Interestingly, the occurrence of the gallbladder not being completely removed, which was rarely seen during open cholecystectomy, is reported more frequently after laparoscopic cholecystectomy.

This poses an interesting issue considering the numerous advantages of laparoscopic surgery. Leaving the base of the gallbladder or an excessively long cystic duct during surgery can lead to unresolved or recurring symptoms for patients. In patients who have undergone cholecystectomy with the gallbladder partially remaining, symptoms such as abdominal pain, indigestion, nausea, and even jaundice can occur. Additionally, cholangitis (inflammation of the bile ducts) or pancreatitis (inflammation of the pancreas) may develop. These symptoms may result from remaining gallstones or the development of new ones over time.

The incomplete removal of the gallbladder during laparoscopic cholecystectomy has been reported in about 13% of cases. In other words, in about one out of every 7-8 patients who undergo gallbladder surgery, the gallbladder may not be completely removed. Several risk factors have been identified for this occurrence, including:

• Inadequate exposure of the gallbladder bed during surgery,
• Severe adhesions due to previous surgery or inflammation,
• Active inflammation of the gallbladder (acute cholecystitis),
• Excessive bleeding during surgery impairing visibility,
• Congenital anomalies of the gallbladder,
• Changes in anatomy due to lesions developing in the gallbladder over time.

In patients who continue to experience symptoms despite gallbladder surgery, the only issue may not be the presence of a remnant gallbladder portion. Specific tests should be conducted to confirm or rule out this possibility. While blood tests and ultrasound may be initial investigations, in many patients, magnetic resonance cholangiography (MRCP), a type of MRI examination of the bile ducts, provides a definitive diagnosis. In some cases, diagnosis occurs during endoscopic retrograde cholangiopancreatography (ERCP), an endoscopic procedure for the bile ducts.

If appropriate investigations reveal no residual stump or stones, other causes of symptoms should be explored. However, if a remnant gallbladder or a stone within a long cystic duct is detected, intervention is often necessary. These interventions may involve endoscopic methods or, in some cases, require open or laparoscopic reoperation. As expected, reoperation carries risks of bile duct injury, vascular injury, or injury to other organs.

Although with increasing experience, the likelihood of incomplete removal of the gallbladder is considered lower, its clinical significance remains a significant concern. Just as in any surgery, having profound anatomical knowledge and extensive experience with challenging cases are crucial for ensuring complete gallbladder removal and minimizing such issues.

Tailgut cysts are rare congenital (present at birth) lesions. It is estimated that one in 40,000 births will have a tailgut cyst. They are typically found behind the anus-rectum junction. Based on their location, they can be grouped with other lesions as retrorectal (located behind the rectum) or presacral (located in front of the sacrum) lesions. Tailgut cysts are also referred to as retrorectal cystic hamartomas.

Although they are known to be congenital lesions, patients often receive a diagnosis in adulthood. They are observed three times more frequently in females than in males. The reason for diagnosis in later ages is twofold: some tailgut cysts remain asymptomatic, while in some patients, symptoms are not attributed to a tailgut cyst, leading to a lack of further investigation.

What are the symptoms of a tailgut cyst?

In nearly half of the patients with a tailgut cyst, there are no symptoms. They are often detected incidentally during radiological examinations conducted for other reasons. In other patients, symptoms may arise due to the pressure of the cyst on surrounding organs or due to infection. While originating from behind the rectum, as the cyst enlarges, it can exert pressure not only on the rectum but also on organs such as the vagina and bladder. A tailgut cyst can cause symptoms such as frequent urination and burning sensation during urination due to pressure on the bladder, as well as a sensation of fullness in the rectum, painful or difficult bowel movements, narrowing of the stool, and constipation due to pressure on the rectum. Because of its space-occupying nature in the retrorectal area, individuals may feel discomfort in the buttocks and coccyx region while sitting, and they may have difficulty sitting comfortably. When infection occurs in these cysts, it can manifest as a pelvic/anal abscess, painful swelling in the anal area, and in some cases, as a fistula.

How is a tailgut cyst diagnosed?

In patients presenting with specific complaints, suspicion of a tailgut cyst may arise during a rectal examination when a mass effect is felt externally behind the rectum, or during a gynecological examination when a cystic lesion is seen on ultrasound. However, the radiological diagnosis of a tailgut cyst is usually made with pelvic MRI. Although a cystic structure may be seen on computed tomography in some patients, MRI is often the preferred radiological diagnostic method for the complete characterization of the lesion. Biopsy of lesions suspected to be tailgut cysts is not recommended.

Does a tailgut cyst turn into cancer?

In the medical literature, malignant transformation on the basis of a tailgut cyst has been reported in many cases, but it is not known exactly how many of these cysts carry the risk of developing cancer. Delay in diagnosis or failure to perform adequate surgery is thought to increase the risk of cancer development.

What is the treatment for a tailgut cyst?

There is no medication for treatment. Surgical removal of the cyst is necessary. Surgically removing the cyst allows for a definitive diagnosis of the suspected disease, resolution of any symptoms the patient may have, and elimination of the risk of cancer development. Extensive surgical intervention is required for tailgut cysts that have developed cancer, similar to any cancer, while for cysts that have not developed cancer, simply removing the cyst is sufficient.

How is surgery for a tailgut cyst performed?

The surgical approach is determined based on the level of the cyst. For cysts located well above the pelvic muscles, an abdominal approach, either open or laparoscopic, may be preferred. If the cyst is located below the pelvic muscles or in an easily accessible area, a posterior (back) approach may be used. In some patients, surgery may need to be performed from both sides.

During the abdominal approach, the surgeon carefully separates the cyst from the rectum, sacrum bone, and, in some cases, the vagina or pelvic muscles, and removes it outside the abdomen in a sterile bag. Maximum care should be taken during this separation process to avoid damage to the rectum, vagina, and surrounding blood vessels. In case of any injury, effective repair should be performed.

In the posterior approach (Kraske approach), with the patient in a prone position, an incision is made through the skin and fatty tissues from the side of the sacrum bone and coccyx (tailbone). After cutting the anococcygeal ligament, the cyst is accessed. In some patients, the coccyx bone may need to be removed at this stage due to reasons such as the need to expand the working area or adhesions of the cyst. Once the cyst is exposed, it is completely removed without causing damage to the levator muscles or rectum and leaving no tissue behind. Depending on the size of the field, the nature of the tissues, and the surgeon’s preference, a drain may be placed in the surgical area. Subsequently, the layers are sutured layer by layer to conclude the operation.

In a combined approach, part of the surgery can be performed abdominally while the rest is done from the back, or vice versa, using the same principles and techniques.

Is surgery for a tailgut cyst risky?

Surgery for a non-malignant tailgut cyst, when performed by experienced hands, is not considered to carry significant risks. However, in cases where malignancy has developed, in patients who have previously had infections, or when surgery is performed by individuals lacking sufficient experience, complications such as rectal injury, vaginal injury, urinary tract injury, vascular injury, residual disease, or damage to the anal sphincter or pelvic muscles may occur. If these problems are not effectively addressed, long-term complications such as recurrence, fistula, or fecal incontinence may develop.

What is the cost of surgery for a tailgut cyst?

The cost of surgery is calculated based on factors such as the duration of the surgery, whether the patient has had previous interventions in the same area, whether the surgery is performed abdominally or posteriorly, and whether malignancy is present.

Recovery after surgery for a tailgut cyst

If the surgery is performed safely without any damage to the rectum or other surrounding organs, one night of hospitalization is usually sufficient. If repair of possible damage to surrounding organs is performed, the patient may need to be hospitalized for observation during the recovery period, which can extend up to 4-5 days. After complete recovery, patients can resume their normal activities without any issues.

Follow-up after surgery for a tailgut cyst

If there are no findings suggestive of malignancy in the cyst removed during surgery and sent for pathological examination, patients do not require any additional treatment. Since recurrence is not expected if the cyst is completely removed, no radiological or clinical examination/control is necessary. However, if the cyst is not completely removed, the surgeon may recommend periodic follow-ups based on the patient’s characteristics. There is no universally accepted follow-up algorithm for this purpose.

Stents are artificial devices placed inside tubular structures or organs such as channels, blood vessels, or intestines, usually to relieve or facilitate the healing of conditions like blockages or injuries. Stents can be made of plastic or metal. Plastic stents maintain a constant diameter within the structure they’re placed in, ensuring fluid flow, while metallic ones can expand to a wider diameter within hours of placement.

Metal stents are typically compressed into a cylindrical shape and, when the surrounding casing is removed, they expand like an umbrella to sit against the walls of the structure they’re placed in. Depending on their purpose, metallic stents can be used with either a partial or complete impermeable coating or without any coating at all. Intestinal stents are always metallic. Although the term “metallic” implies a rigid structure, they are actually made of bendable, soft, thin wires.

Can a stent be placed in the colon?

Like many parts of the digestive system, stents can be placed in the colon.

Why is a stent placed in the intestine?

Stents can be applied to alleviate a blockage or repair an injured area. In the event of a leak following colon surgery, a portion or the entire area can be covered with a stent to facilitate healing. While there are various methods for healing a leaky area, in suitable cases, applying a stent to the colon can promote recovery.

In colon cancer, stent placement is aimed at relieving the obstruction caused by the tumor in the intestine. Typically, surgery is the primary option for colon cancer even in cases of obstruction. However, in patients with widespread metastasis, where chemotherapy is the primary treatment, a stent can be placed in the colon to initiate treatment as soon as possible. Additionally, in cases where there is no immediate danger of death without urgent surgery, a stent may be placed in the colon as an alternative to performing an open and stomal surgery, allowing for laparoscopic and bag-free surgery instead. Once the intestine is emptied and the edema subsides within about a week, laparoscopic colon surgery can be safely performed.

How is an intestinal stent placed?

In cases of colon obstructions, a gastroenterologist or surgeon typically begins the procedure using a gastroscopy or more commonly a colonoscopy, depending on the distance of the mass from the anus. The endoscopist inserts the device through the anus and advances it to the location of the problem. The endoscope is anchored at a visible gap in the middle or edge of the mass. A special wire is then passed through this gap to advance beyond the narrowing. The pre-compressed stent, depending on the production specifications of the stent and the features of the endoscope used, is then advanced using the special wire previously inserted through the endoscope as a guide. With the assistance of a technician or nurse, the stent sheath is correctly positioned and opened in the right place and manner to ensure that the free stent sits in the lumen.

Alternatively, while the wire is held in place beyond the narrowing, the endoscope device is completely removed, and the stent is directly advanced over this wire. In this method, the colonoscope is again advanced through the anus to place the stent, ensuring it is still performed under direct vision.

After the stent is opened in the relevant area, depending on the obstruction rate of the mass and the resilience of the tissues, attempts can be made to advance the endoscopic device through the stent to the other side of the narrowing. In the presence of a tight stricture or delicate tissue, attempting passage through the stent should be avoided, as it may lead to perforation.

While the basic steps for stent placement for repairing leaks after colon surgery are similar, care must be taken to prevent the leakage area from enlarging. In such cases, coated stents are preferred so that feces can pass through the stent while the exterior coating keeps the leakage area clean. However, coated stents carry the risk of displacement. Therefore, clips called “clips” can be used to secure the stent to the intestinal wall from its edges.

Stent placement can also be considered as a treatment option for strictures developing in old surgical sites or due to inflammatory causes.

Is the patient sedated during colon stent placement?

The procedure is typically performed under sedation administered by an anesthesia team in an endoscopy unit. A patient under sedation is not in a deep enough sleep to not wake up, but they are also in a state where they won’t feel pain or discomfort. The patient naturally wakes up after the procedure.

Depending on the preference of the performing physician or the patient, colon stent placement can also be done under general anesthesia in an operating room setting.

How many days does the patient stay in the hospital after colon stent placement?

If the stent placement procedure is performed safely and there are no other issues requiring the patient to stay in the hospital, the patient can be discharged after waking up from anesthesia and undergoing a physician’s check-up. If there is suspicion of intestinal perforation during the procedure, the patient may be kept in the hospital for observation for a duration recommended by the physician.

Does the colon stent function immediately?

After stent placement for colon cancer, it may take up to 48 hours for the stent to fully expand. Gas and fecal output may begin immediately after the procedure or within hours, depending on the consistency and amount of accumulated feces, the initiation of bowel movements, and the degree of opening of the stent.

Is colon stent placement dangerous?

The most feared complication after applying a stent to the colon is perforation (tearing) of the intestine, primarily due to the tumor. Although the literature reports an increased risk of up to 20%, on average, it can be said that about 7-8 out of 100 patients who undergo stent placement are at risk of perforation. The risk is higher when stents are placed in patients receiving targeted chemotherapy (commonly known as smart drugs) such as bevacizumab.

Additionally, there is a possibility of stent migration. A displaced stent may rarely become lodged in the advanced sections of the intestine, posing a risk of perforation. Although some patients may experience mild and temporary bleeding after the procedure, it is generally not severe.

Similarly, some patients may experience some discomfort after the stent placement, but it is expected to subside quickly. However, if there is severe pain spreading across the abdomen after the procedure, the possibility of perforation should be considered, and the patient should be closely monitored and investigated.

In patients with stents, recurrent blockages may occur due to tumor growth. In such cases, reapplication of the stent may be possible, or surgery may be considered as an option.

What is the cost of colon stent placement?

Stents are mostly imported products and can vary in quality and features. The price of the procedure is determined by the specific product features needed for the patient’s condition.

A rectovaginal fistula is the formation of a tunnel or canal between the rectum, the final portion of the large intestine, and the vagina. Through this tunnel, gas and feces may pass from the vagina. It can be considered a significant health problem due to its negative impact on quality of life and the low success rates of treatment.

What Causes It?

The most common cause is trauma during childbirth, accounting for nearly 85% of cases. Additionally, previous surgeries can also lead to rectovaginal fistulas. These may occur after procedures such as rectal surgery, pelvic floor surgery, hemorrhoid surgery, or local tumor excision. Rough sexual intercourse or intercourse with foreign objects can also lead to fistula formation.

It’s also possible for rectovaginal fistulas to develop secondary to rectal or gynecological tumors, as well as due to radiotherapy. Inflammatory conditions such as Crohn’s disease or inflammatory conditions like Bartholin’s abscess can also play a role in fistula formation.

How Is a Rectovaginal Fistula Identified, and What Are Its Symptoms?

The most common symptom is the passage of gas and/or fecal matter from the vagina, either during normal activities or during defecation. In some patients, recurrent urinary tract infections or vaginal infections may indicate an underlying rectovaginal fistula.

How Is It Examined?

In patients presenting with complaints of gas or fecal matter coming from the vagina, a detailed medical history is taken before proceeding to examination. Examination can be performed in the lithotomy position, lying on the left side, or in the knee-chest (prayer) position. During the examination, the fistula tract can be attempted to be felt with a finger through the anus, and the fistula opening can also be felt from the vagina.

In cases suspected of having a fistula, examination and the dye-soaked gauze method can be used as a diagnostic tool. After gently inserting moist gauze into the vagina, the patient is laid on their side. Betadine or methylene blue is applied to the anus, and whether the dye has spread to the gauze in the vagina is checked. To avoid confusion during this examination, the colored fluid should not leak from the anus to the vaginal side. After 1-2 minutes, the gauze in the vagina is removed, and if the color of the substance given from the anus is seen on the gauze, a diagnosis of rectovaginal fistula can be made. However, it should be noted that even if a fistula is present in the patient, there may be no contamination with the colored fluid.

How Is It Diagnosed?

Although diagnosis can be made using the methods mentioned above, the best diagnostic method for rectovaginal fistula is pelvic MRI. Pelvic MRI evaluates findings such as the level, course, presence of accompanying abscess, and whether it affects the sphincters.

Does Rectovaginal Fistula Heal on Its Own?

In some cases, the fistula may heal spontaneously. The rates of spontaneous healing vary depending on the reason for the fistula. Analyses from clinics that see a high number of rectovaginal fistula patients have indicated that non-surgical treatment can be applied to about 20% of patients. Improvement was observed in about 50% of patients who were expected to undergo non-surgical treatment. Therefore, it can be said from these data that spontaneous healing will occur in only about 10% of all rectovaginal fistula cases.

How Is It Treated?

The main treatment for rectovaginal fistula is surgery. The problem can be resolved with appropriate surgery performed by a colorectal surgeon.

What Happens If It’s Not Treated?

If left untreated, a fistula can lead to recurrent urinary tract infections, vaginitis, painful sexual intercourse, or perineal rash. In very rare cases, cancer may develop at the site of the fistula many years later.

Rectovaginal Fistula Surgery

Several techniques have been identified for the treatment of rectovaginal fistula. One of these is the application of a special staple resembling an OTSC (Over-The-Scope Clip) colonoscopically to close the fistula. This staple is expelled through the anus within weeks. Success rates of up to 40% have been reported.

Fistula plugs, which have also been tried for anal fistulas, can be used for rectovaginal fistulas as well. This involves inserting a specially manufactured plug into the fistula to fill it, extending from the vagina to the bowel. Success rates of around 20-30% have been reported.

Although attempts have been made to heal rectovaginal fistulas using special tissue adhesives called fibrin glue, success has only been achieved in about 30% of cases. Stem cell therapy has been tried, particularly for rectovaginal fistulas associated with Crohn’s disease, and improvement has been observed in about 27% of cases.

In addition to these local treatments, many surgical methods have been described. Depending on the approach area during surgery, these methods can be categorized into four different approaches: transperineal (entered between the vagina and anus), transvaginal (from the vagina side), transanal (from the anus side), and abdominal (entered through the abdomen). While the goal in all approaches is to eliminate the fistula, the techniques vary.

The Martius flap technique has been described as a method used to repair fistulas between the urinary tract and vagina, where a flap of bulbocavernous muscle is used as a filler. Subsequently, a modified Martius flap technique has been described for rectovaginal fistulas. In the modified Martius flap technique, a cut is made in the perineal skin between the vagina and anus, and tissues between the rectum and vagina are separated. After identifying the fistula tract, it is sutured from both sides and cut in the middle to divide the fistula. Subsequently, usually a straight incision is made from the left labium majus (outer lips) to free the subcutaneous fat tissue without disrupting the vascular structure. This fat flap is then spread between the rectum and vagina to separate the fistula. Finally, the incisions made in this area are closed with absorbable sutures. Cuts are present both in the perineum and on the outer lips. Success rates of between 65-100% have been reported.

In the method where the gracilis muscle is used as a flap, similar to the Martius flap, after preparing the tissues, the gracilis muscle is used as the flap. The gracilis muscle is a thin, long muscle that extends to the knee. The lower parts of this muscle are freed and cut with incisions made in the thigh. Then, it is passed under the skin and spread into the space between the rectum and vagina, and secured. The incision sites are sutured to conclude the surgery.

The endorectal advancement flap is a method applied through the anal route. The patient is preferably placed in the prone jack-knife position (lying face down with knees bent). After identifying the fistula tract, similar to the application in anal fistulas, the fistula tract extending from the rectum to the vagina is completely removed as much as possible without damaging the muscle tissue. The rectum wall is lifted upwards for about 4-5 cm. There should be mucosa and submucosa in the lifted wall. Depending on the surgeon’s preference, there may be some amount of muscle tissue. It is even possible to lift the entire rectum wall. The lifted flap can be in the form of a broad-based V or U shape. The prepared flap should be tension-free to be sutured smoothly under the dentate line. At this stage, the area from which the fistula is removed is tightly closed with absorbable stitches. Then, the prepared flap is sewn onto the anal mucosa with absorbable stitches in a regular manner. There is no visible incision on the patient in this method. The healing rate of the fistula is reported within a wide range of 42-78%. Success rates are influenced by factors such as the tension of the flap, ischemia of the tissue, the cause of the fistula, and whether the patient has additional diseases.

In classical fistula surgery, as done in traditional methods, the cutting of all muscles until reaching the fistula can also be considered. After cutting the muscles and exposing the fistula, the fistula tissue is removed. The sphincter muscles can be repaired by suturing them back together with absorbable or non-absorbable stitches, depending on the surgeon’s preference. After repairing the mucosa on both the rectum and vagina sides, the skin is sutured to conclude the surgery. Healing rates have been reported as 78-100%. However, it should be noted that in patients with birth injuries undergoing sphincter repairs, there is a possibility of developing sphincter dysfunction over time, as the effectiveness of the repair may diminish.

For high-positioned fistulas, an abdominal approach is generally preferred. Open, laparoscopic, or robotic techniques can be applied. The basic principle is the removal of the tissue causing the fistula and closure of the vaginal side. The removal of the tissue causing the fistula usually involves a procedure requiring anastomosis in the small intestine, colon, or rectum. Therefore, there is a possibility of leakage and recurrence of the fistula. In an attempt to prevent this, abdominal fat tissue called omentum is spread between the vagina and tissues. Success rates have been reported around 50%.

The surgeon will choose the most familiar and successful method personally, considering factors such as the characteristics of the tissues, whether the fistula is close to the anus or positioned higher, the presence of active infection, and the cause of the fistula development.

Is a Stoma Created in the Treatment?

The opening of a stoma is a approach that can be considered at every stage in the treatment of rectovaginal fistula. It has been observed that spontaneous healing can occur if there is a stoma opened in the first surgery for fistulas developing after rectal surgery. In cases where a stoma was not opened in the first stage after rectal surgery and a rectovaginal fistula develops, opening a stoma as an ileostomy or preferably colostomy can promote spontaneous healing.

Additionally, a surgeon applying the aforementioned methods may decide to open a stoma in addition. The aim here is to keep the surgical area dry and clean, thus increasing the healing rates. When making this decision, the benefits of opening a stoma should be compared with the psychological impact it may have on the patient, and a decision should be made on a case-by-case basis.

How Long Does Rectovaginal Fistula Surgery Take?

The duration of the surgery can vary between 20 minutes to 180 minutes, depending on factors such as the technique applied, the surgeon’s experience and dexterity in this field, the presence of obesity in the patient, and the presence of fibrosis due to previous surgeries.