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Laparoscopic Assisted Posterior Sagittal Anorectoplasty

Video Published 2025-01-14 Updated 2026-08-01

Timestops (3)

Anatomy and Fistula Assessment

Port Placement and Rectal Mobilization

Pelvic Dissection and Rectal Pull-Through

Topic Overview

This is a surgical demonstration of laparoscopic-assisted posterior sagittal anorectoplasty (PSARP) for anorectal malformation with a high rectoprostatic fistula. The presenter describes anatomical classification of fistula types based on urethral entry point, explains case selection criteria using the pubococcygeal line on distal colostography, and demonstrates the technical steps: laparoscopic mobilization of distal rectum preserving the inferior mesenteric artery, circumferential dissection to the fistula, perineal approach to create the pull-through tract, fistula ligation with endoloop, and anoplasty creation within the marked sphincter complex.

Key Takeaways

Distal colostogram determines fistula level; laparoscopic view alone cannot identify urinary tract entry point. (1:17)
High rectoprostatic fistulas above PC line suit laparoscopic approach; bulbar fistulas favor posterior sagittal. (1:30)
Preserve IMA arcade during laparoscopic dissection; intramural blood supply perfuses rectal wall adequately. (2:55)
Mobilize rectum to stoma level before fistula ligation to ensure tension-free pull-through. (3:59)
Mark sphincter complex with electrical stimulator before muscle relaxant; guides anoplasty placement. (2:30)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1

Chapters

0:00Case Introduction and Fistula Classification — Introduction of laparoscopic-assisted PSARP case with high rectoprostatic fistula. Anatomical classification system for fistula types based on urethral entry point is presented using a Rodin statue analogy.
1:30Case Selection and Operative Setup — Distal colostography criteria for laparoscopic versus posterior sagittal approach. Port placement, patient positioning, and sphincter mapping with electrical stimulator are described.
2:45Laparoscopic Rectal Mobilization — Circumferential dissection of distal rectum staying close to rectal wall, preserving IMA and its arcade. Dissection continues until rectum tapers to fistula approximately 3mm in diameter.
4:20Perineal Approach and Anoplasty Creation — Perineal dissection to create pull-through pathway, fistula ligation with endoloop, division of distal rectum, pull-through of rectum to perineum, and anoplasty construction.

Key claims

0:50A fistula entering the deltoid or shoulder region of the urethra is a bladder neck fistula — Speaker 1
0:57A fistula entering the triceps or humerus area of the urethra is a prostatic fistula — Speaker 1
1:03A fistula entering at the elbow of the urethra is a bulbar fistula — Speaker 1
1:17The laparoscopic view alone does not help the surgeon know where the distal rectum enters the urinary tract — Speaker 1
1:25A properly done distal colostogram is required to determine where the distal rectum enters the urinary tract — Speaker 1
1:30A high rectum with fistula to lower prostatic level where the rectum is above the pubococcygeal or PC line is amenable to a laparoscopic approach — Speaker 1
1:47A lower rectum with fistula to the bulbar urethra is ideal for a posterior sagittal approach — Speaker 1
1:58The laparoscopic setup uses a 5 millimeter port at the umbilicus for the camera, which is then moved to the right upper quadrant for best visualization of the pelvis — Speaker 1
2:30The sphincter is marked with silk sutures after defining its extent using an electrical stimulator — Speaker 1
2:38Muscle relaxant is provided by the anesthesiologist once the sphincter has been marked — Speaker 1
2:55The laparoscopic dissection stays intimately attached to the rectal wall, preserving the IMA in its arcade — Speaker 1
3:01The intramural blood supply profuses the rectal wall — Speaker 1
3:06Redundancy in the sigmoid indicates the colostomy was correctly opened in the proximal sigmoid, leaving the distal aspect for the pull through — Speaker 1
3:34Dissection continues until the rectum tapers into a narrow fistula — Speaker 1
3:39The goal is to have the tapered fistula area be the size of a 3 millimeter Maryland grasper — Speaker 1
3:59Dissection up to the stoma frees the rectum so the pull through will not be under any tension — Speaker 1
4:20Before ligating the fistula, the perineum is opened at the intended location of the anoplasty — Speaker 1
4:28Blunt, gentle dissection finds the path into the pelvis which will be the trajectory of the pull through — Speaker 1
4:40The fistula is ligated by preloading the Maryland grasper over an endo loop — Speaker 1
4:47The distal rectum is cut with sharp scissors and the urinary tract is closed with the endo loop — Speaker 1
5:42The anoplasty is created with tacking of the posterior rectal wall to the edge of the muscle complex — Speaker 1

Cases discussed

0:06Male patient with anorectal malformation and high rectoprostatic fistula treated with laparoscopic-assisted PSARP

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Laparoscopic-Assisted Posterior Sagittal Anorectoplasty: Surgical Decision-Making and Technique

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Preoperative imaging determines the surgical approach

The single most important preoperative decision is whether the anatomy favors a laparoscopic or posterior sagittal approach, and this cannot be determined by laparoscopy itself. "The laparoscopic view alone does not help the surgeon know where the distal rectum enters the urinary tract" 1:17. A properly done distal colostogram is required 1:25. The classification system uses urethral anatomy: a fistula entering the deltoid or shoulder region of the urethra is a bladder neck fistula 0:50, the triceps or humerus area indicates a prostatic fistula 0:57, and the elbow of the urethra marks a bulbar fistula 1:03. A high rectum with fistula to the lower prostatic level—where the rectum sits above the pubococcygeal line—is amenable to a laparoscopic approach 1:30. A lower rectum with fistula to the bulbar urethra is ideal for a posterior sagittal approach 1:47. This is not a preference; it is anatomy dictating access.

Sphincter mapping precedes paralysis

The sphincter is marked with silk sutures after defining its extent using an electrical stimulator 2:30. This step must happen before muscle relaxant is given 2:38. Once you paralyze the patient, you lose the ability to map the muscle complex accurately. The sequence matters: prep, stimulate, mark, then relax. Reversing this order means operating without knowing where the functional sphincter lies.

Dissection technique preserves blood supply while achieving mobility

The laparoscopic dissection stays intimately attached to the rectal wall, preserving the IMA in its arcade 2:55. The intramural blood supply profuses the rectal wall 3:01, and staying on the rectal surface protects this network. Dissection continues until the rectum tapers into a narrow fistula 3:34, with a specific target: the tapered fistula area should be the size of a 3 millimeter Maryland grasper 3:39. This is not approximate—it is a measurable endpoint that tells you when to stop dissecting distally. Proximally, dissection extends up to the stoma to free the rectum completely 3:59. Redundancy in the sigmoid indicates the colostomy was correctly opened in the proximal sigmoid, leaving the distal aspect for the pull through 3:06. If you see redundancy, the colostomy was done right. If you do not, the pull-through will be under tension, and tension is the enemy of healing.

Sequence the perineal and abdominal steps to control the fistula safely

Before ligating the fistula, the perineum is opened at the intended location of the anoplasty 4:20. Blunt, gentle dissection finds the path into the pelvis which will be the trajectory of the pull through 4:28. Establishing this path before dividing the fistula means you know the rectum will reach without tension and that the trajectory is correct. Only then is the fistula ligated by preloading the Maryland grasper over an endo loop 4:40. The distal rectum is cut with sharp scissors and the urinary tract is closed with the endo loop 4:47. This sequence—open perineum, confirm trajectory, then divide—prevents the scenario where you have divided the fistula and discover the pull-through will not reach or is misdirected.

The anoplasty is a tacking procedure, not an anastomosis

The anoplasty is created with tacking of the posterior rectal wall to the edge of the muscle complex 5:42. This is not a circumferential anastomosis under tension. The posterior wall is secured first, establishing the hinge point around which the rest of the anoplasty is constructed. The laparoscopic setup uses a 5 millimeter port at the umbilicus for the camera, which is then moved to the right upper quadrant for best visualization of the pelvis 1:58, converting the umbilical port into an instrument port for the surgeon's left hand. This port repositioning is not incidental—it optimizes the angle for deep pelvic dissection and pull-through.

The operation succeeds or fails on three principles: accurate preoperative imaging to select the right approach, complete mobilization to eliminate tension, and preservation of blood supply throughout dissection. Each step builds on the one before it, and skipping or reversing the sequence introduces failure modes that are difficult to recover from intraoperatively.

Takeaways from this story

Distal colostogram, not laparoscopy, determines whether anatomy favors laparoscopic or posterior sagittal approach.
Map and mark the sphincter with electrical stimulation before giving muscle relaxant—paralysis erases your roadmap.
Dissect the fistula until it tapers to 3mm Maryland grasper size, then dissect proximally to the stoma for tension-free pull-through.
Open the perineum and confirm pull-through trajectory before ligating the fistula—sequence prevents misdirection.
Stay on the rectal wall during dissection to preserve IMA arcade and intramural blood supply.

Laparoscopic-Assisted Posterior Sagittal Anorectoplasty: Technical Execution for High Rectourethral Fistulas

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

Case Selection

The laparoscopic approach applies to high rectourethral fistulas where the rectum sits above the pubococcygeal line with fistula entry at the lower prostatic level 1:30. The laparoscopic view alone does not determine fistula location 1:17 — a properly done distal colostogram is required 1:25. Lower rectum with bulbar urethral fistula is better suited to posterior sagittal approach 1:47.

Port Placement and Sphincter Mapping

A 5 millimeter umbilical port is placed for the camera, then moved to the right upper quadrant for optimal pelvic visualization 1:58. The umbilical site becomes the left-hand instrument port. Additional ports are placed in the left upper quadrant for the assistant and right lower quadrant for the surgeon's right hand. Before insufflation, the sphincter is mapped with an electrical stimulator and marked with silk sutures 2:30. Only after marking is muscle relaxant administered 2:38.

Rectal Mobilization

Dissection remains intimately on the rectal wall, preserving the IMA and its arcade 2:55. The intramural blood supply perfuses the rectal wall 3:01. Redundancy in the sigmoid confirms correct colostomy placement in the proximal sigmoid, leaving distal bowel for pull-through 3:06. Dissection continues until the rectum tapers to a narrow fistula 3:34, ideally the diameter of a 3 millimeter Maryland grasper 3:39. Complete mobilization to the stoma ensures a tension-free pull-through 3:59.

Fistula Division and Anoplasty

Before ligating the fistula, the perineum is opened at the intended anoplasty site 4:20. Blunt dissection establishes the pull-through trajectory 4:28. The fistula is ligated by preloading a Maryland grasper over an endo loop 4:40. The distal rectum is divided with sharp scissors and the urinary tract closed with the endo loop 4:47. The anoplasty is created by tacking the posterior rectal wall to the edge of the muscle complex 5:42.

Critical Technical Points

The distal colostogram determines operative approach. Sphincter mapping precedes relaxation. Rectal mobilization preserves intramural blood supply. Fistula tapering to 3 millimeters confirms adequate dissection. Tension-free pull-through requires mobilization to the stoma.

Takeaways from this story

Distal colostogram is mandatory for case selection; laparoscopic view alone cannot determine fistula location
Sphincter mapping with electrical stimulator must precede muscle relaxant administration
Rectal dissection stays on the wall to preserve IMA arcade and intramural blood supply
Target fistula taper is 3 millimeter Maryland grasper diameter before division
Complete mobilization to stoma level ensures tension-free pull-through

Laparoscopic-Assisted Posterior Sagittal Anorectoplasty: Surgical Decision-Making and Technical Execution

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Teaching arc · AI-written, human-reviewed

Preoperative imaging determines the entire approach

The single most important decision in anorectal malformation repair happens before the first incision. The laparoscopic view alone does not help the surgeon know where the distal rectum enters the urinary tract 1:17. A properly done distal colostogram is required to determine where the distal rectum enters the urinary tract 1:25. This imaging distinguishes a high rectum with fistula to lower prostatic level where the rectum is above the pubococcygeal or PC line — amenable to a laparoscopic approach 1:30 — from a lower rectum with fistula to the bulbar urethra, which is ideal for a posterior sagittal approach 1:47. The anatomic classification uses urethral landmarks: a fistula entering the deltoid or shoulder region of the urethra is a bladder neck fistula 0:50, one entering the triceps or humerus area is prostatic 0:57, and one entering at the elbow is bulbar 1:03. Without this roadmap, the surgeon is guessing.

Map the sphincter before paralysis

The sphincter is marked with silk sutures after defining its extent using an electrical stimulator 2:30. This step must happen while the muscle is responsive. Only after the sphincter has been marked does the anesthesiologist provide muscle relaxant 2:38. Once paralyzed, the sphincter complex becomes invisible — the sutures are your only guide for the anoplasty site. This is not a step you can revisit.

Dissection plane preserves blood supply

The laparoscopic dissection stays intimately attached to the rectal wall, preserving the IMA in its arcade 2:55. The intramural blood supply profuses the rectal wall 3:01. Straying even slightly off the rectal surface risks devascularizing the pull-through segment or injuring pelvic nerves. The correct plane is bloodless and follows the rectal contour exactly. Redundancy in the sigmoid indicates the colostomy was correctly opened in the proximal sigmoid, leaving the distal aspect for the pull through 3:06 — if you see this, the prior surgeon set you up well.

Taper the fistula to a precise diameter

Dissection continues until the rectum tapers into a narrow fistula 3:34. The goal is to have the tapered fistula area be the size of a 3 millimeter Maryland grasper 3:39. This is not approximate. Too wide and you risk leaving rectal mucosa in the urinary tract; too narrow and you are dissecting into virgin tissue at the urethral entry point, risking injury. The Maryland grasper is your gauge — when the fistula fits snugly around it, stop.

Mobilize to eliminate tension

Dissection up to the stoma frees the rectum so the pull through will not be under any tension 3:59. A pull-through under tension will retract, dehisce, or stenose. Mobilization to the stoma is not excessive — it is the minimum required for a straight, unstressed path to the perineum. Check reach before dividing the fistula; if the rectum does not easily reach the intended anoplasty site, you have not mobilized enough.

Sequence the perineal and abdominal steps

Before ligating the fistula, the perineum is opened at the intended location of the anoplasty 4:20. Blunt, gentle dissection finds the path into the pelvis which will be the trajectory of the pull through 4:28. Creating this path first ensures the pull-through will follow the correct vector through the sphincter complex. Only then is the fistula ligated by preloading the Maryland grasper over an endo loop 4:40, the distal rectum cut with sharp scissors, and the urinary tract closed with the endo loop 4:47. The sequence matters: path first, division second. Reversing this leaves you pulling blind.

Posterior tacking anchors the anoplasty

The anoplasty is created with tacking of the posterior rectal wall to the edge of the muscle complex 5:42. The posterior wall bears the mechanical load during defecation. Anterior sutures alone will not hold. The tacking must be to the muscle edge, not to skin — skin will not provide structural support. This final step converts a mobile tube into a fixed, functional anus.

Takeaways from this story

Distal colostogram determines surgical approach; laparoscopic view alone cannot localize fistula entry into urinary tract
Sphincter mapping with electrical stimulator must occur before muscle relaxant; once paralyzed, the complex is invisible
Fistula must taper to exactly 3mm Maryland grasper diameter — too wide leaves rectal mucosa in urethra, too narrow risks injury
Mobilization to stoma eliminates pull-through tension; inadequate mobilization causes retraction, dehiscence, or stenosis
Create perineal path before ligating fistula to ensure correct trajectory through sphincter complex

Keywords

anorectal malformation rectoprostatic fistula rectovesical bladder neck fistula bulbar urethral fistula laparoscopic assisted posterior sagittal anorectoplasty PSARP distal colostogram colostomy anoplasty laparoscopic dissection pull-through

Hashtags

#LaparoscopicSurgery #AnorectalMalformation #SurgicalTechnique #PediatricSurgery #FistulaRepair #SphincterSurgery #EndoscopicSurgery #RectalSurgery #PelvicAnatomy #SurgicalEducation #Anoplasty #SurgicalDissection #HighRecoprostaticFistula #PosteriorSagittalAnorectoplasty #Colostomy #SurgicalPorts #SutureTechnique #MuscleRelaxant #ElectricalStimulator #DistalCallostogram #LaparoscopicPSARP #ColorectalSurgery

Transcript

Laparoscopic assisted posterior sagittal anorectoplasty. In this video, we present a case of a laparoscopic assisted PSAP for a patient with an anorectal malformation and a high recoprostatic fistula. Here is a typical perineum of a male with an anorectal malformation. The location of the intended anoplasty is obvious, with a discoloration in the area of the sphincteric ellipse. Remember the schema of determining the location of the distal rectum relative to the urinary tract as imposed on the elbow of this Rodin statue. If the fistula enters the deltoid or shoulder region of the urethra, it is a bladder neck fistula. If it enters the triceps or humerus area, it is a prostatic fistula. And if it enters at the elbow of the urethra, it is a bulbar fistula. Here are representative distal callostrograms of a recoprostatic fistula on the left and erectile bladder neck fistula on the right. The laparoscopic view alone does not help the surgeon know where the distal rectum enters the urinary tract. This requires a properly done distal callostogram. The image on the top right shows a high rectum, with a fistula to the lower prostatic level. This kind of case is amenable to a laparoscopic approach, as the rectum is above the pubococcygeal or PC line. The image on the bottom right shows a lower rectum with a fistula to the bulbar urethra. This case is ideal for a posterior sagittal approach. In our case today, the laparoscopic setup for a high recoprostatic fistula uses a 5 millimeter port at the umbilicus for the camera, which is then moved to the right upper quadrant for best visualization of the pelvis. The umbilical port then becomes the instrument for the surgeon's left hand. A left upper quadrant port is for the assistant, and the right lower quadrant port is for the surgeon's right hand instrument. A total body prep is performed and a Foley catheter inserted. The legs are then lifted up and the sphincter marked with silk sutures after we have defined its extent using an electrical stimulator. Now, once the sphincter has been marked, the anesthesiologist can provide muscle relaxant with the patient in supine position. 4 ports are inserted for dissection of the deep pelvis. The laparoscopic dissection of the distal rectum begins. The dissection stays intimately attached to the rectal wall, preserving the IMA in its arcade. You can see the intramural blood supply well, which profuses the rectal wall. There appears to be plenty of redundancy in the sigmoid, meaning the colostomy was correctly opened in the proximal sigmoid, leaving the distal aspect for the pull through. The dissection continues circumferentially around the distal rectum. We keep dissecting until the rectum tapers into a narrow fistula. Our goal is to have this tapered area be the size of a 3 millimeter Maryland grasper. We dissect up to the stoma to free the rectum so the pull through will not be under any tension. And now we check that the rectum will easily reach the perineum. Now before ligating the fistula we open the perineum just at the intended location of the anoplasty. With blunt, gentle dissection, we find the path into the pelvis which will be the trajectory of the pull through. We see that the fistula tissue is smaller than the Maryland. Now we ligate the fistula by preloading the Maryland over an endo loop. And now we cut the distal rectum with sharp scissors and therefore can close the urinary tract with the endo loop. Here you see the pull-through of the distal rectum through our previously created pathway. And we ensure that the pull through is straight. We grasp the distal rectum with a suture. And can now create the anoplasty with tacking of the posterior rectal wall to the edge of the muscle complex.

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