We present a case of robotic-assisted laparoscopic repair of rectal marginal fistula after failed previous endoscopic attempt. Patient is 55-year-old with history of adenocarcinoma of rectal sigmoid colon, who underwent laparotomy and low anterior rectal sigmoid colon resection in 2018, complicated by anastomotic leak and pelvic abscess. She underwent successful endoscopic repair. She presented three years later with yellowish vaginal discharge. Pelvic MRI and colonoscopy confirmed rectal marginal fistula. Attempt for endoscopic repair failed this time. for robotic repair of the fistula and bilateral salpingo-ophorectomy, cystoscopy, insertion of urethral catheters for injection of indiocyme green for identification of the urethra using firefly. Interoperatively, a 2-3 cm fistula was noted between rectum and upper vagina. Dense adhesions between both tube and ovaries and pelvic sidewalls was also noted laparoscopically. This is the view of the vagina with fistula and sutures from previous failed repair. First, laparoscopically, part of the omentum was mobilized at the level of the hepatic flexure for later use. After evaluation of pelvic cavity and layers of adhesions bilateral tube and the ovaries were removed robotically. Following identification of the urethras using firefly, dissection of posterior cul-de-sac and mobilization of the rectum from posterior vagina is being performed. Branches of inferior hypogastric plexus nerves were identified and preserved. Ureters can be seen laterally. Interior to the vagina is noted. Fibrotic tissue of posterior vagina was gradually separated from the rectum. A spark is noted after electrosurgery contacted retained surgical clips. Vaginotomy anteriorly and intratomy posteriorly can be seen. Clips and sutures from previous failed repair were removed from the rectum. After mobilization of the posterior vagina further, fibrotic vaginal part of the fistula was excised. rectum was further mobilized, centrally and laterally, an injury to rectal vaginal space was obtained. As you see, further extrusion of fibrotic vaginal tissue was performed until healthy vaginal and rectal tissue was visualized. Cup of the uterine manipulator anteriorly in the vagina and rectal scythe in the rectum posteriorly can be seen. Vagina was closed using two OBOP sutures in continuous fashion in one layer. Rectal eddies perforation up, an intrathemy was repaired in two layers, first layer two above suture in continuous fashion. And second layer interrupted 0-6 suture, implicating the first layer. Repair of fistula is completed. Integrity of ureters are confirmed by using Firefly. Posterior cul-de-sac was filled with normal saline and sigmoidoscopy was performed to confirm integrity of the repair. Finally, mobilized omentum was brought down and placed and secured between the rectum and the vagina. Estimated blood loss was 50 cc. There was no intraoperative or postoperative complications. Patient was discharged home on postoperative second after tolerating regular diet. She was seen 2 and 6 weeks post-op and is doing well with no sign of recurrent fistula. Thank you.

rectal sigmoid colon cancer

anastomotic leak

pelvic abscess

rectal marginal fistula

robotic-assisted laparoscopic repair