Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy.
Case presentation with showing anatomical structures in detail.
Tertiary academic teaching hospital.
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 found to have bacteremia. Abdomen and pelvic MRI showed a presacral and pre- coccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. Trans-gluteal 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 plan for 6 weeks antibiotic course. Her blood sugars were well controlled during hospitalization with baseline insulin and moderate sliding scale. Physical therapy started pre-operative and continued post-operative. She was managed with an interdisciplinary team of GYN, urogynecology, orthopedic, and neuro-surgery, nutritionists, infectious disease, endocrinology, hematology, rehabilitation specialists and physical therapists. This video showcases laparoscopic resection of sacrospinous fistula tract. Post-operative pathology result showed Squamous mucosa, submucosa and deep soft tissue with a submucosal abscess surrounded by fibrosis, consistent with a fistula tract.
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 precise anatomy of critical structures close to the area of interest is crucial.

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