Vesico vaginal fistula

Author: A. Rossetti / M. Schettini (manlioschettini@libero.it) / O. Sizzi

This movie shows the laparoscopic treatment of vesico-vaginal fistula. The patient underwent a supracervical hysterectomy because she had a bladder lesion during a previous C-section.

Despite the SCH she had anyway a vesico-vaginal fistula. The fistula was already treated twice by vaginal way without success. The first steps of the procedure was the sounding of the fistula by vaginal way and the introduction of a catheter number 8 through the fistula into the bladder.
When the catheter ballon is inflated the fistula hole in the bladder is occluded and marked.

Then the pneumoperitoneum is crated and an umbilical trocar for the optic is inserted, under laparoscopic vision 3 suprapubic trocars are inserted: 2 lateral trocars are positioned at 1.5 cm medially and 1.5 cm above the superior iliac spine and one in the umbilico-pubic line 8-10 cm below the umbilicus.

150 cc of saline are introduced into the bladder to delineate the bladder margins and a forceps with a sponged is inserted inside the vagina to push up the cervical stump.

The peritoneum covering the vagina and the cervical stump is then opened and a sharp and blunt dissection of the connective tissue between bladder and vagina is performed. The dissection is performed mostly from the lateral margins of the bladder bilarally towards the lesion.

The area of the fistula is delineated and with a sharp dissection the margins in the bladder and in the vagina are removed of debris until healthy tissue is reached. The catheter is then removed.
The bladder hole is sutured with single stitch 2-0 Vycril in double layers and the bladder integrity is checked filling the bladder with 200 cc of saline.

Then the cervical stump is removed and the vaginal cuff is sutured with a 0 Vycril running suture. A flap of omentum is positioned to cover the bladder hole and to separate the bladder and the vaginal sutures.
The patient was discharged with the bladder catheter that was removed after two weeks.