Diverticular disease with colo-vesical fistula. Surgical treatment by MIS

Case

A 58-year-old male with a previous history of High Blood pressure, duodenal ulcer, hiatal hernia, a recent episode of orchi-epidydimitis and inguinal hernioplasty.

He suffered from an episode of diverticulitis complicated with small collections that were solved with medical treatment

A colonoscopy was performed in the outpatient clinic, revealing diverticular orifices at the sigmoid and a descending colon, plus two small polyps that were resected. Pathological examination was compatible with tubular adenomas with low-grade dysplasia

This patient mentioned pneumaturia, and a CT Scan was performed, revealing a colo-vesical fistula. The cystoscopy suggested that the fistula affected the vesical dome.

Treatment

Surgical treatment was laparoscopic.

The patient was placed in the supine position with open legs. The leading surgeon stood at the right of the patient with one assistant on each side. A total of 4 trocars were used. A 12mm port at the umbilicus was placed for a 30º scope. Other 12mm port was placed at the right iliac fossa plus a 5mm port located on each flank.

The recommendation in this type of case is to begin by assessing the feasibility of the resection and the MIS approach. Don’t perform any irreversible maneuver that places restrictions on the procedure. Some lateral detachment of the colon was performed.

The colo-vesical fistula area was identified. Tissues were rigid. An avascular plane was identified and the hook was used to achieve the individualization of the anatomical structures. Using her non-dominant hand, the leading surgeon performs traction of the colon improving the visualization of the avascular plane.

The use of fully opened laparoscopic DeBakeys simulates the traction performed by fingers against the colon. This maneuver is useful in fragile tissues that can be torn by pulling them. A 30º scope makes it possible to change the angle of visualization in order to show the correct plane to the leading surgeon. The rotation of the scope should be smooth.

Now the fistulous tract can be seen. Section of all the fibrotic tissue continues and the colon gets released from the vesical dome. Lateral detachment of the colon continues making it possible to mobilize the sigmoid colon and achieving a correct exposure of the mesosigmoid.

Using the hook a window is opened at the peritoneum. The pneumo helps by exposing the avascular plane. Medial to lateral mobilization and dissection of the IMA begin.  Opening a window behind the IMA pedicle creates a landmark for future section and makes it safer and easier to place any section or coagulation device.

The left hand of the leading surgeon is essential to perform traction and achieve exposure during the medial to lateral mobilization. The left ureter is identified and pulled below with the gonadal vessels by means of blunt dissection.

The LigaSure™ was used to confirm the orientation in order to make the mechanical suture. Here you can see the connection between the iliac arteries, the aorta and the IMA.

A grey Endo GIA was used for the vascular section. We always check that the tip doesn’t catch any surround organs.  The assistant surgeon perform cranial traction from the vascular stump exposing the posterior plane. Medial to lateral dissection progress. The hook was used for sharp and blunt dissection

One maneuver to improve safety is to introduce a gauze and place it between the posterior plane and the colon, following this strategy the ureter is protected from unexpected injuries during the lateral mobilization of the colon.

Now both dissections are connected and the sigmoid colon is mobilized. The distal landmark of mobilization in a diverticular disease is below the promontory. To dissect the right lateral and posterior margin of the recto-sigmoid junction the colon is pulled up by the assistant surgeon and the non dominant hand of the leading surgeon.

The colon is dissected to section below the recto-sigmoid junction. The hook takes down the fatty tissue around the colon. The LigaSure™ can also be used for this dissection. With the colon clearly dissected an EndoGIA was introduced for further section.

It is reticulated and placed with the intention to use as few mechanical sutures as possible. It is preferable to use a small mechanical suture to fully section the colon. It is better to have a sealed rectal stump.

The bladder was filled with methylene blue. There was no leak. A couple of intracorporeal Vicryl knots were used to seal the fistulous orifice. This can be a technically demanding maneuver as the angle is awkward and the camera is placed below.

A small Pfannenstiel incision was made, a protective bag was placed and the colon was extracted for section of the proximal margin and to set the anvil shaft. The mechanical suture was introduced through the anus and finally a mechanical end-to-end circular anastomosis was created under direct laparoscopic supervision.

A drain was placed for postoperative surveillance.