Technique: Laparoscopic-Assisted Pull-through for Imperforate Anus
With Dr. Dr. Steve Rothenberg · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
More about imperforate anus
same diagnosisVideo
Technique: Laparoscopic-Assisted Pull-through for Imperforate Anus
Dr. Steve Rothenberg · 15 min · Published Nov 2018
Video
Laparoscopic Surgery for Male Imperforate Anus and Rectourethral Fistula:...
25 min · Published Jul 2017
Video
Imperforate Anus & Rectourethral Fistula Technique & Discussion: Difficult Cases
25 min · Published Dec 2013
Video
Tricks - Imperforate Anus and Rectourethral Fistula
45 min · Published Nov 2018
Podcast
The Colorectal Quiz: Episode 1
Marc Levitt · 15 min · Published Jan 2021
Podcast
Colorectal Quiz Episode 12: Newborn ARM Part 1
12 min · Published Jun 2021
Only a few other public items share this expert — go deeper there →
Video
Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
56 s · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
56 s · Published May 2026
Video
The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
44 s · Published May 2026
Video
Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
1 min · Published May 2026
What the experts said
The patient is placed transversely on the table with the surgeon standing at the head
Three trocars are used: one umbilical for the scope, and 3mm and 5mm trocars in right and left mid-quadrants just below the umbilicus
The technique uses fine dissection just on the serosa of the bowel wall
Small vessels are individually isolated, grasped with the sealer, sealed, and retracted away from the bowel
This is a very safe and efficient technique for mobilizing the distal bowel without devascularizing it
This technique is much safer than using electrocautery which could spread to surrounding structures causing injury to the vas deferens, bladder, ureter, and other structures, and could damage surrounding nerves
The 3mm sealer has very limited heat spread
Using the sealer in the right hand allows the surgeon to dissect with both hands, providing traction with the left and fine dissection with the right
The instruments can be switched to allow dissection on the left side of the bowel
In this case, the fistula is a high fistula at the level of the bladder neck
There is no bleeding because each of the vessels is sealed
Posteriorly, the dissection goes quite quickly and rapidly down to the level of the pelvic floor
The most difficult portion of the dissection is always anteriorly where the fistula comes up into the bladder
In the anterior area, one needs to be very careful to prevent injury to the prostate, seminal vesicles, or vas deferens
A hitch stitch is placed through the anterior abdominal wall down to the peritoneal reflection to retract the bladder up and out of the way, exposing the anterior rectum more completely
The anterior dissection can be difficult as the tissue planes can be very dense and difficult to differentiate between the rectum and surrounding structures
The colon tapers relatively quickly as it enters down into the bladder neck
This is a relatively high fistula; most fistulas dealt with in this procedure are closer to the level of the prostate
The fistula is taken using the 5mm stapler, with the best angle achieved by placing it through the left hand port in this case
Whether the left or right hand port is upsized to 5mm for the stapler depends on the particular anatomy of the child
The fistula is taken almost completely flush with the bladder neck
This technique allows for easy division of the fistula in a safe and secure fashion and removes any residual fistula so there is no chance of a diverticulum
Once the fistula is divided, the bowel is retracted superiorly to mobilize more mesentery to allow for the eventual pull-through
In most cases, it is not necessary to mobilize the rectosigmoid much above the pelvic reflection
The dissection stays relatively close to the bowel wall to prevent devascularization of the colon and injury to surrounding structures
The technique of sealing blood vessels and gently tearing them away from the colon works extremely efficiently and prevents the need for changing to scissors to cut tissue
This technique prevents the heat spread seen with monopolar hook cautery
The baby's feet and legs are prepped at the beginning of the procedure and retracted up towards the head to expose the area of the external sphincter
The nerve stimulator is used to identify the center of the sphincter, which is marked
A skin incision is made at the center of the sphincter mark, just over 1 centimeter
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 dissection does not wander off to the right or left and stays in the center as close as possible
After dissecting through skin and subcutaneous tissue down to the sphincter level, blunt dissection is performed right in the center of the sphincter to preserve the circular fibers as much as possible
A Veress needle is inserted through the center of the external sphincter and into the center of the pelvic floor under direct visualization
The tip of the needle should come out in the center of the levator complex well away from the bladder neck
It is important that needle placement be visualized as it is possible to injure the urethra or bladder if not careful
A 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
With the 10mm trocar in the neo-anus, a Babcock clamp is passed through the trocar and 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 ensure the orientation of the bowel is correct and it does not get twisted or kinked in the mesentery
Occasionally there is too much tension and more mobilization needs to be done, which can be achieved relatively easily
The staple line is resected and a series of stay sutures are placed to give better exposure
A series of 4-0 interrupted vicryl sutures are used to create the neo-anus, going full thickness through the colon and then through the skin
Because 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 and should not be made ischemic
Calibration and anal dilatations are generally started at approximately 2 weeks of age and often are only necessary for a few weeks
Two to three stitches are placed in each quadrant after the four corners are placed
Once the anastomosis is complete, the anus is already retracting somewhat, creating a more normal skin line and external column
Hitch stitches are placed in the colon, attaching the distal or mid rectum to the presacral fascia to help prevent prolapse later on
Usually two stitches, one on each side, is sufficient for presacral fixation
Presacral fixation can also retract the anus, giving a more normal-looking anal canal