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

Anoplasty or PSARP is the most commonly used technique to repair an imperforate anus

Laparoscopic assisted anorectal pull through allows for earlier postoperative recovery, minimal perineal dissection, and accurate placement of the rectum in the sphincter muscle complex

The patient was an ex-38 weeker born with multiple congenital anomalies including clubbed foot and high imperforate anus

Patient underwent diverting sigmoid loop colostomy on day of life 2

Distal stomogram showed a blind ending rectum several centimeters from the anus without an obvious fistula

Preoperative workup included echocardiogram, renal ultrasound, and X-ray to evaluate for vertebral anomalies

Definitive repair was performed at 3 months of age

The procedure was performed using 3 ports: a 4 millimeter infraumbilical camera port and two 3 millimeter working ports in the right and left lower quadrants

Care must be taken to avoid injury to the right ureter during dissection of the peritoneal reflection

A 3 millimeter bipolar vessel sealer was used to seal and tease off small vessels off the bowel

Bipolar energy device has minimal energy spread, minimizing the risk of injury to surrounding structures

The rectal pouch was found connected to the lower half of the vagina, indicating a likely rectovaginal fistula

A 5 millimeter stapler was used to divide the fistula flush with the muscular wall of the vagina, leaving no diverticulum

The sphincter complex was identified using a transcutaneous electrostimulator

A 1 centimeter incision was made in the center of the sphincter complex at the point of maximum contraction

The rectal pouch was pulled into the anus directly in the middle of the sphincter complex

Anal cutaneous anastomosis was performed using interrupted vicryl sutures

Two hitch stitches with vicryl suture were placed between the colon and the fascia anterior to the sacrum on both sides to help prevent rectal prolapse

Patient was discharged home on postoperative day one

Anal dilations were started 1 month postoperatively

Colostomy takedown was performed approximately 6 weeks post-op

Laparoscopic assisted anorectal pull through allows for minimal perineal dissection, which results in less soft tissue scarring around the rectum and possible improvement in rectal compliance in the future

The procedure preserves the distal rectum

The procedure allows for accurate placement of the rectum in the middle of the sphincter complex