, and/or transperineal approach of resection, or

rectal anastomosis or repair. Operation of the middle and

lower rectum is associated with complications, including

urinary and sexual dysfunction. The management of RVF

depends on size, location, cause, anal sphincter function

and overall health status of the patient. Low fistulas can

be repaired through perineal approach. Transabdominal

approach is standard for high fistula. Total laparoscopic

repair of RVF is still rare. Nezhat CH et al. [6] reports

correction of two cases of RVF by laparoscopy. Pelosi et

al. [1] reported laparoscopic upper rectovaginal mobili-

sation with transvaginal repair of recurrent RVF. Pala-

nivelu et al. [2] reported 2 cases of high RVF managed

laparoscopically. Schwenk et al. [7] reported a case of

intracorporeal colorectal anastomosis for which they had

performed a laparoscopic resection of the sigmoid colon

with the fistulous tract and. They all concluded that

laparoscopic repair of RVF is feasible but it demands

adequate experience in advanced laparoscopic proce-

dures and proper identification of tissue planes. Good

preparation of the bowel is essential to avoid any faecal

contamination of the operative area. Fistulous tract is

generally divided and closed by using suture. But, in our

case we used linear stapler for this purpose. The idea

behind using it was to make procedure simpler and faster

and avoidance of faecal contamination as well. And thus,

we were able to close the ileostomy at the same time and

avoided one more surgical burden on the patient. This is

probably first case of laparoscopic stapler repair of RVF

in literature.

5. CONCLUSION

Laparoscopic repair of RVF is challenging and requires

advanced laparoscopic skill. Laparoscopy is a promising

alternative in selected cases of RVF and yields faster

recovery and good patient compliance. We found that

stapler repair as compared to primary intracorporeal clo-

sure makes the procedure simpler, faster, and easy.

Safety and long term outcomes of laparoscopic repair is

yet to be proved by long term follow up and further

studies.

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