ksb0211
Guest
The colovaginal fistula repair is what is throwing me off on this procedure. I can't imagine it would be bundled, but I know I could be wrong there. Does anyone have thoughts on this one?
Thanks.
PRE/POSTOPERATIVE DIAGNOSIS
Colovaginal fistula.
PROCEDURES
1. Laparoscopic hand-assisted sigmoid resection with repair of vaginal fistula.
2. Mobilization of the splenic flexure.
PROCEDURE IN DETAIL
The patient was brought to the operating room and after attainment of sufficient general anesthesia, She was pretreated with antibiotics and prepped and draped in the usual sterile fashion.
A 5-mm supraumbilical incision was made, we insufflated to 14 mmHg, placed another 5-mm port in the subxiphoid region, another one in the left hypogastrium. We took down the white line of Toldt, brought our incision around and reflected the transverse colon downward at the level of the splenic flexure to get us more room for our eventual resection. We then moved down into the pelvis and found that the area of the pelvis that the diverticular disease had sort of fused the colon into the wall of the pelvis and down around the area of the vaginal cuff. Went ahead at this point and opened just below the umbilicus, used a Bookwalter retractor. The patient's obesity required us to take a Bookwalter and to actually combine 2 Bookwalters in order to get enough length to afford us the ability to get the Bookwalter into position above the patient's abdominal wall. Made our incision, developed our exposure, took down this fistula, which we divided with a Bovie pretty much throughout. At this point we saw that we had a relatively localized area of sigmoid disease. The patient's visualization was made much more difficult by her compact obesity, which was mostly central. We fired a GIA proximally and then a Contour stapler distally and then using the Harmonic scalpel and 2-0 silks we were able to get complete hemostasis and remove the area of diseased sigmoid. We then carried out repair of the vaginal cuff. We identified the area of interest, placed 3 figure-of-8 sutures of 2-0 Vicryl into that area, covered with surrounding fat as well and at this point we irrigated. We used a pursestring stapler to divide the distal end of the descending colon, sized out the colon to 28 mm, placed an anvil into position, closed down on the anvil with the pursestrings, then went up through the rectal vault, came up into the sigmoid, or the remains of the sigmoid, and got a 28-mm stapler, brought it through the anterior wall of the colon, placed a pursestring in that area then connected the distal descending colon to the area of pursestring, fired it making anastomosis at the level just about the sigmoid. We air tested this anastomosis, placed a clamp proximally, filled the pelvis with fluid and air testing on the several occasions revealed no bubbles whatsoever, we had an airtight anastomosis. We then mobilized the omentum in part and brought it down into the pelvis, put it adjacent to the vaginal repair to make sure that we had isolated that repair from the colon. At this point we irrigated, placed a 10-mm Jackson-Pratt then close the fascia with a running double-stranded #1 PDS. Following that we irrigated the wound copiously. The patient was quite heavy, as mentioned, with about maybe a 4-inch panniculus. We irrigated, irrigated and irrigated some more then closed with deep sutures of 2-0 Vicryl followed by skin staples. The patient tolerated the procedure quite well.
Thanks.
PRE/POSTOPERATIVE DIAGNOSIS
Colovaginal fistula.
PROCEDURES
1. Laparoscopic hand-assisted sigmoid resection with repair of vaginal fistula.
2. Mobilization of the splenic flexure.
PROCEDURE IN DETAIL
The patient was brought to the operating room and after attainment of sufficient general anesthesia, She was pretreated with antibiotics and prepped and draped in the usual sterile fashion.
A 5-mm supraumbilical incision was made, we insufflated to 14 mmHg, placed another 5-mm port in the subxiphoid region, another one in the left hypogastrium. We took down the white line of Toldt, brought our incision around and reflected the transverse colon downward at the level of the splenic flexure to get us more room for our eventual resection. We then moved down into the pelvis and found that the area of the pelvis that the diverticular disease had sort of fused the colon into the wall of the pelvis and down around the area of the vaginal cuff. Went ahead at this point and opened just below the umbilicus, used a Bookwalter retractor. The patient's obesity required us to take a Bookwalter and to actually combine 2 Bookwalters in order to get enough length to afford us the ability to get the Bookwalter into position above the patient's abdominal wall. Made our incision, developed our exposure, took down this fistula, which we divided with a Bovie pretty much throughout. At this point we saw that we had a relatively localized area of sigmoid disease. The patient's visualization was made much more difficult by her compact obesity, which was mostly central. We fired a GIA proximally and then a Contour stapler distally and then using the Harmonic scalpel and 2-0 silks we were able to get complete hemostasis and remove the area of diseased sigmoid. We then carried out repair of the vaginal cuff. We identified the area of interest, placed 3 figure-of-8 sutures of 2-0 Vicryl into that area, covered with surrounding fat as well and at this point we irrigated. We used a pursestring stapler to divide the distal end of the descending colon, sized out the colon to 28 mm, placed an anvil into position, closed down on the anvil with the pursestrings, then went up through the rectal vault, came up into the sigmoid, or the remains of the sigmoid, and got a 28-mm stapler, brought it through the anterior wall of the colon, placed a pursestring in that area then connected the distal descending colon to the area of pursestring, fired it making anastomosis at the level just about the sigmoid. We air tested this anastomosis, placed a clamp proximally, filled the pelvis with fluid and air testing on the several occasions revealed no bubbles whatsoever, we had an airtight anastomosis. We then mobilized the omentum in part and brought it down into the pelvis, put it adjacent to the vaginal repair to make sure that we had isolated that repair from the colon. At this point we irrigated, placed a 10-mm Jackson-Pratt then close the fascia with a running double-stranded #1 PDS. Following that we irrigated the wound copiously. The patient was quite heavy, as mentioned, with about maybe a 4-inch panniculus. We irrigated, irrigated and irrigated some more then closed with deep sutures of 2-0 Vicryl followed by skin staples. The patient tolerated the procedure quite well.