Technique: Laparoscopic-Assisted Pull-through for Imperforate Anus

This video shows a laparoscopic assisted pull through for high imperfianus. The baby is placed transversely on the table, and the surgeon stands at the head. We use 3 trochars, one in the umbilicus for the scope, and then a 3 and a 5 millimeter trochar placed in the right and left mid quadrants just below the umbilicus. The dissection has started out in the lower sigmoid. Using the 3 millimeter. Just right sealer, the mesentery to the lower colon is mobilized. This technique uses fine dissection just on the serosa of the bow wall. The small vessels which are seen clearly here, each individually isolated, grasped with the sealer, sealed, and then retracted away from the bow. This is a very safe and efficient technique for mobilizing the distant bowel without devascularizing it. It is also much safer than using electrocautery in this area which could spread to surrounding structures causing injury to the vast deferences, the bladder, the ureter, and other structures. Could also damage the surrounding nerves. By using the 3 millimeter sealer, fine dissection can be done completely around. The cirrhosis of the bowel. With a very limited heat spread. Also, by using the sealer in the right hand, the surgeon has the ability to dissect with both hands, providing traction with his left hand and doing the fine dissection around the bowel. With his right. These instruments can also be switched to allow for the section on the left side of the bowel as seen here. Again, the ability to dissect and then seal and distract the tissues away from the colon, uh, provides a very safe and efficient technique. This dissection is carried down towards the fistula. In this case, the fistula is a high fistula at the level of the bladder neck. Again, you can see we're dissecting directly on the bowel wall and eliminating any injury to surrounding structures by using this technique. There's also no bleeding because each of the vessels is sealed. And then isolated and Torn. Posteriorly, the dissection goes quite quickly and rapidly, uh, we were down at the level of the bladder, of the pelvic floor. The most difficult portion of the dissection is always anteriorly, uh, where the fistula crumbs up into the bladder. In this area, one needs to be very careful to prevent injury to the Prostate Or the seminal vesicles. Or the vast step. Here you see a hitch stitch being placed uh through the anterior abdominal wall and down to the peritoneal reflection, and this helps retract the bladder up out of the way, exposing the anterior rectum uh more completely. Again, this part of the dissection can be difficult as the tissue planes can be very dense and diff difficult to differentiate between the rectum. And surrounding structures. As we continue our dissection, we gradually see. fistula come into view. But initially it appears quite thick and large. At this point there's still work done. That needs to be done in order to completely immobilize it. The colon tapers relatively quickly as it enters down into the bladder neck. This is a relatively high fistula. Most of the fistulas that we deal with in this procedure. Or closer to the level of the prostate. You see we're using. Find a section to try and break through that. A thicker plane and once we've done so, we can use the 3 millimeter sealer again to help. Seal and separate these tissues. Uh, in a very safe fashion fashion, preventing any bleeding or injury to the surrounding structure. Here we can see the fistula dissected out. Again, this is relatively high. Because of the position of the fistula in this case, uh, we will. Take the fistula using the 5 millimeter stapler. In this case, the best angle was achieved by placing the 5 millimeter stapler through the left hand port. Whether or not the left or right hand port is upsized to a 5 for the stapler depends on the particular anatomy of the child. Here you can see We're taking the fistula and we're almost completely flush with the bladder neck. This technique allows. Uh, for easy division of the fistula in a safe and secure fashion. any residual. Fistula so that there is no chance of a diverticulum. Once the fistula is divided. The ball is then retracted somewhat superiorly to mobilize more of the mesentery to allow for the eventual pull through. In most cases. It is not necessary to mobilize. Uh, the rectosigmoid much above. The pelvic reflection Again, we stay relatively close to the bowel wall to prevent devascularization of the colon. And injury to surrounding structures. Last attachments of the distal segment are then taken down, in this case again, sealing the blood vessels and then gently tearing them away from the colon. This technique works extremely efficiently. And prevents the need for changing to scissors in order to cut the tissue. It also prevents the heat spread seen with monopolar uh hook cautery. If this completed, we'll now turn to the perineal portion of the operation. Uh, the baby's, uh, feet and legs were all prepped, uh, at the beginning of the procedure and now retracted, uh, up towards the baby's head, exposing. The area of the external sphincter. The nerve stimulator is used to identify the center of the sphincter, and this is marked. This area is just over 1 centimeter. With the center of the sphincter mark, a skin incision is made. Uh. In the center Of the sphincter And then a needle tip cautery is used to gently divide the tissues in the midline. Trying to stay within the center of the sphincter. The stimulator is used throughout this portion of the procedure to ensure that This section does not wander off to the right or left, and that we stay in the center as close as possible. Once we've dissected through the skin and subcutaneous tissue. Down to the level of the sphincter, we bluntly dissect right in the center of the sphincter, trying to preserve uh the circular fibers as much as possible. Get this done and We then insert a various needle through the center of the external sphincter. And into the center of the pelvic floor under direct. Uh, visualization. Here you can see the tip of the needle coming out from the center of the levator complex, well away from the bladder neck. It's important that This be visualized as it is possible to injure the urethra of the bladder. Uh, if you're not careful doing it. Once the angle is determined, we then insert a sheath over the various needle and then use a series of Uh, the radio expandable trocar is to go from a 5 up to a 10 to create the anal canal. With the 10 millimeter trochar now in the neo anus. A Babcock clamp is passed through the trocar. And is used to grasp. Your and Rectum. Because of the staple line, there is no spillage. Or other issue during this portion of the procedure. Care should be taken to make sure that the orientation of the valve is correct and that it does not get twisted. Or the mesentery king. With the bow grasped, the Babcock and the chokar gently eased out and. The end of the bow is grassed. At the level of the anus. Occasionally, there is too much tension and more mobilization needs to be done, and this can be achieved relatively easily. Here you see the appropriate orientation of the ballad as, as it is pulled through. Then on the perineal portion of the procedure. The exteriorized end is. Grasped and the staple line resected. A series of stay sutures are then placed to give better exposure. Uh, and we You said. Just a little bit more of the staple line. And the exteriorized belt. A series of 40 interrupted viral sutures are then used to create the neo anus going full thickness through the. Colon. Uh And then through the skin. Because the patient has a diverting colostomy, uh, it is only necessary to place about 12 to 16 sutures. Uh, as this, uh, anastomosis does not need to be airtight, and we do not want to, uh, make it ischemic. Last bit of trimming of the exteriorized portion is then performed. The posterior wall is then shown in place. In general, uh, we will start, uh, calibration and anal dilatations at approximately 2 weeks of age. Often this is only necessary for a few weeks. Here you can see 2 to 3 stitches being placed in each quadrant after the uh 4 corners are placed. Once the anastomosis is complete, You can see that the uh And it's. Already is retracting somewhat, creating a more normal skin line. Uh, external column. We then go back into the abdomen and put hitch stitches in the colon. Uh, attaching the. Just all Or mid rectum to the presacral fascia. This helps prevent prolapse later on. Usually 2 stitches, one on each side, is sufficient. This can also retract the Anus giving a more normal. Um, looking anal canal. Again, the orientation of the bowel is checked to make sure that nothing is caught on the mesentery, and here you see the neo anus.