Introduction: Urachal remnants are rare in adulthood with only a few cases of urachal-sigmoid fistula reported in the literature. We report the first case of a laparoscopic resection of a urachal-sigmoid fistula resulting from diverticulitis in an immunosuppressed heart transplant patient. Case Description: The patient is a 43-year-old male who underwent an orthotopic heart transplant one month prior for dilated cardiomyopathy. His presenting symptom was abdominal pain and imaging showed a sigmoid-urachal fistula. A laparoscopic sigmoidectomy with resection of the urachal cyst and drainage of pelvic abscess was performed. The cyst was found to be contiguous and inseparable from the bladder, and therefore a small cuff of bladder was included with the specimen followed by primary laparoscopic cystorrhaphy. He had an uncomplicated hospital course. Discussion: Our case contained several unique aspects that altered the ultimate care and hospital course of the patient. Immunosuppressed patients possess multiple risk factors predictive of poor surgical outcome—infection, bleeding, and hollow organ perforation. The patient in this study was on multiple immunosuppressants and exhibited no peritoneal signs despite an elevated leukocytosis and some worrisome radiologic findings. Our decision to operate early was influenced by the aforementioned factors and led to an uncomplicated recovery.