Robotic Assisted Laparoscopic VRAM Flap for Interposition During Vesicovaginal Fistula Repair

Objectives: To demonstrate a unique robotic assisted laparoscopic technique for Vertical Rectus Abdominis Musculocutaneous (VRAM) interposition graft during complex vesicovaginal fistula repair.

Methods: The video shows a technique for robotic assisted laparoscopic VRAM flap in a 38 year old female who is status post robotic hysterectomy with BSO, omentectomy, and macro debulking procedure for high grade endometrial carcinoma. Biopsy of the fistula prior to the procedure indicated no residual disease. VRAM flap receives blood supply from the deep superior and inferior epigastric arteries and can be used as a muscle only or myocutaneous flap. Robotic approach offers a minimally invasive technique for harvesting this graft for placement in the pelvis. The robot was docked with ports placed across the abdomen at the level of the umbilicus with an assistant port in the left upper quadrant. Using vaginal manipulation the plane between the bladder and the vagina was dissected down to the level of the fistula and the fistulous tract removed. Bladder and vaginal flaps were further developed to allow for water tight closure without tension. Space was developed along the proximal vagina for placement of the flap later in the case. Stay sutures were placed to hold the graft in place. The robot was undocked and two extra robotic ports were placed on the patient's left side in order to harvest the graft robotically. The posterior fascia and peritoneum under the right rectus muscle was incised and dissected off the muscle from the arcuate line to the right costal margin. The rectus muscle was then dissected off the anterior fascia and lateral abdominal wall. Vessel sealer device was used to divide the superior portion of the muscle off the costal margin securing the superior epigastric artery. Once there was adequate length for the graft to reach the pelvis, the graft was secured with stay sutures between the vaginal and bladder. Care was taken to ensure the VRAM flap was laying flat between the bladder and vagina. The flap was also attached to the anterior abdominal wall to ensure a tension free flap.

Clinical Relevance: It is often difficult to mobilize adequate tissue for an interposition graft in complex vesicovaginal fistula repair, especially in patients who have had prior surgery for malignancy. This video highlights a unique technique for mobilization of a VRAM flap not commonly used in gynecologic surgery. This is a seldom used robust graft that can be used when there are other limited options in complex patients.