Robot assisted laparoscopic ventral rectus abdominis muscle flap for interposition during complex vesicovaginal fistual repair

Objective

This video aims to provide a detailed description of a robot-assisted laparoscopic harvest of a vertical rectus abdominis muscle (VRAM) for interposition in a complex vesicovaginal fistula repair.

Patient

The case presented involves a 38-year-old female patient with a body mass index of 54, who was undergoing chemotherapy for stage 3 high-grade endometrial carcinoma. The patient experienced recurrent urinary tract infections and continuous leakage of fluid per vagina one month after undergoing a robot-assisted laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and macrodebulking. Cystoscopy revealed a 3 cm vesicovaginal fistula, which was biopsied and found to exhibit necrosis and dystrophic calcification.

Surgical procedure

Considering the size of the fistula, interposition tissue was deemed necessary for the repair. The patient had previously undergone omentectomy, and macrobulking of the peritoneum was performed by the gyn-oncologists. Consequently, the VRAM was identified as the most suitable option. The vesicovaginal fistula repair was conducted using standard pelvic port placement. 3–0 PDS stay sutures were placed between and around the bladder and vaginal closures to secure the VRAM in place. The robot was undocked and re-docked to a retroperitoneal configuration, and with the aid of a 30 up camera, the posterior rectus sheath was opened. The muscle was dissected off the anterior sheath, with any perforating vessels being ligated and the superior epigastric artery being sealed using a vessel sealer. The flap was then rotated into the pelvis and secured over the bladder and vaginal defect closure. The inferior epigastric artery supplies the flap. With the robotic approach the anterior sheath remains intact. The posterior sheath is not closed. This can cause a post-operative budge in the area.

Results

The patient was discharged with an 18 Fr foley catheter, and a postoperative cystogram was performed at 3 weeks, revealing no evidence of a leak. The patient has been followed for 15 months without reporting any urological complaints.

Conclusion

The VRAM represents a robust and healthy flap that can be safely harvested using robotic techniques. It can be effectively employed in pelvic reconstruction to fill dead space or serve as tissue interposition