Laparoscopic Repair of Colo-Ovarian Fistula

Objective To demonstrate a laparoscopic approach to managing a colo-ovarian fistula. Design Narrated video outlining surgical technique. Setting Colo-ovarian fistulas are a rare entity with a lack of systematized evidence to guide surgical treatment.1-3 Available case reports describe open en-bloc resection of the colon and adnexal organs with colorectal anastomosis.3 We present a case of a colo-ovarian fistula managed laparoscopically with discoid resection of the fistulous tract, a technique used for rectosigmoid endometriosis.4 Intervention A 51-year-old G0 presented with fevers, leukocytosis, and CT imaging showing a peripherally-enhancing adnexal complex highly suspicious for tubo-ovarian abscess that was refractory to antibiotics and interventional-radiology guided drainage. The patient elected for definitive surgery with hysterectomy, bilateral salpingo-oophorectomy, and indicated procedures. Preoperatively, there was no evidence of gastrointestinal tract involvement but intraoperatively, a colo-ovarian fistula was discovered. General surgery was consulted for en-bloc resection, but given the small size of the fistula and absence of acute inflammation, a discoid resection was deemed a possible alternative. This video highlights: 1. Lysis of adhesions to restore normal anatomy 2. Identification of avascular spaces to secure uterine arteries at the origin 3. Excision of the fistula with an advanced bipolar device enabling surgeon control of energy dispersed prior to cutting 4. Two-layer closure reapproximating bowel with bubble-test to ensure airtight repair Postoperatively, there were no complications. The final pathology confirmed tubo-ovarian abscess, endometriosis, and a fistulous tract. Conclusion Colo-ovarian fistulas are rare with little to guide surgical treatment. This video demonstrates a laparoscopic alternative to open en-bloc resection of the colon and adnexa.