Deep Pelvic Side Wall Anatomy: A Case of Laparoscopic Management of Vaginal Vault Fistula to the Presacral Area.

Study Objective: Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy [1-3].

Design: Case presentation with showing anatomic structures in detail.

Setting: Tertiary academic teaching hospital.

Interventions: A 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension 9 years ago presented with fever and was found to have bacteremia. Abdomen and pelvic magnetic resonance imaging showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. Transgluteal drain placed with cultures growing Streptococcus constellatus and Gemella morbillorum. Blood cultures grew same bacteria. She was started on vancomycin, cefepime, and metronidazole and was transitioned to ceftriaxone with a plan for 6-week antibiotic course. Her blood sugar levels were well controlled during hospitalization with baseline insulin and moderate sliding scale. Physical therapy started preoperative and continued postoperative. She was managed with an interdisciplinary team of gynecologists, urogynecologists, orthopedic doctors, neurosurgeons, nutritionists, infectious disease doctors, endocrinologists, hematologists, rehabilitation specialists, and physical therapists. This video showcases laparoscopic resection of sacrospinous fistula tract. Postoperative pathology result showed squamous mucosa, submucosa, and deep soft tissue with a submucosal abscess surrounded by fibrosis, consistent with a fistula tract.

Conclusion: Preoperative planning is of paramount importance in cases with multiple comorbidities. Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection. Knowing the precise anatomy of critical structures close to the area of interest is crucial.