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

Good morning and thank you for giving us the opportunity to present our video today. An ectoplasty or PSARP is the most commonly used technique to repair an imperforated anus. However, now 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. Our patient is an ex-38 weeker who was born with multiple congenital anomalies including clubbed foot, pilot. and a high and perforated anus, she was taken for a diverting sigmoid loop colostomy on day of life 2. Afterwards, she underwent a distal stomogram that showed a blind ending rectum that was several centimeters from the anus without an obvious fistula. After appropriate further workup to rule out other congenital anomalies such as an echocardiogram, renal ultrasound, and an X-ray to evaluate for vertebral anomalies, she was taken to the OR at 3. Months of age for a laparoscopic assisted anal rectal pull through, a Foley catheter was placed and the patient was prepped from the nipples down to the lower extremities, including the perineal region. The procedure was performed using 3 ports a 4 millimeter infra umbilical camera port and two additional 3 millimeter working ports in the right and left lower quadrants. The procedure was started by first following the colon down to the pelvic floor and opening the perineal reflection. Care must be taken to avoid injury to the right ureter during this part of the dissection. The distal rectal pouch is mobilized using a combination of blunt dissection and a 3 millimeter bipolar vessel sealer to seal and tease off small vessels off the bow. A bipolar energy device was used as it has minimal energy spread, minimizing the risk of injury to the surrounding structures. Dissections carried out circumferentially on the rectal wall towards the vagina. Again, care is taken not to injure any of the surrounding structures. The dissection is carried down directly on the rectal wall until the rectal pouch is narrowed. It can be seen connected to the lower half of the vagina, indicating a likely rectal vaginal fistula. Dissection is continued until the rectal fistula is flushed with the vaginal wall. And then a 5 millimeter stapler is used to divide the fistula flush with the muscular wall of the vagina, leaving no diverticulum. The rectum is then mobilized proximately to allow for attention-free pull through. The sphincter complex is then 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 various needle is placed through the incision into the abdomen under laparoscopic visualization and then dilated with a 5 millimeter trochar and then exchanged out for a 10 millimeter trochar. A clamp is placed through the trochar into the abdomen and used to pull the rectal pouch into the anus directly in the middle of the sphincter complex. The rectal pouch is then opened using electrocautery, and an anal cutaneous anastomosis is performed using interrupted vicral sutures. Two hitch stitches with two Oethebo suture are then placed between the colon and the fascia just anterior to the sacrum on both sides. This is to help prevent rectal prolapse. The patient tolerated the procedure well and was discharged home on post-op day one. She was started on anal dilations 1 month postoperatively and taken back to the OR for a colostomy takedown approximately 6 weeks post-op. This is a picture of her newly constructed anus 1 month after a colostomy takedown. The key points of this case are laparoscopic assisted anal rectal pull through operation 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. Second, it preserves the distal rectum. And third, it allows for accurate placement of the rectum in the middle of the sphincter complex. I'll be happy to take any questions.