eP408 - Recto-Vaginal Fistula: TAMIS as a Surgical Option

Purpose/Background: Many different surgical techniques have been developed for the treatment of recto vaginal fistulas, however the ideal or gold standard technique remains unclear. The most used technique for colorectal surgeons , when using TAMIS as their surgical choice, is the endorectal advancement flaps with technical differences between surgeons, however those fistulas that are far above the anal canal struggles arise and we require the use of a laparoscopic approach due to the poor access, poor exposure and visualization. The TAMIS approach gives numerous benefits, so we hypothesized that we could use this surgical option, without the use of an advancement flap and using the same principle as the OVESCO clip or endoscopic metallic clips.Methods/Interventions: We present a 41 year old female patient who had 6 abdominal surgerys due to the ginecological pathology and the incidental lesion of the colon, with colorectal anastomosis, posteriorly she presented symptoms ( fecaloid secretion through the vagina and in the right lower quadrant ) and the presence of a rectovaginal fistula and a colocutaneous fistula. The fistulas where demonstrated with a fistulography and endoscopic assessment, showing an orifice at 18 cm from the anal margin, posteriorly 3 attempts of endoscopic closure with metallic clips where done, however the recurrence of the fistula was presentResults/Outcomes: The patient received general anesthesia and was placed in modified jackknife position followed by the proper insertion of the TAMIS platform, after the insufflation began, the fistula was clearly identified. The fistula was repaired without the use of an advancement flap, instead we used full thickness suture with Vicryl 2-0, followed by hydropneumatics test, which demonstrated no evidence of leak. The patient tolerated the procedure and was discharge home. We followed the patient for 22 months and no recurrence of the fistula was present.Conclusion/

Discussion: The TAMIS approach provides access and overcomes many struggles, since the pneumorectum allows an adequate view and exposure, also this approach is an attractive option for the repair of rectovaginal fistulas. Using this technique we were able to avoid the abdominal approach, since our patient had multiple abdominal interventions and it would have increased the morbidity.
We consider TAMIS repair as a safe option, even for fistulas that far above the anal canal, however this technique has a learning curve, and should be performed by a colorectal surgeon."Endoscopic view of the fistula

Endoscopic view of the fistula at 18 como from the anal margin, and the use of metallic clips for the closure of the fistula
Colocutaneous fistula

An image of the colocutaneous fistula in the right lower quadrant, and the evidence of the multiple abdominal surgeries the patient had
Fistulography

Fistulography demonstrating the colocutaneous and rectovaginal fistula
TAMIS

TAMIS view of the closure of the fistula with Vicryl 2-0."