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Dr. Steve Rothenberg

Pediatric Surgery · View profile →

Technique: Laparoscopic-Assisted Pull-through for Imperforate Anus

Video Published 2018-11-17 Updated 2026-06-10

Timestops (8)

Laparoscopic Mesenteric Mobilization with Sealer

Posterior Dissection to Pelvic Floor

Hitch Stitch Placement and Distal Dissection

Stapler Application and Fistula Management

Perineal Dissection and Sphincter Identification

Trocar Placement and Colon Exteriorization

Neo-Anus Creation with Interrupted Sutures

Final Anastomosis and Postoperative Care

Topic Overview

This is a technical demonstration of laparoscopic-assisted pull-through for high imperforate anus with rectourethral fistula. The procedure uses three-trocar laparoscopy with a 3-millimeter vessel sealer for mesenteric mobilization, staying directly on the bowel serosa to preserve vascularity and avoid injury to surrounding pelvic structures including the vas deferens, bladder, ureter, and nerves. The fistula is divided flush with the bladder neck using a 5-millimeter stapler. The perineal dissection uses nerve stimulation to identify and preserve the external sphincter, and the bowel is pulled through a dilated tract created under direct visualization. The anastomosis is performed with interrupted absorbable sutures, and the colon is fixed to the presacral fascia to prevent prolapse.

Key Takeaways

3mm vessel sealer enables safe mesenteric mobilization with minimal heat spread, protecting vas deferens, bladder, ureter, and nerves. (0:38)
Anterior dissection near bladder neck requires careful technique to avoid injury to prostate, seminal vesicles, and vas deferens. (2:49)
Fistula division flush with bladder neck using 5mm stapler eliminates risk of residual diverticulum formation. (5:05)
Nerve stimulator guides perineal dissection to maintain midline trajectory through external sphincter during pull-through. (7:45)
Presacral fixation with 2 hitch stitches prevents prolapse; limited sutures (12-16) avoid anastomotic ischemia with diverting colostomy. (11:54)

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
Speaker 2
Speaker 3

Chapters

0:00Patient positioning and initial laparoscopic mobilization — Patient positioned transversely with surgeon at head. Three trocars placed: umbilical scope, 3mm and 5mm in bilateral mid-quadrants. Mesenteric mobilization of lower sigmoid begins using 3mm vessel sealer with fine dissection on bowel serosa.
2:00Fistula dissection and division — Dissection carried down to high rectourethral fistula at bladder neck level. Anterior dissection most difficult due to dense tissue planes near prostate and seminal vesicles. Hitch stitch used to retract bladder. Fistula divided flush with bladder neck using 5mm stapler.
5:58Completion of laparoscopic mobilization — Rectosigmoid mobilized above pelvic reflection. Dissection stays close to bowel wall to prevent devascularization. Final distal attachments taken down using vessel sealing and gentle tearing technique.
7:24Perineal dissection and pull-through — Nerve stimulator identifies center of external sphincter. Midline incision made and dissection through sphincter performed under stimulation guidance. Veress needle inserted through sphincter center into pelvic floor under direct visualization. Tract dilated to 10mm and bowel grasped and pulled through.
10:21Anastomosis and fixation — Staple line resected and 12-16 interrupted 4-0 absorbable sutures placed full-thickness through colon and skin. Anal dilations planned to start at 2 weeks. Two hitch stitches placed from mid-rectum to presacral fascia to prevent prolapse.

Key claims

0:10The procedure uses three trocars: one umbilical for the scope, and 3mm and 5mm trocars in the right and left mid-quadrants just below the umbilicus — Speaker 1
0:32The technique uses fine dissection just on the serosa of the bowel wall — Speaker 1
0:38Small vessels are individually isolated, grasped with the sealer, sealed, and then retracted away from the bowel — Speaker 1
0:50This is a very safe and efficient technique for mobilizing the distal bowel without devascularizing it — Speaker 1
0:57This technique is much safer than using electrocautery in this area which could spread to surrounding structures causing injury to the vas deferens, the bladder, the ureter, and other structures — Speaker 1
1:10Electrocautery could also damage the surrounding nerves — Speaker 1
1:13The 3 millimeter sealer has very limited heat spread — Speaker 2
1:25Using the sealer in the right hand allows the surgeon to dissect with both hands, providing traction with the left hand and doing fine dissection with the right — Speaker 2
2:05In this case, the fistula is a high fistula at the level of the bladder neck — Speaker 2
2:26There is no bleeding because each of the vessels is sealed — Speaker 2
2:49The most difficult portion of the dissection is always anteriorly, where the fistula comes up into the bladder — Speaker 2
2:56In the anterior area, one needs to be very careful to prevent injury to the prostate or the seminal vesicles or the vas deferens — Speaker 2
3:12A hitch stitch is placed through the anterior abdominal wall down to the peritoneal reflection to retract the bladder up and out of the way — Speaker 2
3:26The anterior dissection can be difficult as the tissue planes can be very dense and difficult to differentiate between the rectum and surrounding structures — Speaker 2
4:07The colon tapers relatively quickly as it enters down into the bladder neck — Speaker 2
4:15This is a relatively high fistula; most of the fistulas dealt with in this procedure are closer to the level of the prostate — Speaker 2
5:05The fistula is taken using the 5 millimeter stapler almost completely flush with the bladder neck — Speaker 2
5:43This technique removes any residual fistula so that there is no chance of a diverticulum — Speaker 2
6:09In most cases, it is not necessary to mobilize the rectosigmoid much above the pelvic reflection — Speaker 2
6:26Staying relatively close to the bowel wall prevents devascularization of the colon and injury to surrounding structures — Speaker 2
7:00This technique prevents the need for changing to scissors in order to cut the tissue — Speaker 2
7:10This technique prevents the heat spread seen with monopolar hook cautery — Speaker 2
7:29The baby's feet and legs are prepped at the beginning of the procedure and retracted up towards the baby's head exposing the area of the external sphincter — Speaker 2
7:45The nerve stimulator is used to identify the center of the sphincter — Speaker 2
8:19The stimulator is used throughout the perineal portion to ensure that dissection does not wander off to the right or left and stays in the center as close as possible — Speaker 2
8:53A Veress needle is inserted through the center of the external sphincter and into the center of the pelvic floor under direct visualization — Speaker 2
9:07It is important that the needle insertion be visualized as it is possible to injure the urethra or the bladder if not careful — Speaker 2
9:24A sheath is inserted over the Veress needle and a series of radially expandable trocars are used to go from 5mm up to 10mm to create the anal canal — Speaker 3
10:02Because of the staple line, there is no spillage during the pull-through portion of the procedure — Speaker 2
10:10Care should be taken to make sure that the orientation of the bowel is correct and that it does not get twisted or the mesentery kinked — Speaker 2
11:54Because the patient has a diverting colostomy, it is only necessary to place about 12 to 16 sutures as the anastomosis does not need to be airtight — Speaker 2
12:02Too many sutures could make the anastomosis ischemic — Speaker 2
12:57Calibration and anal dilations are started at approximately 2 weeks of age — Speaker 2
13:06Anal dilations are often only necessary for a few weeks — Speaker 2
14:17Hitch stitches are placed in the colon, attaching the distal or mid rectum to the presacral fascia to help prevent prolapse later on — Speaker 2
14:37Usually 2 stitches, one on each side, is sufficient for presacral fixation — Speaker 2

Cases discussed

0:00Infant with high imperforate anus and rectourethral fistula at bladder neck level undergoing laparoscopic-assisted pull-through

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.

Keywords

imperforate anus rectourethral fistula high fistula laparoscopic-assisted pull-through mesenteric mobilization fistula division perineal dissection anal anastomosis presacral fixation anal dilation diverting colostomy

Hashtags

#PediatricSurgery #ImperforateAnus #LaparoscopicSurgery #ColorectalSurgery

Transcript

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 vas deferrons, 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 deception 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 To. Posteriorly, the dissection goes quite quickly and rapidly, 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 def. 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 and 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 difficult to differentiate between the rectum. Uh 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. We see we're using. Find the 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, 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. And removes 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. With this completed, we'll now turn to the perineal portion of the operation. The baby's feet and legs were all prepped at the beginning of the procedure and now retracted. 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. At 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 in 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 trochar. And it's used to grasp the end of the 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. Uh, or the mesenteric king. With the bow grasped, the Babcock and the choke car gently eased out and The end of the bowel is grasped. 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 ballot as it is pulled through. Then on the perineal portion of the procedure. The exteriorized end is Graft and the staple line resected. A series of stay sutures are then placed to give better exposure. Uh, and we He 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, flowing 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. The last bit of trimming of the exteriorized portion is then performed. And the posterior wall is then sewn 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 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. You 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 Uh, 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.

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