Cristina R Harnsberger, MD, Ryan C Broderick, MD, Hans F Fuchs, MD, Moneer E Almadani, MD, Santiago Horgan, MD, Elisabeth C McLemore, MD. University of California, San Diego, Department of Surgery
We present a technical video on the laparoscopic management of a colovesical fistula via a clinical case. The patient on whom the procedure was performed is a 53 year old HIV positive male with a large colovesical fistula able to be traversed with an endoscope, which has caused pneumaturia and fecaluria for six months. Laparoscopic port sites are illustrated and patient positioning is described. The principles of dissection are detailed, with an emphasis on blunt technique when possible. However, should division of the colovesical fistula be unable to be accomplished with blunt dissection alone, a combination of sharp dissection and energy can be applied. Care should be taken to avoid the use of energy in close proximity to the bladder; err on the side of the colon during dissection as it will be removed subsequently. Once the fistula is divided, a looped suture can be placed around the entry point of the fistula into the colon, to limit spillage of enteric contents. The bladder defect should be assessed and repaired primarily if the defect is large, as is illustrated in this case. The sigmoidectomy that follows repair of the colovesical fistula is not shown, as this technique is not the subject of the video. However the general principles of extension of the sigmoidectomy proximally to a region free of diverticular disease, and anastomotic technique are described. The video concludes with a description of the patient’s outcome, and a summary of the technical principles of laparoscopic management of a colovesical fistula.