This video demonstrates the use of sigmoid epiploica for tissue interposition during robot-assisted laparoscopic vesicovaginal fistula repair. The authors have no financial disclosures. The objective of the video is to describe and demonstrate the use of sigmoid epiploica interposition during robotic repair of vesicovaginal fistula using an extravesical technique. Vesicovaginal fistula is an abnormal epithelialized connection between the bladder and vagina. Most cases in the U.S. and developed countries result from iatrogenic trauma during gynecologic surgery with hysterectomy being the most common inciting procedure. The incidence of fistula formation varies depending upon surgical approach and underlying chronic medical conditions. Vesicovaginal fistulas following gynecologic surgery tend to be smaller than those following obstetrical trauma. And a portion resolved with conservative management. The classic tenets for surgical repair of vesicovaginal fistulas was described by J. Marion Sims who found an increased likelihood of successful primary repair when the surgical site was hemostatic with a tension-free layered closure with the epithelialized edges of the fistula removed. This was followed by prolonged drainage of the bladder. These tenets are true regardless of the route of surgical approach and technique used. Although the use of tissue interposition during a primary repair in non-irradiated tissue is controversial, many argue that it may provide the best opportunity for long-term success due to the introduction of a buttress between the vaginal and bladder suture lines as well as access to well-vascularized tissue, promoting healing and reducing the chances of recurrence. The tissue selected for interposition depends on the route of surgical repair, surgeon preference and patient characteristics. Momentum is the most commonly cited tissue used during an intraperitoneal repair with abdominal peritoneum and sigmoid epiploica also mentioned. The sigmoid epiploica are commonly mentioned as a source for tissue interposition. The epiploica are small peritoneal pouches arising from the large bowel serosa that contain fat, a circular artery and vein, and good lymphatic drainage. Roughly 50 to 100 epiploica appendages are present with the highest concentration located at the rectosigmoid. The surgical case presented is of a 67-year-old female who underwent primary surgical repair of a vesicovaginal fistula after failing conservative treatment with a Foley catheter. The fistula developed following a leap procedure on the cervix in 2016 for severe dysplasia. Her gynecologic history is significant for a supra-cervical hysterectomy in the 1990s and a mid-urethral sling in 2008. Her presenting symptoms were recurrent urinary leakage. An operative cystoscope was used to place a catheter through the fistula's tract at the beginning of the procedure. Ureteral catheters were placed preoperatively in order to aid in ensuring correct identification of the fistula throughout the procedure. With traction and counter-traction, sharp dissection with small bursts of monopolar current are used to mobilize the vagina from the bladder. With a manipulator in the vagina to provide gentle counter-traction, the dissection is carried laterally and distally toward the bladder neck, allowing enough room for a tension-free re-approximation of both the bladder and vagina. When the mobilization is complete, the catheter is cut and removed. The epithelialized edges of the fistula are excised, promoting better healing of the opposing edges. The vagina was closed using a delayed absorbable suture in a running, non-locked fashion. The bladder is repaired using a double-layered closure of braided absorbable suture, starting at each angle of the cystotomy and tying in the middle to ensure the correct re-approximation of the mucosa and muscularis layers of the bladder. An imbricating layer is placed with good bites of the muscularis layer, being careful not to include the mucosa. This layered closure relieves tension on the primary suture line. Although not shown in the video, the bladder is then backfilled with 300 milliliters of sterile water and tested to ensure watertight closure. Using a previously placed anchor stitch, a sigmoid epiploica is selected for interposition and carefully brought to the operative site. It is important to choose an appendage that has enough length to cover the entire surface of the dissection while keeping the bowel from being positioned in between the bladder and vagina. Multiple interrupted stitches are used to ensure adequate interposition and minimize tension on individual sutures. A second epiploica is interposed, increasing the size of the buttress between the bladder and vaginal suture lines. Sigmoid epiploica is an easily accessible tissue for interposition. As demonstrated, interposition of the epiploica is efficient and eliminates the need for access to the upper abdomen or formation of an omental flap. The patient was discharged to home in stable condition on postoperative day number one with a Foley catheter for bladder drainage, and she remains without recurrence or complications at seven months from repair. To date, we have a series of five patients who have undergone primary surgical repair of vesicovaginal fistula using a robot-assisted laparoscopic extravesical technique with sigmoid epiploica interposition. All patients have had successful outcomes to date without any additional morbidity. Follow-up time period has ranged from two months to 12 months. In conclusion, we would like to reiterate that use of sigmoid epiploica interposition is a safe and feasible surgical technique with a tissue that is often easily accessible. This may allow for interposition of tissue in an increased number of patients due to the avoidance of operating in the upper abdomen and in those patients who have had an omentectomy or radical hysterectomy. Thank you for your time and attention. We look forward to your feedback about our video.

sigmoid epiploica tissue interposition

robot-assisted laparoscopic vesicovaginal fistula repair

healing promotion

recurrence rate reduction

surgical case