Complex Diverticular Disease: Colovaginal and Colovesicle Fistula Repair
Michelle F. Deleon
Steven D. Wexner
Bradley J. Champagne
Perioperative Considerations
Colonoscopy, cystoscopy (for colovesicle fistula), and a vaginal examination/vaginoscopy (for colovaginal fistula) should be performed, if possible, to exclude cancer and confirm fistula.
We normally attempt to “cool” patients down with intravenous (IV) antibiotics and wait 6-8 weeks after the flare to undergo a semi-elective operation.
Though ureteral stents have not been shown to decrease the rate of ureteral injury during colorectal surgery, they do allow for earlier detection of injury. In these cases where ureteral anatomy may be distorted secondary to inflammation and scarring, we recommend placement of ureteral stents to aid in detection of the ureter.
Bowel preparation and perioperative antibiotics are routinely given.
Patients should be considered for marking for a stoma (colostomy vs. diverting ileostomy), depending on the degree of inflammation.
Laparoscopic Approach
Patient Positioning
The patient is placed in the modified lithotomy position (+/− bean bag).
The arms are tucked at the patient’s side, and the bean bag is placed to suction.
If the patient is too obese to have both arms tucked, the left one remains out.
An oral gastric tube and a bladder catheter are placed.
Any hair on the abdomen is clipped from xiphoid to pubis and out to the anterior axillary line.
Surgeon and Monitor Positioning
The primary surgeon stands on the right side of the patient, with the assistant on the left side.
After all ports have been inserted, the assistant moves to the right side of the patient, to the left of the primary surgeon.
The primary monitor should be placed on the left side of the patient toward the hip.
The secondary monitor is on the right side of the patient toward the head and is used primarily for port placement.
Sterile Surgical Equipment
Gastrointestinal (GI) laparoscopic tray with atraumatic graspers
GI open tray with pelvic retractors (add on for other specialties if further work is needed)
Knife handle
Adison forceps
Ochsner clamp
Allis clamp
Kelly clamp
Moynihan clamp (short and long)
Babcock clamp (short and long)
Kocher clamp
Tonsil clamp
Dennis clamp
Suction tip
Metzenbaum scissors
Mayo scissors
Harrington scissors
Jones scissors
Needle holder
Monopolar cautery
Bonnie forceps
Appendiceal retractors
Bookwalter retractor
St. Mark’s retractor
Included in this tray also long instruments for the pelvic dissection
Laparoscopic and open linear and end-to-end staplers
Energy device
Flexible sigmoidoscope
Hassan, 10-12 mm and 5 mm trocars
0- and 30-degree, 10 and 5 mm laparoscope
Additional instruments are usually needed depending on the combined part with the proctectomy, gynecology tray, or urology or orthopedic specials
Technique
Port Placement
 FIGURE 36-1 ▪ Port placement for laparoscopic sigmoid resection. |
Using the Hassan approach, a supraumbilical 10-mm port is placed (Fig. 36-1).
A 12-mm port is placed in the right lower quadrant (RLQ), 2-3 cm anteromedial to the anterior superior iliac spine.
A 5-mm port is placed in the right upper quadrant, in line with a hand’s breadth away from the 12-mm RLQ port.
A 5 mm left lower quadrant is inserted for additional retraction.
For a difficult splenic flexure mobilization or in a morbidly obese patient, an extra 5-mm port may be placed in the left upper quadrant.
These ports should be placed under direct visualization, lateral to the inferior epigastric vessels and perpendicular to the abdominal wall to avoid unnecessary torque.
Note: One author (SDW) utilizes a 12-mm infraumbilical Hassan cannula followed by a right upper quadrant and a RLQ 10-mm port. For a difficult splenic flexure mobilization or in a morbidly obese patient, a 10 mm left lower quadrant port may be added.
Procedure Details
Medial-to-Lateral Approach
The patient is placed left side up, in steep Trendelenburg position.
This method allows the small bowel to fall out of the pelvis.
With the aid of gravity, the small bowel is placed in the right upper quadrant.
The greater omentum is reflected cephalad to expose the transverse colon.
A small sponge may be placed through the 10-mm port, to aid in minor diffuse bleeding that is often encountered with inflammatory tissue.
For uncomplicated sigmoid resections, a medial-to-lateral approach is preferred, though one author (SDW) prefers a lateral to medial.
The “preferred” approach may always not be possible with diverticular fistula as the sigmoid or the upper rectum is adherent to either the bladder or the vagina. This situation causes the mesentery to fold on itself and prohibits adequate retraction to expose the inferior mesenteric artery.
For this reason, lateral attachments must be released first along with the colovesicle or colovaginal fistula before approaching the inferior mesenteric artery medially.
Start by mobilizing lateral attachments away from the fistula and inflammatory process. This maneuver will guide the surgeon to the correct plane when approaching the diseased colon.
If there is not significant inflammation, and the fistula is clearly away from the trajectory of the ureter, the fistula may be taken down with relative ease. When doing so, err on the side of the colon to avoid exacerbating the existing defect in the bladder or the vagina.
After this is done, the operation can proceed from medial to lateral, as optimal traction can now be placed on the inferior mesenteric artery.
Lateral-to-Medial Approach
If the fistula has significant surrounding inflammatory tissue, and the surgeon cannot be certain the ureter is away from the fistula, a complete lateral-to-medial approach may be preferred to first identify the ureter before taking down the fistula.
The colon is grasped with the surgeon’s left hand, drawing it anterior and to the right.
This exposes the lateral attachments of the sigmoid colon that are divided using hot scissors.
To ensure the correct plane is entered, the lateral attachments should be taken just 1 mm medial to the white line of Toldt.
As dissection proceeds, the surgeon will first encounter the gonadal vessels and then the ureter located just medial.Related posts:
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