Case reportA 49 year old woman underwent abdominal hysterectomy indicated by metrorrhagia and a very large fibroid uterus. A bladder injury occurred during the dissection and was sutured immediately. Postoperatively the patient developed a vesico-vaginal fistula between the vaginal apex suture and the upper third of the bladder, as demonstrated by cystogram and intravenous pyelogram. Cystoscopy revealed a fistula five millimeter in diameter located posterior and superior to the trigone. The fistula was too high to be reached by a finger. Continuous drainage via a Foley catheter for three weeks failed to allow closure. A vaginal approach was not appropriate because of the location of the fistula. We proposed a laparoscopic approach, following the same principles as laparotomy. The woman was aware that conversion to laparotomy might be required.Four months after hysterectomy, we performed laparoscopy, as follows. A video-laparoscope was inserted through a 10 mm trocar at the umbilicus, and two 12 mm trocars were set in the lower abdomen to insert grasping forceps, scissor, suctionirrigator probe and staplers. Inspection of the pelvic and abdominal cavity revealed a few pelvic adhesions, easily lysed. The bladder was dissected away from the vagina, with a vaginal tampon exposing the vaginal cul-de-sac to orient the dissection. The fistula was excised and the bladder wall repaired with one layer of a continuous suture (Endostitch Polysorb zero). Closure of the vagina was not necessary. An omental J flap was then dissected, based on the gastrointestinal vessels, with five cartridges of Endo-GIA 30 staples (Fig. 1) and inserted between vagina and bladder to enhance blood supply, protect suture lines, and close dead space2. This flap was stapled to

A 40-year-old woman underwent laparoscopic-assisted vaginal hysterectomy for severe endometriosis (stage IV of the AFSR classification), which involved transsection of the left ureter. The ureteral injury was immediately recognized and repaired successfully with a laparoscopic ureteroureterostomy. The operative technique is described, and data about ureteral injury are discussed. (J GYNECOL SURG 14:81, 1998).