|Year : 2022 | Volume
| Issue : 2 | Page : 81-83
Total laparoscopic management of uterocutaneous fistulas: A case report and review of literature
Abhilash Nali1, Chandra Mansukhani2, Ashish Dey3, Vinod K Malik4
1 DNB Resident, Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India
2 Senior Consultant, Department of Obstetrics and Gynaecology, Sir Ganga Ram Hospital, New Delhi, India
3 Consultant, Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India
4 Senior Consultant, Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India
|Date of Submission||16-Oct-2021|
|Date of Decision||22-Feb-2022|
|Date of Acceptance||28-Feb-2022|
|Date of Web Publication||26-Apr-2022|
Dr. Ashish Dey
Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi - 110 060
Source of Support: None, Conflict of Interest: None
Uterocutaneous fistulae are rare fistulas of the female genitourinary tract. It mostly follows caesarean section and subsequent post-operative wound infection. Only a handful of cases have been published in the literature. Surgical excision is the definitive management in most cases. Laparoscopic management has been used by many authors and gives good results. A 30-year-old multigravida presented with symptoms typical of uterocutaneous fistula and confirmed by magnetic resonance imaging of the pelvis. On diagnostic laparoscopy, the tract was delineated by methylene blue dye both through the opening in the skin as well as through the cervix. The complete excision of fistulous tract was done laparoscopically along with omental interposition between the uterus and the abdominal wall at the site of the fistula. Histopathologic examination of the tract confirmed endometriotic tissues without any chronic inflammation, typical of uterocutaneous fistula. The patient had an uneventful recovery, was started on diet the following day and discharged the next day. There was minimal post-operative pain and helped in early ambulation. On follow-up at 12 months, the tract had completely healed and the patient was completely asymptomatic. Uterocutaneous fistula is a rare complication that follows wound infection or suboptimal wound closure following caesarean section. As compared to the traditional excision by laparotomy, laparoscopy not only aids in confirmation of the diagnosis but also helps in complete excision of the tract with good results.
Keywords: Laparoscopic excision, uterocutaneous fistula, complication
|How to cite this article:|
Nali A, Mansukhani C, Dey A, Malik VK. Total laparoscopic management of uterocutaneous fistulas: A case report and review of literature. Curr Med Res Pract 2022;12:81-3
|How to cite this URL:|
Nali A, Mansukhani C, Dey A, Malik VK. Total laparoscopic management of uterocutaneous fistulas: A case report and review of literature. Curr Med Res Pract [serial online] 2022 [cited 2022 May 19];12:81-3. Available from: http://www.cmrpjournal.org/text.asp?2022/12/2/81/343928
| Introduction|| |
Uterocutaneous fistula is less commonly seen in surgical practice as compared to rectovaginal and vesicovaginal fistulas. Most uterocutaneous fistulas develop secondary to post-partum or post-operative complications following complicated lower segment caesarean sections followed by wound complications. Herein, we report a case of surgical management Uterocutaneous fistula (UCF) following caesarean section, treated by complete laparoscopic excision.
| Case Report|| |
A 30-year-old female, P2L2, presented with complaints of cyclical blood-stained discharge from the lateral end of the lower segment caesarean section (LSCS) scar. The discharge occurred at the time of menstruation and was associated with pain. The last childbirth by LSCS was 5 months ago. Following that, there was post-operative wound infection that necessitated daily dressings. She resumed her periods after 1 month of LSCS along with associated bleeding from the Pfannenstiel scar site.
Clinical examination revealed a healed Pfannenstiel scar in suprapubic region and a sinus was noted in the middle of the puckered scar through which bloody discharge was evident [Figure 1]. Magnetic resonance imaging (MRI) pelvis showed a focal full-thickness myometrial defect in the anterior wall of corpus uteri with a fistulous tract seen extending from the defect up to the skin on the anterior abdominal wall scar site. Medical management using gonadotropin-releasing hormones (GnRH) had failed to resolve her symptoms and was referred to the surgeon for definitive management.
On day 3 of her menstrual cycle, the patient was posted for diagnostic laparoscopy and proceeded under general anaesthesia. She was placed in lithotomy position and a Foley catheter was inserted. Methylene blue dye was injected into cutaneous fistulous to delineate the fistulous tract. Diagnostic laparoscopy was performed using 5 mm ports that showed dense adhesions of the fundus of the uterus to the anterior abdominal wall [Figure 2]. Adhesiolysis was done using Harmonic Shears (Ultracision, Ethicon Endosurgery, PR, USA) and the fistulous tract was divided. Uterine opening of fistulous tract was confirmed by injecting methylene blue transcervically, showing the dye squirting out through the uterine end of the fistula and was almost completely removed. The defect in the uterine fundus was repaired with non-absorbable barbed suture 2-0 (V-Loc, Covidien, Mansfield, USA) absorbable wound closure sutures in two layers. Following closure, a vascularised omental pedicle was mobilised and sutured to cover the suture line over the uterus. Bladder integrity was confirmed by filling the bladder with normal saline through the Foley catheter and looking for any leak laparoscopically [Video 1]. Residual fistulous tract in the skin and subcutaneous fat was excised till the level of sheath. The skin sinus was excised and the wound was left open to heal by secondary intention. Foley catheter was removed on POD1 and the patient was discharged on POD2. She was started on GnRH analogues as she had no wish for childbearing in the nearby future. Histopathology was suggestive of 'inflammatory tract with scar endometriosis' without any evidence of chronic granulomatous changes. She was under follow-up for 12 months following surgery and the external opening had healed completely. There is no recurrence of pain or discharge.
|Figure 2: Diagnostic laparoscopy showing dense adhesions of the fundus of uterus to the anterior abdominal wall|
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| Discussion|| |
UCFs represent abnormal communication between the endometrial lining and the skin. Most such fistulas would have a history of caesarean section. The incidence, however, has decreased following the decline in 'classical' mid-line caesarean sections and increasing use of the LSCS. Multiple abdominal operations, use of drains, incomplete closure of caesarean section wounds, septic abortion, pelvic abscesses or use of intrauterine contraceptive devices with the presence of Actinomyces may predispose to UCF. Few patients may have a history of endometriosis that may be a contributory factor. Bloody discharge during menstruation through the scar sinus almost confirms uterocutaneous fistula. Sometimes, when the diagnosis is doubtful, various investigations can be helpful including contrast fistulogram, contrast computed tomography scan, MRI (pelvis) or intraoperative methylene blue test. In our patient, the history and symptoms were classical of UC fistula. MRI plays a great role in accurate diagnosis of this condition and also helps to delineate the tract completely.
Treatment of UCFs is mostly surgical and involves complete excision of the fistula although a few studies had shown successful medical management with GnRH for uterocutaneous fistula. Complete excision of the tract gives almost complete cure of the condition.
In recent years, diagnostic laparoscopy has been used increasingly both to diagnose and manage the problem. Laparoscopic-assisted techniques have been described by many authors with good functional results. In our patient also, the complete surgical excision was possible laparoscopically. This was followed by vascularised omental interposition that has been shown in studies to allow better healing and avoid recurrence in other viscerocutaneous fistulas of varying aetiology. In this case, intraoperative use of the methylene blue dye also greatly helped properly delineate the tract and allowed proper suture closure of the uterine opening.
Although rare, this clinical condition should be kept in mind when patients present with symptoms, typical of this condition. In experienced hands, complete laparoscopic management in tertiary centres can be performed that almost resembles the steps of traditional laparotomy but with good post-operative results.
Definitive management of uterocutaneous fistula is by the complete surgical excision, either by open or laparoscopic techniques. Complete laparoscopic excision is possible, safe and results in early post-operative recovery and good post-operative long-term outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]