Robotic repair of cystotomy with fistula to hysterotomy site following cesarean section 

Objectives: In this video we aim to demonstrate a robotic approach to identifying and repairing a cystotomy with excision of fistulous tract from bladder to hysterotomy site following cesarean section.



Methods: A 37-year-old female presented for evaluation of cystotomy after a complicated postoperative course following cesarean section and emergent laparotomy for hemoperitoneum with cardiac arrest and return of spontaneous circulation. During emergent laparotomy she had a cystotomy which was repaired. On postoperative day 10 a CT cystogram was performed which showed an intact bladder and foley was removed, however the following day urine was noted from JP drain resulting in replacement of foley catheter. On presentation, she reported clear urine with occasional hematuria in foley. Physical exam in the office was unremarkable. Repeat CT cystogram performed outpatient revealed bladder perforation with extravasation of contrast into the left anterior pelvic extraperitoneal space. Decision was made to repair the cystotomy robotically.

The surgery began with a laparoscopic lysis of omental and small bowel adhesions to the anterior abdominal wall, followed by robotic dissection of sigmoid bowel adhesions to uterus. The uterus and bladder were noted to be adherent and carefully dissected upon which there was noted to be a 3 cm cystotomy with fistulous tract to the uterine hysterotomy site. No additional cystotomies were identified via cystoscopy and the ureters were visualized effluxing clear urine through the cystotomy site. The edges were cleared of all debris and fistulous tracts excised. The clean edges of cystotomy were repaired in two layers robotically with suture and water-tight seal was confirmed with cystoscopy. The hysterotomy was also repaired in a T-shaped incision robotically.



Clinical Relevance: Cystotomy was repaired and fistulous tract from cystotomy to hysterotomy was excised and repaired robotically. Hysterotomy was also repaired robotically. The patient was discharged with a transurethral foley for 4 weeks with follow up cystogram negative for bladder leak after which foley was removed. This case demonstrates a feasible minimally invasive option to repair a known cystotomy with excision of fistulous tract following an unusual presentation.