IPEG 2018 - LAPAROSCOPIC-ASSISTED ANORECTAL PULL-THROUGH FOR HIGH IMPERFORATE ANUS IN A FEMALE

Anoplasty or PSARP is the most commonly used technique to repair an imperforate anus.

Laparoscopic assisted anorectal pull through is increasingly being used because it allows for an earlier postoperative recovery, minimal perineal dissection, and accurate placement of the rectum in the sphincter muscle complex.

The patient underwent a diverting sigmoid loop colostomy on day of life 2.

Distal stomogram showed a blind ending rectum that was several centimeters from the anus without an obvious fistula.

Appropriate workup to rule out other congenital anomalies includes echocardiogram, renal ultrasound, and X-ray to evaluate for vertebral anomalies.

The patient was taken to the OR at 3 months of age for laparoscopic assisted anorectal pull through.

The procedure was performed using 3 ports: a 4 millimeter infraumbilical camera port and two additional 3 millimeter working ports in the right and left lower quadrants.

Care must be taken to avoid injury to the right ureter during dissection following the colon down to the pelvic floor.

A 3 millimeter bipolar vessel sealer is used to seal and tease off small vessels off the bowel during distal rectal pouch mobilization.

A bipolar energy device has minimal energy spread, minimizing the risk of injury to the surrounding structures.

The rectal pouch can be seen connected to the lower half of the vagina, indicating a likely rectovaginal fistula.

A 5 millimeter stapler is used to divide the fistula flush with the muscular wall of the vagina, leaving no diverticulum.

The rectum is mobilized proximally to allow for tension-free pull through.

The sphincter complex is identified using a transcutaneous electrostimulator.

After identifying the point of maximum contraction, a 1 centimeter incision is made in the center of the sphincter complex.

A Veress needle is placed through the incision into the abdomen under laparoscopic visualization and then dilated with a 5 millimeter trocar and then exchanged out for a 10 millimeter trocar.

The rectal pouch is pulled into the anus directly in the middle of the sphincter complex using a clamp placed through the trocar.

An anorectocutaneous anastomosis is performed using interrupted Vicryl sutures.

Two hitch stitches with 2-0 Ethibond suture are placed between the colon and the fascia just anterior to the sacrum on both sides to help prevent rectal prolapse.

The patient was discharged home on post-op day one.

Anal dilations were started 1 month postoperatively.

Colostomy takedown was performed approximately 6 weeks post-op.

Laparoscopic assisted anorectal pull through allows for minimal perineal dissection, which will result in less soft tissue scarring around the rectum and possible improvement in rectal compliance in the future.

Laparoscopic assisted anorectal pull through preserves the distal rectum.

Laparoscopic assisted anorectal pull through allows for accurate placement of the rectum in the middle of the sphincter complex.