Recto-Bladderneck Fistula: Laparoscopic-Assisted Anorectoplasty

Laparoscopic-assisted repair of an anorectal malformation with a rectal bladder neck fistula. We present the laparoscopic repair of a male infant with an anorectal malformation and a rectal bladder neck fistula. As you can see on the distal cholostrogram, the rectum is high, connected to the bladder, and is not reachable safely from a posterior sagittal approach. Umbilical axis was obtained. Additionally, 4 millimeter trochars were placed in the right upper quadrant and right mid abdomen. The right upper quadrant port is for the camera axis. The right lower quadrant is for the surgeon's right hand, and the umbilicus is for the surgeon's left hand. If needed, a left upper quadrant port can be placed to help retract the sigmoid. Our first step in this case was to fix the bladder to the anterior abdominal wall with a transcutaneous stay suture so that we would have better exposure of the pelvis. The distal rectum is then mobilized using hook electrocautery in a circumferential fashion, starting with the anterior attachments and working laterally until the posterior attachments are able to be visualized and released. While doing this dissection, both ureters and vas deferens were identified and avoided. The 3 millimeter endoceler was used for the attachments near the bladder to avoid thermal spread. Great care was taken to preserve the IMA and its branches, which provide intramural blood supply to the distal rectum. Once the fistula is dissected circumferentially, 1/4 3 millimeter instrument assists with division of the fistula at the point of maximal tapering of the distal rectum near the bladder. The fistula is divided. The bladder side is closed with a grasper and a preloaded endo loop. Now that the fistula is ligated, the next step is to gain length on the rectum in order to perform annoplasty without tension. Once we have enough rectal length, we put the patient's legs up. There is no need for prone positioning. The muscle complex is identified with the nerve stimulator, and a limited posterior sagittal incision is made. This incision makes for the safer passage into the pelvis and allows for tacking of the rectum to the posterior edge of the sphincter complex. Blunt dissection is used to create a space between the sacrum and the pubis. Once the peritoneum is entered, the abdomen is insufflated. And the rectum passed into the tract. Once you pull the rectum down, it is placed within the center of the sphincter and anchored to the posterior aspect of the sphincter complex. An nanoplasty with 16 sutures is made, and the posterior sagittal incision closed.