Rectovaginal fistulae resulting from rectal surgery for cancer, especially in the irradiated field, represent a difficult situation for colorectal surgeons. To avoid radical and mutilating solutions and to limit morbidity, several therapeutic approaches have been described, but no consensus has yet been established. Omental and pedicled muscular flaps interpositioned between the rectum and vagina offer good outcomes; nevertheless, the cosmetic result is poor and the short- and long-term morbidity is high, and resection of the previous anastomosis and redo is often required. Technique: Surgery is represented by usual laparoscopy using five 5 mm ports; the first step consists of the dissection of the rectovaginal space down to the pelvic floor; afterwards, a modified Vertical Rectus Abdominis pedicled flap (m-VRAM) can be easily harvested full laparoscopically and simply interposed in the rectovaginal space. No additional skin or fascial incisions and no repeat anastomosis were needed. No recurrence, stenosis, or other short- or long-term complications were noted. Conclusion: Our technique is minimally invasive and offers a valid alternative for the treatment of rectovaginal fistulae with low morbidity and no additional incision.

Redo cardiac surgery following a prior sternotomy presents significant technical challenges and increased risks due to potential injuries during sternal re-entry, mediastinal adhesions and hemorrhage. Endoscopically assisted coronary artery bypass grafting (CABG) offers a minimally invasive alternative approach, avoiding sternotomy while achieving complete revascularization and reducing operative morbidity. An 86-year-old male with prior CABG in 2011 who presented with recurrent angina due to graft occlusion and a circumflex lesion unsuitable for intervention. Revascularization was performed using thoracoscopic adhesiolysis and internal mammary harvesting, followed by a hand-sewn coronary anastomosis through a limited left thoracotomy under femoral cardiopulmonary bypass. The patient recovered uneventfully and was discharged on postoperative day 6. At one-month follow-up, he remained asymptomatic with preserved ventricular function. Endoscopically assisted coronary bypass grafting is a safe and feasible alternative in selected patients while reducing surgical trauma and allowing rapid recovery.