Advanced Laparoscopic Skills Research Articles

An AAGL Task Force Consensus Statement: A Standardized Approach to LESS Hysterectomy

Single incision gynecologic laparoscopy was first described in 1991, but did not really emerge until 2007 as an advanced laparoscopic approach. This approach is known my many different names and acronyms. Laparoendoscopic single site (LESS) surgery is the accepted acronym to describe this advanced approach. The feasibility of LESS for complex surgical procedures is no longer an issue; however, the generalizability of LESS has been questioned, given the above factors and need for advanced laparoscopic skills. More importantly, it may play an essential role in the reproducibility and diffusion of LESS. Information about training and education on LESS is scarce in the current literature. With the support of AAGL, a working group of expert LESS surgeons and educators developed and described a standardized consensus technique for LESS supracervical hysterectomy that can be easily understood, replicated, and is useful in learning the LESS technique.

Robotic spleen preserving distal pancreatectomy: how I do it (with video).

Laparoscopic hepatobiliary surgery, although technically demanding, gains popularity due to the patient benefits of a mini-invasive approach. Laparoscopic distal pancreatectomy is a technically feasible and reproducible operation that doesn't require complex digestive reconstruction. It requires advanced laparoscopic skill for vascular dissection and control. Due to the absence of trials proving its oncological results it is mainly indicated for benign or borderline tumours of the pancreatic body and tail. Since for these tumours there is no indication for a lymph node dissection, there are benefits for the patient if the spleen is preserved. There is some evidence that robotic assistance facilitates the procedure and makes it accessible to surgeons diminishing the necessity of advanced laparoscopic skills. In this technical multimedia article, we present our method for a robotic mini-invasive spleen preserving distal pancreatectomy with preservation of the splenic vessels. The technique is presented in a stepwise approach with an accompanying video. We believe that the use of the Da Vinci robotic platform facilitates this demanding procedure.

Mental Practice to Enhance Advanced Laparoscopic Surgical Performance in the Operating Room: A Randomized Controlled Trial

INTRODUCTION: Mental practice (MP), the cognitive rehearsal of a task without physical movement, is known to enhance performance in sports and music. However, investigation of this technique in surgery has been limited to basic operations. The purpose of this study was to develop mental practice scripts, and assess their effect on advanced laparoscopic skills and surgeon stress levels in a crisis scenario.

Low-hanging fruit: a clementine as a simulation model for advanced laparoscopy.

Low-cost, high-fidelity models for training in advanced laparoscopic surgery techniques are not currently available. The objective of this study was to evaluate a model and assessment protocol for developing associated fine, precise laparoscopic dissection skills with accompanying surgical decision making. Novice to expert laparoscopists (n = 41) were asked to remove the peel of a clementine in as few pieces as possible, separate and remove all albedo from and between all fruit segments, and return the clementine to as close to its natural state as possible with completely closed skin (sutured). Clinical decision making included deciding when unacceptable segment damage would result by removing difficult-to-extract albedo, analogous to treating lesions or metastases through other methods, rather than risking damage to vital anatomic structures. Faculty assessed deidentified video-recorded performances. Data analyses included analysis of variance with Bonferroni post hoc. A single-performance construct (operative ability) with 2 scoring dimensions (surgical skills and clinical judgment) was confirmed through factor analysis. There were significant performance differences between all experience levels (F2,41 = 59.175, P < 0.000). There were no statistical time differences between the groups. Validation of this low-cost, easily facilitated model for developing advanced laparoscopic surgical skills may support the preparation of residents and fellows and provide a platform for skill acquisition, assessment, and basic critical thinking for performing laparoscopic tasks.

Evaluation of advanced laparoscopic skills tasks for validity evidence.

Since fundamentals of laparoscopic surgery (FLS) represents a minimum proficiency standard for laparoscopic surgery, more advanced proficiency standards are required to address the needs of current surgical training. We wanted to evaluate the acceptance and discriminative ability of a novel set of skills building on the FLS model that could represent a more advanced proficiency standard-advanced laparoscopic surgery (ALS). Qualitative and quantitative analyses were employed. Quantitative analysis involved comparison of expert (PGY 5+), intermediate (PGY 3-4) and novice (PGY 1-2) surgeons on FLS and ALS tasks. Composite scores included time and errors. Standard FLS errors were added to task time to create the composite score. Qualitative analysis involved thematic review of open-ended questions provided to experts participating in the study. Out of 48 participants, there were 15 (31 %) attendings, 3 (6 %) fellows and 30 (63 %) residents. By specialty, 54 % were general/MIS/bariatric/colorectal (GMBC) and 46 % were other (urology and gynecology). There was no difference between experience level and performance on FLS and ALS tasks for the entire cohort. However, looking at the GMBC subgroup, experts performed better than novices (p = 0.012) and intermediates performed better than novices (p = 0.057) on ALS tasks. There was no difference for the same group in FLS performance. Also, GMBC subgroup performed significantly better on FLS (p = 0.0035) and ALS (p = 0.0027) than the other subgroup. Thematic analysis revealed that the majority of experts felt that ALS was more realistic, challenging and clinically relevant for specific situations compared to FLS. For GMBC surgeons, we were able to show evidence of validity for a series of advanced laparoscopic tasks and their relationship to surgeon skill level. This study may represent the first step in the development of an advanced laparoscopic skills curriculum. Given the high degree of specialization in surgery, different advanced skills curricula will need to be developed for each specialty.

Single incision laparoscopic hepatectomy: Advances in laparoscopic liver surgery

BACKGROUND:Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in experienced hands. Single incision laparoscopic surgery (SILS) has been performed for cholecystectomies, nephrectomies, splenectomies and obesity surgery. However, the use of SILS in liver surgery has been rarely reported. We report our initial experience in seven patients on single incision laparoscopic hepatectomy (SILH).PATIENTS AND METHODS:From October 2010 to September 2012, seven patients underwent single-incision laparoscopic liver surgery. The abdomen was approached through a 25 mm periumbilical incision. No supplemental ports were required. The liver was transected using a combination of LigaSure™ (Covidien-Valleylab. Boulder. USA), Harmonic Scalpel and Ligaclips (Ethicon Endo-Surgery, Inc.).RESULTS:Liver resection was successfully completed for the seven patients. The procedures consisted of two partial resections of segment three, two partial resections of segment five and three partial resections of segment six. The mean operative time was 98.3 min (range: 60-150 min) and the mean estimated blood loss was 57 ml (range: 25-150 ml). The postoperative courses were uneventful and the mean hospital stay was 5.1 days (range: 1-13 days). Pathology identified three benign and four malignant liver tumours with clear margins.CONCLUSION:SILH is a technically feasible and safe approach for wedge resections of the liver without oncological compromise and with favourable cosmetic results. This surgical technique requires relatively advanced laparoscopic skills. Further studies are needed to determine the potential advantages of this technique, apart from the better cosmetic result, compared to the conventional laparoscopic approach.

Laparoscopic pancreatectomy: Indications and outcomes

The application of minimally invasive approaches to pancreatic resection for benign and malignant diseases has been growing in the last two decades. Studies have demonstrated that laparoscopic distal pancreatectomy (LDP) is feasible and safe, and many of them show that compared to open distal pancreatectomy, LDP has decreased blood loss and length of hospital stay, and equivalent post-operative complication rates and short-term oncologic outcomes. LDP is becoming the procedure of choice for benign or small low-grade malignant lesions in the distal pancreas. Minimally invasive pancreaticoduodenectomy (MIPD) has not yet been widely adopted. There is no clear evidence in favor of MIPD over open pancreaticoduodenectomy in operative time, blood loss, length of stay or rate of complications. Robotic surgery has recently been applied to pancreatectomy, and many of the advantages of laparoscopy over open surgery have been observed in robotic surgery. Laparoscopic enucleation is considered safe for patients with small, benign or low-grade malignant lesions of the pancreas that is amenable to parenchyma-preserving procedure. As surgeons' experience with advanced laparoscopic and robotic skills has been growing around the world, new innovations and breakthrough in minimally invasive pancreatic procedures will evolve.

Trends in splenectomy: where does laparoscopy stand?

Background and Objectives:Laparoscopic splenectomy (LS) has been shown to offer superior outcomes when compared to open splenectomy (OS). Despite the potential advantages associated with the minimally invasive technique, laparoscopy appears to be underused. We sought to evaluate the nationwide trends in LS.Methods:The Nationwide Inpatient Sample (NIS) database was queried for both OS and LS procedures performed from 2005 through 2010. Partial splenectomies and those performed for traumatic injury, vascular anomaly, or as part of a pancreatectomy were excluded. The included cases were examined for age of the patient and comorbid conditions. We then evaluated the postoperative complications, overall morbidity, mortality, and length of hospital stay.Results:A total of 37,006 splenectomies were identified. Of those, OS accounted for 30,108 (81.4%) cases, LS for 4,938 (13.3%), and conversion to open surgery (CS) for 1,960 (5.3%). The overall rate of morbidity was significantly less in the LS group than in the OS group (7.4% vs 10.4%; P < .0001). The LS group had less mortality (1.3% vs 2.5%, P < .05) and a shorter length of stay (5.6 ± 8 days vs 7.5 ± 9 days).Conclusions:Despite the benefits conferred by LS, it appears to be underused in the United States. There has been an improvement in the rate of splenectomies completed laparoscopically when compared to NIS data from the past (8.8% vs 13%; P < .05). The conversion rate is appreciably higher for LS than for other laparoscopic procedures, suggesting that splenectomies require advanced laparoscopic skills and that consideration should be given to referring patients in need of the procedure to appropriately experienced surgeons.

Laparoscopic robotic liver surgery: the Henri Mondor initial experience of 20 cases.

Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in the hands of trained surgeons. The introduction of robotics into surgery represents progression in the field of minimally invasive surgery but has seen a slow uptake in the hepatopancreaticobiliary subspeciality. We report our initial experience in 20 cases of laparoscopic robotic liver resection (LRLR). From March 2011 to April 2013 patients with lesions within the liver were assessed and consented for laparoscopic robotic liver surgery. This is a retrospective analysis of a prospectively kept database on preoperative details and intraoperative and postoperative outcomes. During the time period there were 20 LRLRs. The median age was 62years (range 39-80years) with a male to female ratio of 14:6. Ten patients had left lateral sectionectomies, 10 patients had atypical segmental resections; 14 patients had resections for malignancies, 6 patients had resections for benign disease. One case was converted to open resection. The mean operating time was 176.4±74.6min (range 60-300min), the mean blood loss was 107±106ml (range 50-700ml) and the mean hospital stay was 6.5±3.7days (range 2-16days). Two patients required blood transfusions. The incidence of postoperative complications was 10% (n=2). LRLR overcomes some of the disadvantages of conventional laparoscopic surgery. It is a technically feasible and safe approach for wedge resections and left lateral sectionectomy of the liver without oncological compromise. However, this surgical technique requires advanced laparoscopic skills and there is an associated steep learning curve. Further studies are needed to determine the potential advantages of this technique for the patient compared to the traditional laparoscopic approach.

Laparoscopic Paraesophageal Hernia Repair

The advent of laparoscopy has significantly improved postoperative outcomes in patients undergoing surgical repair of a paraesophageal hernia. Although this minimally invasive approach considerably reduces postoperative pain and recovery times, and may improve physiologic outcomes, laparoscopic paraesophageal hernia repair remains a complex operation requiring advanced laparoscopic skills and experience with the anatomy of the gastroesophageal junction and diaphragmatic hiatus. In this article, we describe our approach to patient selection, preoperative evaluation, operative technique, and postoperative management. Specific attention is paid to performing an adequate hiatal dissection and esophageal mobilization, the decision of whether to use a mesh to reinforce the crural repair, and construction of an adequate antireflux barrier (ie, fundoplication).

Laparoscopic treatment for adhesive small bowel obstruction: is it the gold standard in children too?

Small bowel obstruction (SBO) due to adhesions is an important cause of surgical admission and postoperative morbidity in the pediatric population [1, 2]. Advanced laparoscopic surgery is now commonly available in the majority of tertiary pediatric centers for the treatment of both urgent and elective cases. In the January edition of Surgical Endoscopy, O’Connor and Winter [3] reviewed the success rate of laparoscopy in the treatment of adult acute SBO. Their review of over 2,000 patients demonstrated clear advantages of laparoscopy (mortality rate 1.5 %, enterotomy rate 6.6 %, and conversion rate 29 %) and concluded that laparoscopic treatment should become the primary surgical technique in the treatment of adult SBO [3]. However, in the pediatric field, data on the laparoscopic treatment of SBO due to adhesions are scarce. We performed a detailed review of the pediatric literature published between 1990 and 2012, and we were able to identify only three retrospective case series on this topic (Table 1). Inclusion criteria for the search were Englishlanguage articles on pediatric SBO and laparoscopy, case series with more than 10 patients, and patients age younger than 18. A meta-analysis of the 150 cases identified showed a mortality rate of 0.7 %, an enterotomy rate of 4.0 %, and a conversion rate of 27.3 % (Table 2). Table 3 lists laparoscopic failure. These results surpass those shown by O’Connor and Winter, suggesting that laparoscopic treatment should also become the gold standard for the treatment of SBO in children. Despite this, a recent report of 20,679 cases of pediatric adhesive bowel obstruction undertaken in the United States from 1997 to 2009 showed that only 17 % were treated with laparoscopy, with laparotomy and open adhesiolysis remaining by far the most common surgical technique used [4]. This study also confirmed the well-known benefits of laparoscopy, such as shorter lengths of stay (6 vs. 8 days), reduced hospital costs ($38,241 vs. $48,552), and reduced complication rates (5.6 vs. 10.4 %) compared to open surgery. Historically, pediatric surgery has shown a delay in embracing minimally invasive surgical techniques. Some could argue that the delay was due to the lack of pediatric instruments at that time, or perhaps due to longer learning curves due to the reduced frequency of some operations (e.g., cholecystectomy), but we also know that the time taken for pediatric surgeons to mentally switch to convert their practice to minimally invasive surgery played a role. On the subject of SBO, a problem common to patients of all ages, pediatric surgeons should be receptive and open to follow adult results, with an aim to better surgical practice and outcomes for children and their families. In conclusion, even if the amount of data is not yet consistent and comparable to that of the adult field, we are confident in supporting the fact that pediatric surgeons with advanced laparoscopic skills are safe and highly efficacious in treating pediatric SBO with minimally invasive techniques and that laparoscopy should become the gold standard for the treatment of this condition in children. Nadja Apelt and Neil Featherstone contributed equally to this work, and both should be considered first author.

PTU-155 Lessons Learnt from the First 50 Consecutive Primary Laparoscopic Nissen Fundoplications in a Single Surgeon’S Practice

IntroductionLaparoscopic Nissen fundoplication (LNF) is widely used in the surgical management of gastroesophageal reflux disease (GORD). However, it is a complex operation that requires advanced laparoscopic skills. Very few studies...

Transvaginal sonographic sliding sign: accurate prediction of pouch of Douglas obliteration

Transvaginal sonographic sliding sign: accurate prediction of pouch of Douglas obliteration

A Systematic Review on Low-cost Box Models to Achieve Basic and Advanced Laparoscopic Skills During Modern Surgical Training

Low-cost box models (BMs) are a valuable tool alternative to virtual-reality simulators. We aim to provide surgical trainees with a description of most common BMs and to present their validity to achieve basic and advanced laparoscopic skills. A literature search was undertaken for all studies focusing on BMs, excluded were those presenting data on virtual-reality simulators only. Databases were screened up to December 2011. Numerous studies focused on various BMs to improve generic tasks (ie, instrument navigation, coordination, and cutting). Only fewer articles described models specific for peculiar operations. All studies showed a significant improvement of basic laparoscopic skills after training with BMs. Furthermore, their low costs make them easily available to most surgical trainees. BMs should be developed by all surgical trainees during their training. Fields for future improvement regard endoscopy and complex laparoscopic operations for which ad hoc BMs are not available.

An analysis of the impact of previous laparoscopic hysterectomy experience on the learning curve for robotic hysterectomy.

To analyze and compare the safety and perioperative outcomes of newly trained robotic surgeons with previous laparoscopic hysterectomy experience (TLH Exp) and those without previous laparoscopic hysterectomy experience (Non-TLH Exp). The purpose is to determine the effect of previous advanced laparoscopic skills on the performance in robotic assisted laparoscopic surgery. We will also compare the perioperative outcomes between the total laparoscopic hysterectomies (TLH), and robotic assisted laparoscopic hysterectomies (RALH) of a single experienced (TLH Exp) robotic surgeon. The purpose is to determine benefits and/or risks, if any, of one approach over the other in the hands of an experienced laparoscopic surgeon. Prospective data were collected on the first consecutive series of RALH performed by (TLH Exp) and (Non-TLH Exp) surgeons, with perioperative outcomes and morbidity being evaluated. In addition, retrsopective data were collected on a consecutive series of patients in a TLH group and compared with the outcomes in the robotic group for benign hysterectomies by the same surgeon. The parameters that were analyzed for associations with these two groups were estimated blood loss (EBL), Hb drop, length of hospital stay (LOS), procedure time, pain medication use, and complications. The (TLH Exp) group had 64 patients, and the (Non-TLH Exp) group had 72 patients. When comparing patients in the (TLH Exp) group with patients in (Non-TLH Exp) group, the mean age was 44 and 45 (P=0.8), mean BMI was 27.7 and 29.5kg/m(2) (P=0.2), mean procedure time was 121 and 174min (P<0.05), mean console time was 70 and 119min (P<0.05), mean EBL was 64 and 84ml (P=0.3), with a Hb drop 1.7 and 1.33 (P=0.2), uterine weight was 192 and 205 gms (P=0.7), and length of stay was 1.07 and 1.33days (P=0.2), respectively. The (TLH Exp) surgeons had a lower OR, procedure and console time, but a higher hemoglobin drop, with no difference in EBL. There were no operative deaths, or conversions in either group. Morbidity occurred in two patients (3%) in each group, with no statistically significant difference between the groups. In the (TLH Exp) group it included a blood transfusion and a readmission for a postoperative ileus. In the (Non-TLH Exp), the complications included a blood transfusion and a return to the OR for a vaginal cuff dehiscence. When comparing a single (TLH Exp) surgeon's own TLH versus RALH, there were 64 RALH and 49 TLH cases. There was a statistically significant difference in the mean procedure time 121.1 versus 88.8min (P<0.05), mean Hb drop 1.7 versus 2.3 (P<0.05), and mean EBL 64.2 versus 158ml (P<0.05), respectively. The RALH group had a longer procedure time, but lower Hb drop, and less estimated blood loss. There were no operative deaths, or conversions in either group. Morbidity occurred in 2 patients in the robotic group, and included one blood transfusion, and one postoperative ileus. There were no complications noted in the laparoscopic hysterectomy group. Previous advanced laparoscopic skills appear to only significantly impact the length of the procedure, but not other variables. Robotic surgery may level the playing field between the basic and advanced laparoscopic surgeon for robotic assisted laparoscopic hysterectomy. In comparing the outcomes of RALH versus TLH by a single surgeon, the robotic assistance appeared to lengthen the procedure time, but reduce the amount of blood loss. Robotic surgery may offer a benefit of reduced blood loss at the expense of longer operating time. Similar studies including different surgeons are needed to validate these points, and thereby determine the risk-benefit balance between the two approaches for benign simple hysterectomies.

Laparoscopic partial nephrectomy: The McMaster University

Introduction: Laparoscopic partial nephrectomy (LPN) remains one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumour. We report a large Canadian series of laparoscopic partial nephrectomy with intermediate follow-up.Methods: Between September 2000 and August 2008, 152 consecutive laparoscopic partial nephrectomies were performed at our centre. Demographic, pathological and clinical data were collected through a retrospective review of the charts.Results: The average tumour size was 2.68 cm (Range: 0.5-8.8.The vast majority of tumours were malignant (80%). All marginswere negative, except for 2 patients who underwent an immediate re-resection. There were no local recurrences or distant metastasis during the follow-up period of 44.3 months. Most procedures required hilar clamping (93.4%) with a mean WIT of 34 minutes, with a clear trend for declining WIT with increasing experience. Live procedures were converted to laparoscopic radical nephrectomy, 10 converted to a hand-assisted procedure, and 1 was converted to an open partial nephrectomy. The average blood loss was 162 cc. Complications related to the procedure were classified according to the Clavien grading system. The average drop in the glomerular filtration rate was calculated by the Modification of Dietin Renal Disease (MDRD) Study equation between preoperativeand 2.5 months postoperative was 8.6 mL/min/1.73 m2.Conclusions: LPN is a challenging procedure that requires advanced laparoscopic skills. LPN is feasible with excellent oncological outcomes, and an acceptable complication profile. The short-term impact on overall renal function is minimal. The most common postoperative complication was pseudo-aneurysm requiring embolization, which reinforces the intra-operative need for meticulous and a quick suture-ligation of blood vessels during LPN.

Single-port laparoscopic right hemicolectomy: the learning curve.

Single-port laparoscopic colectomy is described as a new technique in colorectal surgery. The initial case reports show the safety and feasibility, but the learning curve for this technique is unknown. Between July 2009 and September 2010, 20 consecutive patients with an indication for right hemicolectomy underwent a single-port laparoscopic approach without bias in selection. The only exclusion criterion was a prior midline laparotomy. The patients were followed up for 30 days. Chart review was completed for up to 35 months to assess long-term morbidity and mortality rates. The median age was 65 years (range, 59-88 years). Ninety percent of patients were men. The median body mass index was 28 kg/m(2) (range, 20-35 kg/m(2)). Seventy-five percent of patients had significant comorbidities with an American Society of Anesthesiologists class of 3 or 4. The estimated blood loss was 25 mL (range, 25-250 mL). The median number of pathologic lymph nodes for patients diagnosed with adenocarcinoma was 16 (range, 8-23). There was one conversion to hand-assisted laparoscopic (case 6) and one to open colectomy (case 9) because of the inability to achieve safe vessel ligation. The median hospital stay was 4.5 days (range, 3-7 days). The length of stay for the first 10 patients was 5.1 days, and it was 3.9 days for the last 10 patients (P = .045). There were no significant postoperative complications within 30 days. The mean operative time for the first 10 cases was 198 minutes (range, 148-272 minutes), and it was 123 minutes (range, 98-150 minutes) for the subsequent 10 cases (P = .0001). All intraoperative complications (minor bleeding) occurred within the first 10 patients, with no significant bleeding recorded for the last 10 cases. Single-port laparoscopic right hemicolectomy can be safely performed in patients who are candidates for conventional or hand-assisted right hemicolectomy with very low intraoperative and postoperative complication rates. The 30-day morbidity rate remained low with this technique. The higher technical difficulty compared with conventional laparoscopy is reflected in the longer initial operative times. The learning curve for a surgeon with advanced laparoscopic skills and adequate procedure numbers seems to be short, requiring approximately 10 cases to decrease operative times to baseline. The role and feasibility of broad adaptation for single-incision laparoscopy in colorectal surgery need to be further evaluated in larger case series and trials.

Laparoscopic vs Robotic-assisted Sacrocolpopexy

Background: Laparoscopic sacrocolpopexy has been in vogue since 1993. Robotic technique has started only since 2004. 1 In this article both the techniques are reviewed and an attempt is made to discuss the advantages of each. Objective: Initially, a description of the procedure is given. Then, the article will review the recent published studies on the procedure, patient selection, intraoperative complications, postoperative complications, recovery, postoperative pain, quality of life and economic aspect of sacrocolpopexy performed laparoscopically and robotic assisted and discuss the merits of each. Materials and methods: Literature review conducted from Google, PubMed, Springer Link, Highwire Press, da Vinci surgery community. Conclusion: The minimal access approach offers reduced morbidity, shorter hospitalization, and decreased postoperative pain. The disadvantages of the laparoscopic approach compared to open include longer operating time and need for advanced laparoscopic surgical skills including suturing. Robotassisted laparoscopic procedure allows the performance of complex laparoscopic maneuvers with less ergonomic difficulty, and thereby simplifies the complex procedure but is currently expensive.

Emergency Laparoscopic Ileocecal Resection for Crohn's Acute Obstruction

Emergency surgery for Crohn's disease (CD) is a rare entity, and its indications are scant in the published literature. Emergency laparoscopy for small bowel obstruction has gained wide dissemination with the spread of advanced laparoscopic skills within surgical practice. Therefore, incidental terminal ileitis after exploration might be a more-common finding in the near future, and further studies are needed to better ascertain proper surgical treatment. We report on a case of acute obstruction caused by undiagnosed terminal ileitis associated with CD. The patient underwent explorative laparoscopy and subsequent video-assisted ileocecal resection with an optimal outcome.

Laparoscopic stapler repair of high rectovaginal fistula: A case report

For thousands of years, women simply tolerated the distressing symptoms generated by rectovaginal fistulas (RVFs). This is no longer necessary because most RVFs can be surgically corrected via a number of approaches. Most rectovaginal fistulas are acquired; obstetric injury alone accounts for nearly 88% of the cases. The high fistulas are repaired by abdominal approach, while middle or low fistulas are best approached perineally. There are only few case reports of laparoscopic RVF repair noted in literature till date. Laparoscopic repair of RVF is challenging and requires advanced laparoscopic skill. Laparoscopy is a better alternative in selected cases of RVF and yields faster recovery and good patient compliance. We present a case of high RVF managed laparoscopically by using stapler.