Laparoscopic repair of high imperforate anus

Current practice of diagnosis and treatment for rectourethral fistula in male patients with anorectal malformation: a multicenter questionnaire survey in Japan

PURPOSE

Surgical procedures for anorectoplasty for anorectal malformations (ARMs), particularly rectourethral fistula (RUF), depend on the institution. We investigated the diagnosis and treatment of RUF in male patients with ARMs in Japan using a questionnaire survey.

METHODS

An online survey inquiring about the diagnosis and treatment (diagnostic modalities, surgical approaches, fistula dissection devices, and fistula closure techniques) of each type of ARM in male patients was conducted among institutional members of the Japanese Study Group of Anorectal Anomalies. Fisher's exact test was used to compare surgical methods between posterior sagittal anorectoplasty (PSARP) and laparoscopy-assisted anorectoplasty (LAARP).

RESULTS

Sixty-one institutions (100%) completed the survey. LAARP was the preferred approach for high-type ARM (75.4%). PSARP was preferred for intermediate-type ARM (59.0%). Monopolar devices were most commonly used (72.1%) for RUF dissection. Blunt dissection was more frequent in the PSARP group (PSARP vs. LAARP: 55.6 vs. 20.0%, p < 0.005). Cystoscopy/urethroscopy to confirm the extent of dissection was used more frequently in the LAARP group (70.0% vs. 25.0%, p < 0.005). Clips and staplers were used more frequently in the LAARP group (p < 0.05).

CONCLUSION

Distinct fistula management strategies for PSARP and LAARP were revealed. Further studies are needed to investigate the postoperative outcomes associated with these practices.

Simple division of rectourethral fistula as an alternative to ligation during laparoscopic repair of anorectal malformation

Background

Various techniques are described to manage the rectourethral fistula during laparoscopic repair of anorectal malformation (LAARP). The fistula can be ligated with sutures, clips, staplers, or simply divided flushed with the urethra.

Objective

The aim of our study is to share our experience of simply dividing the rectourethral fistula during LAARP without ligation.

Patients and methods

A retrospective chart review conducted between January 2005 and April 2020 including male children with rectourethral fistula. The fistula was managed by laparoscopic simple division without ligation along with temporary urinary diversion.

Results

Twenty-six patients were included. None of the patients had short- or long-term urinary complications due to the technique used. All patients had a regular follow-up for a minimum of 1 year.

Conclusion

Simple division of rectobulbar or rectoprostatic fistula is a safe, easier alternative to ligation of the fistula during laparoscopic repair of ARM.

Two-Staged Versus Three-Staged Laparoscopic Anorectoplasty for Patients with Rectoprostatic and Bladder Neck Fistulas: A Comparative Study

Purpose: To compare the results of two- versus three-staged laparoscopic anorectoplasty (LARP) in children with rectoprostatic and bladder neck fistulas. Materials and Methods: The present study was retrospectively initiated among 32 consecutive patients who underwent two-staged LARP from October 2010 to December 2012. The associated defects, age at the operation, operative time, complications, length of the postoperative hospital stay, total hospitalization cost, and functional results (according to the Krickenbeck scoring system) were evaluated. The results were compared with those of 19 cases who underwent three-staged LARP from October 2008 to September 2010. Results: The average age at the second operation was 4.5 ± 1.2 months in the two-staged group, and 4.2 ± 1.3 months in the three-staged group. In the two-staged group, there were statistically shorter overall operative time and postoperative hospital stay duration. Also, a significantly lower total hospitalization cost was achieved. There was no anastomotic leak in either group. The rates of perineal wound infection, recurrent fistula, and rectal prolapse were 3.85% versus 0% (P = 1.000), 0% versus 5.3% (P = .422), and 11.5% versus 15.8% (P = .686), respectively (two-staged versus three-staged group). The median follow-up time was 67 (range, 54-80) months and 88 (range, 81-104) months, respectively. No significant difference in functional outcome was observed. Conclusions: Two-staged LARP is feasible, safe, and more cost-effective, with comparable incidences of complications and functional outcomes with respect to a three-staged procedure.

The midterm outcomes of 1-stage versus 3-stage laparoscopic-assisted anorectoplasty in anorectal malformations with rectoprostatic fistula and rectobulbar fistula: A retrospective cohort study

The aim of this study was to compare the midterm outcomes of 1-stage and 3-stage surgical procedures to treat anorectal malformations (ARMs) with rectoprostatic and rectobulbar fistula using laparoscopic-assisted anorectoplasty (LAARP).A total of 56 patients with ARMs and rectoprostatic and rectobulbar fistula who underwent LAARP from January 2011 to May 2014 in our institution were included in the study. They were divided into 2 groups according to the stage of procedure. The patients' data and postoperative complications were compared between the 2 groups. The Krickenbeck classification was used for assessing the bowel functions.About 20 ARM newborns (rectoprostatic fistula [12], rectobulbar fistula [8]) successfully underwent a 1-stage LAARP, and about 36 ARM children (rectoprostatic fistula [20], rectobulbar fistula [16]) underwent a 3-stage LAARP (colostomy, LAARP, and closure of colostomy). The average age at the LAARP procedure in 1-stage group was significantly lower than that in 3-stage group (39.8 ± 8.1 hours vs 4.9 ± 1.2 months; P = .00). The average operative time during the definitive procedure was 132.2 ± 15.9 minutes in the 1-stage group and 120.5 ± 12.7 minutes in the 3-stage group (P = .13). There was only 5 to 10 mL of blood loss during the LAARP procedure both the groups (P = .75). There were no significant differences between the 2 groups in postoperative hospital stay during the definitive procedure (10.2 ± 2.3 days vs 8.5 ± 2.2 days; P = .22). The rate of surgical site infection and dehiscence was 5% (1/20) in the 1-stage group and 5.6% (2/36) in 3-stage group (P = 1.00). During the period of follow-up, the rate of voluntary bowel movement was 90% (18/20) in 1-stage group and 94.4% (34/36) in 3-stage group (P = .94). Free from soiling or grade I soiling was 80% (16/20) in 1-stage group and 83.3% (30/36) in 3-stage group (P = 1.00); grade II soiling was found in 3 (10%) patients in 1-stage group and 85.7% in 3-stage group (P = .75); grade III soiling was found in 3 (10%) patients in 1-stage group and 85.7% in 3-stage group (P = 1.00). Three patients (15%) in 1-stage group and 5 patients (13.9%) in 3-stage group suffered from grade I constipation (P = 1.00); while 3 (15%) patients in 1-stage group and 4 patients (11.1%) in 3-stage group had grade II constipation (P = 1.00); no patients in the 2 groups suffered from grade III constipation.The 1-stage LAARP procedure for neonate with rectoprostatic and rectobulbar fistula can achieve comparable midterm outcomes as the conventional 3-stage LAARP procedure. It provides an alternative method to rectify the ARMs with rectoprostatic fistula and rectobulbar fistula without colostomy.

Anorectal Malformations

Anorectal malformation are common congenital problems occurring in 1 in 5,000 births and have a spectrum of anatomical presentations, requiring individualized treatments for the newborn, sophisticated approaches to the definitive reconstruction, and management of long-term treatments and outcomes. Associated anomalies related to the cardiac, renal, gynecologic, orthopedic, spinal, and sacral systems impact care and prognosis. Long-term results are good provided there is an accurate anatomical reconstruction and a focus on maximizing of functional results.

Muscle complex saving posterior sagittal anorectoplasty

INTRODUCTION

Posterior sagittal anorectoplasty (PSARP) published by DeVries and Peña in 1982 had become the preferred surgical technique for the management of anorectal malformations (ARM). The original technique is based upon complete exposure of the anorectal region by means of a median sagittal incision that runs from the sacrum to the anal dimple, cutting through all muscle structures behind the rectum by dividing the levator muscle and the muscle complex. Then, the rectum is located in front of the levator and within the limits of the muscle complex. In this review, we described Muscle Complex Saving-Posterior Sagittal Anorectoplasty (MCS-PSARP), which is a less invasive technique that consists of keeping this funnel-shaped muscle complex completely intact and not divided, and pulling the rectum through this funnel, toward fixing the new anus to the skin. This technique aimed both to respect the lower part of the sphincter mechanism consisting of the muscle complex, and to avoid the disturbance of this important structure by dividing and resuturing it.

METHODS

We presented six cases of male patients who were born with anorectal malformation (ARM) and underwent MCS-PSARP. The surgical technique proved to be feasible to achieve the dissection of the rectal pouch and the division of the rectourethral fistula in all patients, by opening only the upper part of the sphincter mechanism, the levator muscle, and keeping the lower part consisting of intact muscle complex.

RESULTS

The early results in our series are encouraging; however, long-term functional outcomes of these patients are awaited. The surgical tips were also discussed.

CONCLUSIONS

This proposed approach in the management of anorectal malformation cases provides an opportunity to maximize preservation of the existing continence mechanisms. It preserves the muscle complex components of the levator muscle intact, allowing a better function of the continence mechanism.

LAPAROSCOPICALLY ASSISTED ANORECTOPLASTY AND THE USE OF THE BIPOLAR DEVICE TO SEAL THE RECTAL URINARY FISTULA

Background:

The anorectal anomalies consist in a complex group of birth defects. Laparoscopic-assisted anorectoplasty improved visualization of the rectal fistula and the ability to place the pull-through segment within the elevator muscle complex with minimal dissection. There is no consensus on how the fistula should be managed.

Aim:

To evaluate the laparoscopic-assisted anorectoplasty and the treatment of the rectal urinary fistula by a bipolar sealing device.

Method:

It was performed according to the original description by Georgeson¹. Was used 10 mm infraumbilical access portal for 30º optics. The pneumoperitoneum was established with pressure 8-10 cm H₂O. Two additional trocars of 5 mm were placed on the right and left of the umbilicus. The dissection started on peritoneal reflection using Ligasure(r). With the reduction in the diameter of the distal rectum was identified the fistula to the urinary tract. The location of the new anus was defined by the location of the external anal sphincter muscle complex, using electro muscle stimulator externally. Finally, it was made an anastomosis between the rectum and the new location of the anus. A Foley urethral probe was left for seven days.

Results:

Seven males were operated, six with rectoprostatic and one with rectovesical fistula. The follow-up period ranged from one to four years. The last two patients operated underwent bipolar sealing of the fistula between the rectum and urethra without sutures or surgical ligation. No evidence of urethral leaks was identified.

Conclusion:

There are benefits of the laparoscopic-assisted anorectoplasty for the treatment of anorectal anomaly. The use of a bipolar energy source that seals the rectal urinary fistula has provided a significant decrease in the operating time and made the procedure be more elegant.

Laparoscopic approach in the management of anorectal malformations

Seventeen years have passed since the first description of the laparoscopic approach for anorectal malformation and approximately 68 articles have been published on the subject. In this review article, we aim to describe the advantages as well as the indications and contraindications of this approach when dealing with each specific type of anorectal malformation, according to what has been described in the literature and to our own experience. The ideal and undisputable indication for laparoscopy remains for cases in which the abdomen needs to be entered to repair the malformation. Only 10% of male patients with anorectal malformation are born with a recto-bladder neck fistula that requires an abdominal approach, this represents an ideal indication for laparoscopy. In females, only the complex cloacae with a common channel length greater than 3 cm are the ones that require a laparotomy; they represent about 30% of the cloacae. However, the repair of this type of cloacae also requires sophisticated and technically demanding maneuvers that have never been done laparoscopically. In cases of recto-urethral prostatic fistulas the malformation can be repaired either way: laparoscopically or posterior sagitally. In all other malformations: recto-perineal fistula, recto-urethral bulbar fistula, anorectal malformation without fistula, rectal atresia, recto-vestibular fistula; no justification for laparoscopy could be found; and in some cases, laparoscopy is contraindicated. In the published reports, there is no evidence supporting the idea that laparoscopic repair results in better functional results when compared with non-laparoscopic operation; there is a tendency to omit information relevant to bowel control such as the characteristics of the sacrum and the presence or absence of tethered cord; and most authors do not compare results between comparable malformations.

Two-stage laparoscopic approaches for high anorectal malformation: transumbilical colostomy and anorectoplasty

BACKGROUND

Trans-umbilical colostomy (TUC) has been previously created in patients with Hirschsprung's disease and intermediate anorectal malformation (ARM), but not in patients with high-ARM. The purposes of this study were to assess the feasibility, safety, complications and cosmetic results of TUC in a divided fashion, and subsequently stoma closure and laparoscopic assisted anorectoplasty (LAARP) were simultaneously completed by using the colostomy site for a laparoscopic port in high-ARM patients.

METHODS

Twenty male patients with high-ARMs were chosen for this two-stage procedure. The first-stage consisted of creating the TUC in double-barreled fashion colostomy with a high chimney at the umbilicus, and the loop was divided at the same time, in such a way that the two diverting ends were located at the umbilical incision with the distal end half closed and slightly higher than proximal end. In the second-stage, 3 to 7 months later, the stoma was closed through a peristomal skin incision followed by end-to-end anastomosis and simultaneously LAARP was performed by placing a laparoscopic port at the umbilicus, which was previously the colonostomy site. Umbilical wound closure was performed in a semi-opened fashion to create a deep umbilicus.

RESULTS

TUC and LAARP were successfully performed in 20 patients. Four cases with bladder neck fistulas and 16 cases with prostatic urethra fistulas were found. Postoperative complications were rectal mucosal prolapsed in three cases, anal stricture in two cases and wound dehiscence in one case. Neither umbilical ring narrowing, parastomal hernia nor obstructive symptoms was observed. Neither umbilical nor perineal wound infection was observed. Stoma care was easily carried-out by attaching stoma bag. Healing of umbilical wounds after the second-stage was excellent. Early functional stooling outcome were satisfactory.

CONCLUSIONS

The umbilicus may be an alternative stoma site for double-barreled colostomy in high-ARM patients. The two-stage laparoscopic approaches for high-ARM, TUC and stoma closure with simultaneously LAARP are both technically feasible and safe with excellent cosmetic result.

Proktologie

Die verschiedenen Formen der anorektalen Fehlbildungen manifestieren sich mit einer Häufigkeit von 1 : 4000 Lebendgeburten. Jungen sind häufiger betroffen. Die Kloakalfehlbildung macht etwa 10 % aller anorektalen Malformationen aus.

Laparoscopically assisted vaginal pull-through for high urogenital sinus: a new surgical technique

OBJECTIVE

To evaluate feasibility and outcome of a laparoscopically assisted vaginal pull through procedure for suprasphincteric high urogenital sinus malformation with hydrometrocolpos and normal external genitalia.

METHODS

A tension-free anastomosis of the vagina to the perineum was realized after laparoscopic mobilization of the vagina, separation from the bladder neck at the confluence and pull-through via an externally introduced expandable trocar, thereby avoiding perineal or perirectal dissection.

RESULTS

The approach resulted in good cosmetic and unimpaired functional outcome. Voiding cystourethrography showed normal lower urinary tract anatomy. No disturbances of bladder function could be detected 2 years after surgery.

CONCLUSION

Laparoscopic assisted vaginal pull-through is a new approach for high UGS that significantly improved exposure of the uretro-vaginal junction, allowed extensive mobilization of the vagina and showed excellent cosmetic and functional result.

Laparoscopic repair of anorectal malformations at the Red Cross War Memorial Children's Hospital: taking stock

BACKGROUND

The current standard repair for anorectal malformations in children is a posterior sagittal anorectoplasty. Recently, laparoscopic-assisted anorectoplasty (LAARP) was performed at the Red Cross Children's Hospital.

METHODS

A detailed case note review was conducted. Patient outcome was prospectively evaluated by colorectal nurse specialists using the Krickenbeck standardized questionnaire. Comparison among patients undergoing posterior sagittal anorectoplasty was performed.

RESULTS

Between September 2005 and June 2009, 24 children underwent LAARP. Sixteen had associated anomalies, including 7 children with renal and 4 children with cardiac abnormalities. Median age at surgery was 7.5 months (range, 2.6-15.0 months). Subtypes of anorectal malformation were as follows: vestibular, 2; bulbar, 9; prostatic, 7; vesical, 3; and with no fistula, 3. There was a 16% early complication rate. Redo-anoplasty was required in 9 patients. Eleven children had difficulties with follow-up. Thirteen children had regular follow-up and were analyzed further. Toilet training had been completed in 7 children (median age, 4.3 years; range, 3.5-6 years). Six children developed voluntary bowel motions. Six children are awaiting toilet training or are unable to train because of incontinence.

CONCLUSIONS

Anal stenosis was the most common complication post-LAARP. Etiology appeared to be multifactorial, but poor compliance with dilatations was a leading cause.

Laparoscopy and its use in the repair of anorectal malformations

INTRODUCTION

Laparoscopy has been used for the treatment of anorectal malformations (ARMs) in an attempt to be less invasive and with the hope that it would result in a better functional outcome. There remains a significant debate about whether these expectations have been fulfilled.

METHODS

Seventeen patients with ARM for whom laparoscopy was used were retrospectively reviewed. Six were operated on primarily by the authors, and 11 cases were referred after a laparoscopic repair performed elsewhere. In addition, a literature review was performed looking for evidence of less invasiveness and improved functional results in patients operated on laparoscopically.

RESULTS

The diagnosis was imperforate anus with a rectobladder neck fistula in our 6 cases with the fistula ligated laparoscopically in each case. In 1 patient, the malformation was repaired entirely using laparoscopic technique. The other 5 patients had a laparoscopically assisted repair because we had to open the abdomen to taper a dilated rectum in 2, mobilize a very high rectum in 2, and take down a distal colostomy stoma in 1. Eleven patients were referred with a variety of problems after a laparoscopic repair done elsewhere for rectal stricture (5), rectal prolapse (4), recurrent rectourethral fistula (3), rectal mislocation (3), failed attempted repair leading to fecal incontinence (1), and a posterior urethral diverticulum (1). Our literature review included 47 references (involving 323 patients) published between 1998 and 2010. All studies showed that laparoscopic repair of ARMs is feasible. The review, however, did not provide evidence of less invasiveness or improved functional results.

CONCLUSIONS

Laparoscopy for ARM is a less invasive procedure when compared with those operations that would have previously required a laparotomy (rectobladder neck fistula). In cases of rectoprostatic fistulae, the laparoscopic approach is feasible and avoids a lengthy posterior sagittal incision. There is no evidence that the laparoscopic approach is a less invasive procedure for other types of ARMs. In cases of rectobulbar fistula, congenital anal stenosis, perineal fistula, ARM without fistula, the evidence suggests that it may be lead to more complications. There is no evidence in the literature demonstrating better functional results in cases of ARM operated on laparoscopically.

Developing minimally invasive surgery centers within kaiser permanente: the integrated multidisciplinary experience of los angeles

Minimally invasive surgical therapies are growing in type and volume of interventions. As one of the largest health delivery organizations in the US, Kaiser Permanente staff must be aware that the proliferation of these technologies has occurred in parallel within many surgical specialties, with a large variation in level of implementation between different regions and even within regions. In Los Angeles, we have developed the Minimally Invasive Surgery Center, encompassing a multidisciplinary, integrated approach. It unites the effort and expertise of many outstanding practitioners within the organization and consolidates the achievements of many surgical specialties. It also brings together the elements needed to provide the highest level of care to our patients in a safe, efficient, cost-effective environment, with minimal morbidity and best long-term outcome.

Acquired posterior urethral diverticulum following surgery for anorectal malformations

PURPOSE

Despite significant advances in the surgical management of anorectal malformations (ARMs), many children still experience significant debilities from potentially avoidable complications. One complication, the posterior urethral diverticulum, may have untoward consequences if not recognized and treated.

METHODS

A retrospective cohort review was undertaken of male patients who presented to us with persistent problems after being operated on elsewhere for ARM. Twenty-nine patients presented with a urethral diverticulum. Their charts were reviewed for the type of malformation, prior repair, presentation, treatment, and postoperative follow-up.

RESULTS

Twenty-nine patients were identified that fit the criteria for this study. To date, 28 patients have been managed with reoperation. Urinary complaints were the most common presenting symptoms. All patients were repaired using a posterior sagittal approach. Pathology of the diverticulum in one patient revealed a well-differentiated mucinous adenocarcinoma.

CONCLUSION

The incidence of acquired posterior urethral diverticulum has decreased with the popularization of the posterior sagittal incision. There is a theoretical concern that the incidence may increase with the use of laparoscopy for the treatment of ARMs especially those where the fistula is below the peritoneal reflection. Once detected, the diverticulum should be excised.

Long-term functional evaluation of fecal continence after laparoscopic-assisted pull-through for high anorectal malformations

BACKGROUND

The use of laparoscopy while performing an abdominal dissection for the mobilization of rectovesical fistula should have an impact on anorectal function, as compared to the original posterior sagittal anorectoplasty, where muscle complex was not cut and the rectum was pulled in a way similar to the old techniques for the abdominoperineal pull-through. This necessitates a functional reevaluation.

MATERIALS AND METHODS

A prospective case study included 15 patients treated with a laparoscopic-assisted pull-through for high anorectal malformation. Laparoscopy was used for abdominal dissection and ligation of the fistula, with the pull-through completed by a small perineal incision centered over the external sphincter. Nine of them are now older than 3 years for fecal continence evaluation. After the approval of the Ethical Committee for Medical Research in the Department of Surgery at Ain Sams University (Cairo, Egypt) and obtaining an informed consent from the parents, they were subjected to a full clinical history and a checklist about motions and soiling to be filled in over 1 month, a barium enema to check for any dilatation, anorectal manometry to evaluate resting pressure, maximum squeezing pressure, and sphincter relaxation, and MRI (magnetic resonance imaging) to evaluate the central situation of the rectum within the sphincter and the degree of development of the sphincter. Their degree of continence was graded according to the Kelly score.

RESULTS

Six of 9 patients are clean without any attacks of fecal soiling or incontinence, and they evacuate spontaneously but need the application of a rectal suppository for evacuation from time to time. The remaining 3 patients had variable degrees of fecal incontinence. One of them had mucosal prolapse and was excised with good cleanliness postoperatively. The remaining 2 patients are managed by medical control and they are clean with minimal soiling when stools are loose. MRI and barium enema showed a centrally placed rectum in the muscle complex without dilatation in all cases. Manometry showed a high resting pressure that decreased on straining in the 7 clean patients and low in 2. The resting pressure did not increase on squeezing and all showed weak rectoanal inhibitory reflex (RAIR). One patient developed dysurea and constipation 1 year after surgery, as diagnosed by VCUG (voiding cystourethrogram) to have a diverticulum at the site of excised fistula causing rectal and urethral obstruction treated by a transabdominal excision with a good functional result.

CONCLUSION

The state of continence with the laparoscopic technique in high anorectal malformations in this study showed acceptable results but needs bigger series with longer follow-up for a proper evaluation of this technique.

Transperineal rectovesical fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high anorectal malformations

BACKGROUND

Rectovesical fistula ligation after laparoscopic mobilization of the rectum requires either cutting of the fistula and application of endo-loop or laparoscopic endoligation or clip application. These techniques take more time and require a well-trained surgeon for performing the ligation laparoscopically. A simple technique for ligation of the fistula will be described.

MATERIALS AND METHODS

Over the last 5 years, laparoscopic-assisted abdominoperineal pull-through was performed in 12 cases with high anorectal malformation with rectovesical or rectoprostatic fistula. The rectovesical fistula was mobilized initially laparoscopically. The anal site was identified using muscle stimulator and incised at its center. A Hegar dilator was passed through the center of the anal sphincter to exit behind the fistula seen by laparoscopy. The tract was dilated with Hegar dilators till reaching a suitable size for rectal pull-through. A straight clamp holding the ligature was passed through the perineal site and through the dilated tract to emerge on one side of the fistula; then, the ligature was grasped through the abdomen and turned around the junction of the fistula, forming a loop and regrasped and brought outside with the clamp. The two ends of the ligature emerging from the perineal site were tied, and the knot was pushed using the finger till it reached the fistula, and then it was ligated. The fistula was cut and the mobilized rectum was pulled through the perineal incision to be sutured at the site of the future anus.

RESULTS

Twelve patients with imperforate anus with rectovesical or rectoprostatic fistula had fistula ligation with this technique. Their ages ranged from 3 to 9 months. Ligation of the fistula was possible in all patients. Operative time ranged from 90 to 120 minutes (mean 110 minutes). The ascending urethrogram showed no residual diverticulum in all but one case, which presented with difficulty in micturation and needed to be excised.

CONCLUSION

Transperineal rectovesical fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high anorectal malformations is an alternative technique for fistula ligation during laparoscopy. It is simple and easy to perform with acceptable postoperative results.

Division of the fistula in laparoscopic-assisted repair of anorectal malformations-are clips or ties necessary?

BACKGROUND

Laparoscopic-assisted anorectoplasty (LAARP) was introduced in 2000 by Georgeson (J Pediatr Surg. 2000;35:927-930) and has gained interest because of improved visualization of the rectal fistula and the ability to place the pull-through segment within the levator muscle complex with minimal dissection. Currently, there is no consensus on how the fistula should be managed during LAARP. We postulated that the fistula could be managed with simple division and temporary diversion of urine through a Foley catheter without surgical ligation of the fistula similar to the management of a traumatic urethral injury.

METHODS

A retrospective chart review was performed of patients with imperforate anus who underwent LAARP between January 2005 and September 2007.

RESULTS

Eight patients were managed with a LAARP. Five male patients had the fistula simply divided. In these 5 patients, the location of the fistula was rectoprostatic (2) and rectobulbar (3). The Foley catheter was left in position until a retrograde urethrogram demonstrated no evidence of a leak (range, 6-40 days). There were no postoperative urethral strictures and one diverticulum. Follow-up has ranged from 10 to 19 months.

CONCLUSION

Male patients with a rectourethral fistula at or just below the prostate can be safely and successfully managed with simple division of the fistula.

Minimally invasive surgery in infants less than 5 kg: experience of 649 cases

INTRODUCTION

With the development of advanced skills and the introduction of miniature laparoscopic tools, endoscopic procedures in infants and small children have become possible. This report documents our experience in minimally invasive surgery (MIS) in infants under 5 kg.

METHODS

A retrospective database review was performed from September 1993 to September 2007. All children weighing 5 kg or less that underwent a laparoscopic or thoracoscopic procedure were included.

RESULTS

A total of 649 cases were attempted. 43 different procedures were performed, the most common being Nissen fundoplication (310 cases, average operating room (OR) time 43 min, average time to full feeds 2 days), pyloromyotomy (104 cases, average OR time 12.5 min, average hospital days<1), patent ductus arteriosum (PDA) ligation (26 cases, average OR time 31 min, average hospital days<1), tracheoesophageal fistula (TEF) repair (22 cases, average OR time 83 min, average time to full feeds 7.8 days), duodenoduodenostomy (20 cases, average OR time 76 min, average time to full feeds 8.6 days), colonic pull-through for Hirschsprung's disease (18 cases, average OR time 109.6 min, average time to full feeds 3 days), colonic pull-through for imperforate anus (10 cases, average OR time 103 min, average hospital days 2), lung resection (12 cases, average OR time 66.8 min, average hospital days 1.75), congenital diaphragmatic hernia repair (10 cases, average OR time 62.5 min, average time to full feeds 4.75 days). There were no surgery-related deaths. The conversion rate to open was 1.2% (n=8). There were six intraoperative complication rate (0.9%) and the overall complication rate was 3% (20 complications overall).

CONCLUSIONS

The development of modern low-flow CO2 insufflators, smaller instruments and telescopes, as well as advanced techniques, has made MIS in neonates feasible and safe. The greatest challenge remains performing intestinal anastomosis in these confined spaces, and further technical advances will be required to make these techniques universally adopted.

Primary laparoscopic repair of high imperforate anus in neonatal males

PURPOSE

The standard approach to males with high imperforate anus has been a staged procedure starting with a descending colostomy, then posterior sagittal anorectoplasty with colostomy closure after 3 months. Recently, a minimally invasive approach to the repair of high imperforate anus has been described in infants after colostomy. We describe 6 newborn males with high imperforate anus successfully repaired laparoscopically as a primary, single-stage procedure.

METHODS

A retrospective chart review was performed on all patients with imperforate anus from October 2003 to October 2006.

RESULTS

We evaluated 9 newborn males with high imperforate anus. Of these patients, 6 underwent primary laparoscopic repair on day 1 to day 2 of life. Of these 6 patients, 3 were found to have bladder neck fistulas, whereas the other 3 had prostatic urethra fistulas. All patients passed stool within the first 72 hours postoperatively. One patient has required a procedure for a mild rectal prolapse. Follow-up ranges from 2 to 30 months in the single-stage group.

CONCLUSION

Our early results using primary laparoscopic repair appear encouraging. Laparoscopy allows excellent visualization and assessment of the fistula and repair of high imperforate anus without need for colostomy. Long-term follow-up will be needed to assess outcomes and continence rates.

Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations

Background

This report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM).

Methods

Twenty six males with high ARM were treated with SSARP. Preoperative localization of the center of the muscle complex is facilitated using real time sonography and computed tomography. A soft guide wire is inserted under image control which serves as the route for final pull through of bowel. The operative technique consists of a subcoccygeal approach to dissect the blind rectal pouch. The separation of the rectum from the fistulous communication followed by pull through of the bowel is performed through the same incision. The skin or the levators in the midline posteriorly are not divided. Postoperative anorectal function as assessed by clinical Wingspread scoring was judged as excellent, good, fair and poor. Older patients were examined for sensations of touch, pain, heat and cold in the circumanal skin and the perineum. Electromyography (EMG) was done to assess preoperative and postoperative integrity of external anal sphincter (EAS).

Results

The patients were separated in 2 groups. The first group, Group I (n = 10), were newborns in whom SSARP was performed as a primary procedure. The second group, Group II (n = 16), were children who underwent an initial colostomy followed by delayed SSARP. There were no operative complications. The follow up ranged from 4 months to 18 months. Group I patients have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination with an average number of bowel movements per day was 3–5. In group II the rate of excellent and good scores was 81% (13/16). All patients have an appropriate size anus and regular bowel actions. There has been no rectal prolapse, or anal stricture. EAS activity and perineal proprioception were preserved postoperatively. Follow up computed tomogram showed central placement the pull through bowel in between the muscle complex.

Conclusion

The technique of SSARP allows safe and anatomical reconstruction in a significant proportion of patients with ARM's without the need to divide the levator plate and muscle complex. It preserves all the components contributing to superior faecal continence, and avoids the potential complications associated with the open posterior sagittal approach.

Anorectal malformations

Anorectal malformations comprise a wide spectrum of diseases, which can affect boys and girls, and involve the distal anus and rectum as well as the urinary and genital tracts. They occur in approximately 1 in 5000 live births. Defects range from the very minor and easily treated with an excellent functional prognosis, to those that are complex, difficult to manage, are often associated with other anomalies, and have a poor functional prognosis. The surgical approach to repairing these defects changed dramatically in 1980 with the introduction of the posterior sagittal approach, which allowed surgeons to view the anatomy of these defects clearly, to repair them under direct vision, and to learn about the complex anatomic arrangement of the junction of rectum and genitourinary tract. Better imaging techniques, and a better knowledge of the anatomy and physiology of the pelvic structures at birth have refined diagnosis and initial management, and the analysis of large series of patients allows better prediction of associated anomalies and functional prognosis. The main concerns for the surgeon in correcting these anomalies are bowel control, urinary control, and sexual function. With early diagnosis, management of associated anomalies and efficient meticulous surgical repair, patients have the best chance for a good functional outcome. Fecal and urinary incontinence can occur even with an excellent anatomic repair, due mainly to associated problems such as a poorly developed sacrum, deficient nerve supply, and spinal cord anomalies. For these patients, an effective bowel management program, including enema and dietary restrictions has been devised to improve their quality of life.

Outcomes from the correction of anorectal malformations

PURPOSE OF REVIEW

Anorectal malformations have been recognized and managed since antiquity, with surgical treatment evolving to maximize anatomic reconstruction, avoid complications, and understand mechanisms of incontinence, ultimately leading to improved quality of life for patients. This review describes recent advances in the management of anorectal malformations, including prenatal diagnosis, newborn treatment, surgical correction, and postoperative care.

RECENT FINDINGS

Surgical treatment has improved with better understanding and exposure of anatomy and appreciation of the intimate relation between rectum and urinary tract. Repair of cloacal malformations has evolved to include the total urogenital mobilization and an appreciation of the complex associated Mullerian anomalies. The importance of associated urologic, gynecologic, neurologic, and orthopedic malformations has been recognized. Addition of a bowel management program to patients' postoperative care has increased dramatically the number of children who are clean and dry.

SUMMARY

Management of anorectal malformations requires an accurate clinical diagnosis, proper newborn treatment, meticulous anatomic reconstruction, and comprehensive postoperative care with the goal of having a child who is clean and dry, with an excellent quality of life, because they either have the capacity for continence or can be kept artificially clean with a comprehensive bowel management program.

Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations

PURPOSE

Rectal prolapse is a known postoperative problem in children with anorectal malformations. The aims of this study were to determine the incidence of significant rectal prolapse (>5 mm), to objectively quantify its predisposing factors, and to offer recommendations as to its prevention and surgical treatment.

METHODS

The authors reviewed their series of 1619 patients with anorectal malformations; 1169 underwent primary posterior sagittal anorectoplasty (PSARP) at their institution between 1980 and 2002, and complete records were available for 833. The series was analyzed for incidence of prolapse, type of anorectal malformation, status of the sacrum, muscle quality, associated vertebral and spinal anomalies, and postoperative constipation. A specific technique for prolapse repair was used.

RESULTS

Of 833 patients, 45 developed significant rectal prolapse (3.8%). The mean age at the time of PSARP was 0.73 years (range, 0.19-5 years). The average time to recognition of prolapse following PSARP was 13.1 months. Of these 45 patients, 32 required surgical repair and of those, 3 required a second surgical repair. The incidence of prolapse varied by complexity of anorectal defect: cloaca (6.2%), rectobladder neck fistula (6.8%), rectourethral fistula (5.4%), rectovestibular fistula (1.2%), rectal atresia (0%), and rectoperineal fistula (0%). There was a significantly increased incidence of prolapse in patients with a low muscle quality score and in patients with vertebral anomalies (20% vs 3.2%). The presence of a tethered cord and an abnormal sacral ratio did not correlate with an increased incidence of prolapse. Twenty-two patients developed prolapse following colostomy closure, and of these, 12 (55%) suffered from constipation.

CONCLUSIONS

The overall incidence of significant rectal prolapse following PSARP is low. Prevention of prolapse with the PSARP technique may be because of key technical steps. Patients with higher anorectal malformations, poorer muscle quality, and vertebral anomalies had a greater risk of developing postoperative rectal prolapse. The presence of tethered cord and quality of the sacrum were not predictive of postoperative prolapse. Constipation seems to be a factor in the development of prolapse.