Pediatric Colorectal Contraversies Part III: Pediatric Colorectal...
With Dr. Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
ALP's center published experience with laparoscopy on 24 anorectal malformation patients, including bulbar, prostatic, and bladder neck fistulas.
After 24 laparoscopic cases, ALP's center stopped using laparoscopy for bulbar fistulas because the benefits do not justify the longer operative time compared to PSARP.
ALP's center uses laparoscopy for bladder neck fistulas.
In ALP's laparoscopic series, approximately one in three patients developed anal stenosis at the cutaneous junction level requiring anoplasty.
Possible causes of anal stenosis in ALP's laparoscopic series include the long dissection line, ischemic changes, poor follow-up, and inadequate dilatation programs.
Yama performs laparoscopic repair for prostatic urethral fistulas and for low (bulbar) fistulas, using digital dissection and catheter-guided measurement of residual fistula length to divide the fistula approximately 5 millimeters from the urethra.
One expert prefers laparoscopic approach for bladder neck fistulas and a combined laparoscopic plus modified PSARP (keeping sphincter intact) for lower fistulas to avoid leaving remnant tissue that could cause postoperative diverticulum.
Longley's center uses laparoscopic approach for high rectal fistulas and, with accumulated experience, also for rectal bulbar fistulas, using a grasper to pull the distal rectum and make the fistula accessible from the abdominal cavity.
Longley's technique for low fistulas involves dissecting the mucosa of the fistula while leaving the muscular cuff intact to avoid nerve and surrounding tissue damage, and in some cases closing the fistula by suturing the muscular cuff.
In Longley's experience, complete mucosal resection to the most distal rectum rarely results in urethral fistula recurrence after laparoscopic repair, even without fistula ligation or suturing.
Longley's center now uses laparoscopic approach for all three fistula types (bladder neck, prostatic, bulbar) with results comparable to posterior sagittal approach.
Current laparoscopic instruments are viewed as grotesque and rude, but refined instruments are expected in the future that will allow reproduction of open-surgery techniques laparoscopically.
When discussing anorectal malformations, the high/intermediate/low classification is archaic and misleading and should not be used.
Evaluation and comparison of anorectal malformation outcomes must include sacral quality and presence of tethered cord.
The advantage of laparoscopy is avoiding laparotomy and associated pain, which is why it is favored for patients who would otherwise need laparotomy.
At the speaker's institution (with Mark Levitt), laparoscopy is used for prostatic fistulas when the fistula appears more accessible laparoscopically than from below on distal colostogram.
The speaker's institution opposes laparoscopy for bulbar fistulas because PSARP takes approximately 90 minutes, causes minimal pain, allows same-day feeding, permits discharge at 48 hours, and produces excellent results.
The speaker's institution has received referrals of patients who underwent laparoscopic repair of bulbar fistulas and developed huge posterior urethral diverticula and metallic staples in the pelvis with associated complications.
A small, high rectum with prostatic fistula is easier to dissect and free from the urethra laparoscopically.
A large, low rectum with prostatic fistula is easier to access from below via PSARP.
Bulbar fistulas are more difficult to repair laparoscopically and easier to repair from below because they are very close and accessible without a laparoscope.
Smaller fistulas, especially bladder neck and prostatic fistulas, are good candidates for laparoscopy.
Evo's technique is laparoscopy with a small PSARP (mini-PSARP) at the end to place the rectum exactly in the sphincter and muscle complex, rather than just pulling it through.
Robotic surgery offers fantastic three-dimensional visualization and digital instruments that can reproduce the finest hand movements, representing the future of minimally invasive surgery.
Current laparoscopic instruments for procedures like thoracoscopic esophageal atresia repair are large and crude despite excellent visualization.
The surgical goals for anorectal malformations are to find the distal rectum, manage the fistula without leaving distal rectum behind, mobilize the rectum with good blood supply, and place it within the sphincter mechanism.
Literature comparing PSARP to laparoscopy almost never specifies the exact malformation anatomy or the status of the spine and sacrum.
Without knowing the exact anatomy and the status of the sacrum and spine, you cannot make judgments about a patient's prognosis.
When the rectum is very low and bulging, it is difficult transabdominally to dissect the distal rectum elegantly, mobilize enough rectum, and avoid urethral injury, whereas posterior sagittal exposure is excellent for this problem.
A high rectum is easier to access transabdominally, making laparoscopy the ideal route for separating the distal rectum.
Patient prognosis is based on the specific malformation, spine quality, and sacral quality, regardless of surgical technique.
Good surgical results require excellent anatomic reconstruction (mobilizing the rectum well, disconnecting the fistula, not leaving rectum behind) combined with the patient's underlying condition.
Laparoscopic-assisted PSARP combines laparoscopic mobilization and fistula ligation with lifting the legs over the baby's head (no prone positioning) and making a posterior sagittal incision for safe perineal access.
Making a tiny anal incision instead of a posterior sagittal incision creates a more dangerous operation, and most injuries have resulted from blind maneuvers to access the pelvis.
The posterior sagittal incision does not cut the sphincter; Doctor Pena proved that sphincters do not cross the midline, and if the incision stays perfectly midline and is reconstructed, the sphincters work.
Many patients with vestibular malformations and patients who had transanorectal approaches with complete posterior sagittal incision splitting and reconstruction remain perfectly continent.
The posterior sagittal incision allows tacking the rectum to the posterior edge of the muscle complex, which helps avoid prolapse.