Pediatric Colorectal Contraversies Part III: Pediatric Colorectal...

I want to talk a little bit about, uh, the controversial subject of PSARP versus laparoscopy. Um, and, um, I just want to say that I don't understand this argument very well because many of the papers that are written compare the PSARP to laparoscopy. My impression is that our goals are to find the distal rectum. Take care of the fistula, not leave distal rectum behind. Mobilize the rectum with good blood supply and place it within the sphincter mechanism. And however you'd like to achieve that, PSARP laparoscopically doesn't matter as long as those goals are achieved. The, the articles that you will read in the literature that compare PSARP to laparoscopy almost never comment on exactly what the malformation was and what was wrong with the spine or the sacrum. And I think without knowing the exact anatomy and the status of the sacrum and the spine, you cannot make any judgments about the prognosis of a patient. So let's begin this discussion. We have three distal cholostrograms on your screen. And um I guess we could pose this as a question. I'm very curious to know how. Would be handled. Would you do PSARP or laparoscopy in the three types of malformations? Maybe we can go to ALP. Yeah, thank you very much, Mark. I mean, we've just published our experience with laparoscopy on 24 patients and I have to say I have used laparoscopy on all these conditions. Um, the bulbar fistula ones, prosthetic ones, and the bladder neck ones. Our, um, management has changed after the 1st 24 cases. We would not use it for the bulbar fistulas anymore. Um, it can be done technically, it's more challenging, of course, uh, but the benefits of using laparoscopy and spending longer time in theater, um, probably is not there compared to the PA. Um, looking at these pictures, with our experience that we've had so far, um, on the right-hand side, the more bladder neck fistulas, we would approach them with laparoscopy, certainly. It's a nice easy way of doing it. Um, but when it comes to the sort of more on the spectrum of bulbar ones which we're seeing on the left-hand side here, um, we would do them with a piece of. Our experience with laparoscopy, um, in the sort of mid to long term results, the early results, uh, the anal stenosis has been a problem. Um, about 1 in 3 patients we've had anal stenosis at the cutaneous junction level, which required an anoplasty. Um, obviously the, uh, um, long dissection line may have played a role with this. Ischemic changes may have played a role with this. But also our follow-up hasn't been so good and the dilatation programs hasn't been so good. That's what we've established from our little study of 24 cases. Let's hear, uh, uh, Yama. How would you handle these, how would you handle these three cases? I think on the right side, I, I think, uh, prostatic urethra fistula, and I do laparoscopic, uh, treatment in the middle. I think, uh, probably, uh, no fistula, but I do laparoscopically on the left. I think they're very low, they're kind of, uh, r above the fistula, but I do laparoscopically even on the left. And uh uh during dissection I do dissect as much as possible digitally then I put a catheter. From the rectal side of the orifice into the urethra. Another surgeon is watching the, you know, tip of the catheter coming out to the fistula. Then we can measure the residual length of the fistula, so we can continue dissection deeply. Then we can measure the residual fistula again until, you know, we divide the fistula just. Uh, maybe 5 millimeter, uh, on the urethra. That is, uh, what I'm doing now. Uh, OK, when? Uh, yes, for right on versicon fitula, I mean Latin neck. I prefer laparoscopic, uh, right on, right on punctu for lower fitula, I prefer combined between laparoscopic approach and modified PE, keeping the sphincter intact. Because for low feed it's not difficult to dissect fed, but difficult to close the fitula and we could leave some remnant and could cause the diverticulum after the operation. That is why combined with the modified keeping er so far we performed those successful. Uh, very good, and, uh, Longley? Uh, my technique is similar to Professor Yama, uh, only for the high type of, uh, rectal fistula. It's a good opportunity, a good option to take the laparoscopic approach for the, uh, rectal bulbar fistula at the beginning this was considered a contraindication for lap. But with the experience accumulated in our center for this type, I mean the low fistula, they also take the laparoscopic approach our technique is just with the grasper to the distal part of the rectum and then the fistula will become shallow, I mean out from the pelvic floor. Uh, to the, uh, abdominal cavity and then we dissect the mucosa of the fuscular, uh, left the muscular cuff intact to avoid the damage of the nerve. Nerves and the surrounding tissues and in the urethra, in some cases they close the fistula by filtering the muscular cuff. Uh, is, in some very difficult cases, uh, if you resecting the mucosa completely to the most distal part of the rectum, even though without ligation or filtering, the fistula, the, the urethral fuss rarely occurred after the operation by laparoscopic approach. So in our center nowadays, all these three circumstances are indicated for laparoscopic approach. Now with the comparable result. To the posterior sed approach, so we think the laparoscopic approach is very nice with the advantage for the anorectoplasty for high and intermediate. anorectal malformations. OK. OK, um You know, that, um, uh, a very common saying is, uh, there are, there are many ways to skin a cat, and there are many ways to go to Rome. And, um, and, and I encourage all the, all the laparoscopists to continue trying to improve those techniques and moving forward, because what is coming is going to be even better in terms of minimally invasive surgery in the future, and I look forward to see refined instruments with, uh, we already have an excellent view in the laparoscopic field, but the, the instruments, Are currently used from my point of view, the very personal point of view, are still grotesque and rude, but I'm sure that it's coming from a refined instrument that would allow us to reproduce everything that we do under direct vision laparoscopically. That time is coming. Now, having said that, the, um, for all those that are doing laparoscopy, and I happen to review most of the papers that you all guys write. I suggest you, I strongly suggest that when you talk about anorectal malformations, number one, don't keep using the archaic, misleading classification into high, intermediate, and low, or it's like dividing the human beings into bad ones and good ones, or tall, tall ones and short guns, short ones. That's, That's, that's no longer useful for any purpose. Number two, including in your evaluation the quality of the sacrum and whether or not the patient has tested when you compare or try to compare results. Otherwise, don't bother sending those papers because I will be very critical about that until I, until I, I, every, every time I read them. And then, uh, of course, the, the, somebody was asking what's the advantage of laparoscopy. The advantage is try to avoid the laparotomy and the pain related with the laparotomy. So that's why we are very much enthusiastic about laparoscopy in all those patients that need laparotomy. And, and also at our institution, Mark Levitt and I have been there also in patients with, um, Prostatic fistula that we can see in the digital cholestergram like this, we can see that, and that even when some patients have a, a prostatic fistula, that prostatic fistula seems to be more accessible laparoscopically than from below, and we encourage to do it that way. So prostatic fistula, I would say it depends on how, how far, Argue with the laparoscopy. If you feel confident and familiar, go ahead and do it. For bulbar fistulas, we are against, against the use of laparoscopy and for the following reasons. Number one, because it takes us about an hour and a half to repair that malformation. Number two, because they have minimal pain. Number 3, because they eat the same day of surgery, and then because they are discharged 48 hours later, and we can discharge them earlier and because we have excellent. And finally, because we have a series of patients that we receive from surgeons who use laparoscopy in those patients and they refer the patients to us with a huge posterior urethral diverticulum and metallic staples in the pelvis with all the complications that you can imagine about that. And, and that was unnecessary. For those reasons, we believe, but if, but if you feel confident and you follow your patients and you have good results, keep doing it. Let's, uh, let's pull the group on this next slide. I specifically found these two very similar fistulas, but very different rectums. And let's put up laparoscopy, uh, would someone use laparoscopy on the left and on the right? Maybe we can hear from Evo. Uh, these are interesting cases. I, if I look carefully, I think they're both, um, seem to be prosthetic fistulas, and one has, uh, the, what you say on the left side is the smaller fistula, smaller rectum with laparoscopy, it's easier to dissect and to freeze from the urethra. On the right side, you have a larger rectum, and I think for me, uh, I would prefer, I'd probably prefer to do a PSA, um, because it's easier, you can see on the x-ray, it's easier to access, uh, accessible from below, and that's, that's also the reason why I don't see, Any advantages in, uh, in doing a bulbar in laparoscopically, because it's more difficult. It's, it's probably more easier to do it from below, because it's, it's very close, and you don't need a laparoscope to, to get there. And with the smaller fistulas, especially the bladder neck and the prosthetics with a smaller fistula, I think those are the ones you could use laparoscopy. And another thing I'd like to add to it is that, uh, um, and you said it in the beginning, it is, uh, it's not only, uh, PSAP or laparoscopy, but it is, it's PSAP or laparoscopy with a small PSA, because the end phase of your surgery, I, I do not just put it through, but I also make a small incision to do a, a mini PSA to place it exactly in the sphincter, in the muscle complex. So that would be my command to it. Um, let's hear a little bit more about some of the problems that we've seen, uh, from laparoscopy. I think, uh, uh, the reason why these slides, I think, are so instructive and to agree with Evo, when the rectum is very low and bulging, it's very difficult transabdominally to dissect elegantly the distal rectum. Get enough rectum mobilized and not hurt the urethra, whereas posterior sagiti is the exposure to that problem is beautiful. As opposed to the rectum on the left side, which I think is easier to access transabdominally. And laparoscopy is the perfect route for that. Um, um, and you can easily separate the distal rectum. So, in both of these cases, the fistula is very similar, but the rectum are very, is very different. And I think, um, to, um, agree very much with Doctor Pena's point, whenever we talk about these cases, we must say bladder, neck, prostatic or bulbar. We must know the quality of the sacrum, and we must know the quality of the spine, and only then can we compare our results. The reality is that the patient's prognosis is based on what malformation they have and how is their spine and sacrum. No matter how you do the operation, if you do it well and mobilize the rectum well and disconnect the fistula and not leave rectum behind, That gives you the anatomic reconstruction. The results are based on an excellent anatomic reconstruction and the underlying condition of the patient. Um, somebody asked a question mark about robotic surgery. Some think that clear to us about robotics, and I like that question. Let me tell you why I like that. Yes, there are some, there's a recent publication on robotic surgery, one case from an Arab country. They don't give much detail, but I don't know how many of you have had the opportunity to look and play with the robot, and it's really a fantastic view. Not only is it a fantastic view, it's three dimensional, and also you can reproduce. The movements of your, of your hands and all the instruments that we use, uh, in an open surgery, in a, in a robot. And, uh, so it's because all the instruments are digital, so you can make the finest movements that you always dream about. So the future of laparoscopy, I think, is going to be to make the instruments, digital instruments, so we can move inside, and, and, and do beautiful operations very quick and very safe. When I see esophageal attrition repaired thoracoscopically, the image of the fistula and the atticus vein is there, and you feel like walking in and fixing that beautifully. You, you, we basically drool when they decide to go there and repair it because the view is so exciting, but then suddenly you see this monster instrument getting there with movements like that and pulling and pushing and and. Big needle moving like that and I still don't like that, but no question that the, the merge of the technology used for robotic with the with the principles of laparoscopic is with the future and you will be seeing it and doing it. I hope to be part of that. Yeah, and I would also just say that someone asked about whether to use the PSARP. What I would suggest is do the laparoscopy with the PSARP. Don't lose the advantage of the PSARP incision. You don't need as long of a PSARP incision when you do it laparoscopically. What we will do is start with laparoscopy, mo, Mobilize the distal rectum, ligate the fistula, gain adequate length, lift the legs over the baby's head. We don't go back to prone. We don't need prone in this circumstance. Make a posterior sagittal incision. That is the safe way to get into the perineum. There's no reason to make a tiny anal incision. You're just making it a more dangerous, Dangerous operation, and most of the injuries that we've seen have been because there's a blind maneuver to get into the pelvis. So take advantage of the posterior sagittal incision. There's no, nothing bad about the posterior sagittal incision. People talk about you're cutting the sphincter. That is old school. That is not true. We have hundreds of patients who had a, Uh, midline posterior sagittal incision. The sphincters are not cut. Doctor Pena proved to us that the sphincters don't cross the midline. And if you stay perfectly in the midline and reconstruct them, they work. We have patients, many patients, vestibulars. We have patients who've had a trans anorectal approach to problems in the urethra. The posterior sagittal incision is completely split, reconstructed, and the patient remains perfectly continent. So the advantage of the posterior sagittal incision is you help yourself get into the pelvis, you pull on the rectum, and then you can tack the rectum, Two, the posterior edge of the muscle complex, which helps to avoid, uh, prolapse. So what we would suggest is a laparoscopic assisted PSARP, and I would advocate a new terminology, laparoscopic assisted PSARP, because take advantage of the laparoscopy and take advantage of the PSARP. Want to wind it down? Yeah, I, well, talk about perfect. Uh, Well that was I would say we've been doing this for 4 years now I think that was probably the best discussion we've ever had.