# Lap low anterior resection, takedown of colovaginal fistula



## ksb0211 (Aug 31, 2012)

These fistual repairs always throw me for a loop and confuse the heck out of me.  LOL  If there is any input, I would greatly appreciate it.  Thank you so much.


PREOPERATIVE DIAGNOSIS/POSTOPERATIVE DIAGNOSIS
Colovaginal fistula.

OPERATION PERFORMED
Laparoscopic hand-assisted low anterior resection with mobilization of the splenic flexure, takedown of the colovaginal fistula and repair of the vaginal cuff.

DESCRIPTION OF PROCEDURE
The patient was brought to the operating room.  After attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion.  Dr. XXXXX placed stents for us and then at this point we started the procedure.

We got in through an open incision in the upper xiphoid and upper portion of the abdomen, got in under direct vision, took down some adhesions and then mobilized the colon took down the splenic flexure using the Harmonic scalpel; mobilized down into the pelvis proper and then at this point switched over to somewhat of an open technique, opening the abdomen in the midline.  The patient has a BMI of 44 and we could tell at the time of the laparoscopy that the pelvis was nearly frozen.  Went in under open conditions, developed our exposure and found that the floor of the pelvis was just kind of a big indurated mass, mobilized this area very cautiously and then found the stents in the ureter, which were quite helpful, and prevented ureteral injury.  We then mobilized the colon off of the vaginal cuff.  We were not sure because the anatomy was so distorted whether or not we fully mobilized it; went in with a Foley balloon, insufflated it within the vagina and then blew air into the vagina and then we could see the air leak clearly adjacent to the colon.  We mobilized more of the colon at that point and actually freed it up and got it totally separated from the vaginal cuff.  We carried out repair of the vaginal cuff with interrupted sutures of 2-0 Vicryl, but left a long tail and then had about 5 of those coming out in which we put onto a clamp and then we went back up, blew some air and at this point the vaginal repair was airtight.  We then fired a contour device across the base of the colon.  We had mobilized the colon thoroughly, taking down the mesocolon basically with the Harmonic scalpel using some 2-0 silk ties as well.  Once we had handed the colon off, it was clearly quite diseased and very thickened.  We handed off that specimen then brought down the colon which we had previously mobilized, sized it out to a 28 mm diameter.  I neglected to mention that we had divided the colon at the earlier portion of the case with a GIA-75.  We had used a pursestring device on the end of the colon, at that point made sure we mobilized some of the surrounding fat from around the end of the colon then actually sized it out to 28 mm and put in an anvil.  We then went back down.  We had been below the peritoneal reflection.  We went back up with an obturator, could feel where the colon had been divided with the contour device and then went up with a stapler, brought the pointed obturator right through the staple line, connected the proximal rectum to the distal descending colon and then fired the stapler making a 28 mm anastomosis.  Placed a clamp on the colon and then blew air into the colon with the sigmoidoscope.  There was no air leak apparent.  Placed a drain down in the pelvis, irrigated copiously and then closed the patient with a running suture of #1 PDS, placed in 2 strands.  Then, because of her panniculus which was about 6 inches thick, we placed a Jackson-Pratt into the wound and then closed the deep sutures of 2-0 Vicryl and then used skin staples.

She tolerated the procedure quite well.


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