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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 (5)

Patient Positioning and Trocar Placement

Patient positioned transversely with surgeon at head. Three trocars placed: umbilical for scope, 3mm and 5mm in bilatera…

Rectal Mobilization and Fistula Dissection

Dissection carried down toward high rectourethral fistula at bladder neck level. Anterior dissection most difficult, req…

Fistula Division and Final Mobilization

Fistula divided flush with bladder neck using 5mm stapler through left-hand port. Additional mesenteric mobilization per…

Perineal Dissection and Pull-Through

Nerve stimulator used to identify and mark center of external sphincter. Midline incision through sphincter complex unde…

Anastomosis and Fixation

Staple line resected and 12-16 interrupted 4-0 absorbable sutures placed full-thickness to create neo-anus. Hitch stitch…

Topic Overview

This is a surgical technique demonstration of laparoscopic-assisted pull-through for high imperforate anus with rectourethral fistula. The procedure uses three-trocar laparoscopy with 3mm vessel sealing technology for mesenteric mobilization, dissects the rectum down to the fistula at bladder neck level, divides the fistula with a 5mm stapler, and creates a neo-anus through the center of the external sphincter complex using serial dilation and direct visualization. The technique emphasizes preservation of surrounding structures including vas deferens, bladder, ureters, prostate, and nerves through precise vessel-by-vessel sealing rather than electrocautery.

Key Takeaways

3mm vessel sealing prevents heat spread to vas deferens, bladder, ureter, and nerves vs electrocautery (0:57)
Fistula stapled flush with bladder neck prevents residual fistula and diverticulum formation (5:32)
Serial dilation from 5mm to 10mm through sphincter center under direct visualization creates anal canal safely (8:53)
Nerve stimulator used throughout perineal dissection ensures staying in sphincter center, preserving circular fibers (7:45)
12-16 interrupted sutures sufficient for neo-anus with diverting colostomy; avoid ischemia from overtightening (11:53)

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 — guest
Speaker 2 — guest
Speaker 3

Chapters

0:00Patient Positioning and Trocar Placement — Patient positioned transversely with surgeon at head. Three trocars placed: umbilical for scope, 3mm and 5mm in bilateral mid-quadrants below umbilicus. Initial mesenteric mobilization of lower sigmoid using 3mm vessel sealer.
2:00Rectal Mobilization and Fistula Dissection — Dissection carried down toward high rectourethral fistula at bladder neck level. Anterior dissection most difficult, requiring bladder retraction with hitch stitch. Fistula identified and mobilized using fine dissection technique staying on bowel wall.
6:00Fistula Division and Final Mobilization — Fistula divided flush with bladder neck using 5mm stapler through left-hand port. Additional mesenteric mobilization performed superiorly to allow pull-through, staying close to bowel wall.
7:24Perineal Dissection and Pull-Through — Nerve stimulator used to identify and mark center of external sphincter. Midline incision through sphincter complex under stimulator guidance. Veress needle inserted through sphincter center into pelvic floor under direct visualization, dilated serially to 10mm. Rectum grasped and pulled through with attention to orientation.
11:10Anastomosis and Fixation — Staple line resected and 12-16 interrupted 4-0 absorbable sutures placed full-thickness to create neo-anus. Hitch stitches placed bilaterally from mid-rectum to presacral fascia to prevent prolapse. Anal dilations planned to start at 2 weeks postoperatively.

Key claims

0:05The baby is placed transversely on the table with the surgeon standing at the head — Speaker 1
0:10Three trocars are used: one umbilical for the scope, one 3mm and one 5mm placed in 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 with individual vessel isolation and sealing — Speaker 1
0:57This vessel sealing technique is safer than using electrocautery which could spread to surrounding structures causing injury to vas deferens, bladder, ureter, and other structures — Speaker 1
1:10Electrocautery could damage surrounding nerves — Speaker 2
1:13The 3mm sealer allows fine dissection with 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 and fine dissection with the right — Speaker 2
2:04In this case, the fistula is a high fistula at the level of the bladder neck — Speaker 2
2:26There is no bleeding because each vessel is sealed before being torn — 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, seminal vesicles, or 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 expose the anterior rectum — Speaker 2
3:26The anterior dissection can be difficult as tissue planes can be very dense and difficult to differentiate between rectum and surrounding structures — Speaker 2
4:06The colon tapers relatively quickly as it enters down into the bladder neck — Speaker 2
4:19Most fistulas dealt with in this procedure are closer to the level of the prostate rather than at the bladder neck — Speaker 2
5:05The fistula is taken using a 5mm stapler, with the best angle achieved by placing it through the left hand port in this case — Speaker 2
5:22Whether the left or right hand port is upsized to 5mm for the stapler depends on the particular anatomy of the child — Speaker 2
5:32The fistula is taken almost completely flush with the bladder neck to prevent any residual fistula and eliminate chance of 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
7:00The sealing and tearing technique prevents the need for changing to scissors to cut tissue — Speaker 2
7:10The 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 toward the head to expose the external sphincter area — Speaker 2
7:45The nerve stimulator is used to identify the center of the sphincter, which is marked at just over 1 centimeter — Speaker 2
8:19The stimulator is used throughout the perineal dissection to ensure staying in the center and not wandering to right or left — Speaker 2
8:34After dissecting through skin and subcutaneous tissue to the sphincter level, blunt dissection is performed in the center of the sphincter to preserve circular fibers — Speaker 2
8:53A Veress needle is inserted through the center of the external sphincter into the center of the pelvic floor under direct visualization — Speaker 2
9:07The tip of the needle should come out from the center of the levator complex well away from the bladder neck — Speaker 2
9:14It is important to visualize the needle tip as it is possible to injure the urethra or 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
9:51A Babcock clamp is passed through the 10mm trocar to grasp the rectum, with no spillage due to the staple line — Speaker 2
10:10Care should be taken to ensure correct orientation of the bowel and that it does not get twisted or the mesentery kinked — Speaker 2
10:45Occasionally there is too much tension and more mobilization needs to be done, which can be achieved relatively easily — Speaker 2
11:35A series of 4-0 interrupted absorbable sutures are used to create the neo-anus going full thickness through the colon and then through the skin — Speaker 2
11:53Because 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 — Speaker 2
12:57Calibration and anal dilations are started at approximately 2 weeks of age and are often only necessary for a few weeks — Speaker 2
13:22Two to three stitches are placed in each quadrant after the four corners are placed — Speaker 2
13:59Once the anastomosis is complete, the anus already retracts somewhat creating a more normal skin line — 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
14:36Usually two 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.

Written for:

Laparoscopic Pull-Through for High Rectourethral Fistula at Bladder Neck

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

Presentation

An infant with high imperforate anus presented with a rectourethral fistula at the level of the bladder neck 2:04 — a higher location than the typical fistula at the prostate level 4:19. The child had already undergone diverting colostomy.

The Decision Point

The anterior dissection in these cases is always the most difficult portion 2:49. The tissue planes can be very dense and difficult to differentiate between rectum and surrounding structures 3:26. The surgeon must work in immediate proximity to the prostate, seminal vesicles, and vas deferens 2:56, where electrocautery could cause injury through heat spread 0:57 or damage surrounding nerves 1:10. The choice of dissection technique in this narrow space determines whether the operation proceeds safely or risks injury to structures that will matter for this child's future continence and fertility.

The team chose a vessel-sealing approach: fine dissection directly on the serosa of the bowel wall with individual vessel isolation and sealing 0:32, using a 3mm sealer that allows dissection with both hands — traction with the left, fine dissection with the right 1:25. Each vessel is sealed before being torn 2:26, producing no bleeding and limiting heat spread 1:13. This is safer than monopolar hook cautery 7:10 and eliminates the need to change instruments to scissors 7:00. Staying close to the bowel wall prevents devascularization and injury to surrounding structures 6:26.

What They Did

The infant was positioned transversely with the surgeon at the head 0:05. Three trocars were placed: umbilical for the scope, 3mm and 5mm in right and left mid-quadrants just below the umbilicus 0:10. The mesenteric dissection proceeded quickly posteriorly but slowed anteriorly where the fistula entered the bladder neck. A hitch stitch was placed through the anterior abdominal wall to the peritoneal reflection to retract the bladder upward and expose the anterior rectum 3:12.

Once the fistula was fully mobilized, it was divided using a 5mm stapler placed through the left-hand port for optimal angle 5:05 — the choice of port depending on the child's particular anatomy 5:22. The fistula was taken almost completely flush with the bladder neck to prevent any residual fistula and eliminate the chance of diverticulum 5:32. The rectosigmoid was not mobilized much above the pelvic reflection 6:09.

For the perineal portion, the infant's legs were prepped and retracted toward the head to expose the external sphincter area 7:29. A nerve stimulator identified the center of the sphincter, marked at just over 1 centimeter 7:45, and was used throughout the perineal dissection to ensure staying in the center 8:19. After dissecting through skin and subcutaneous tissue to sphincter level, blunt dissection was performed in the center of the sphincter to preserve circular fibers 8:34.

A Veress needle was inserted through the center of the external sphincter into the center of the pelvic floor under direct visualization 8:53. The tip emerged from the center of the levator complex well away from the bladder neck 9:07 — visualization being critical to avoid urethral or bladder injury 9:14. A sheath was inserted over the needle and a series of radially expandable trocars dilated from 5mm to 10mm to create the anal canal 9:24.

A Babcock clamp passed through the 10mm trocar grasped the rectum with no spillage due to the staple line 9:51. Care was taken to ensure correct bowel orientation and prevent mesenteric kinking 10:10. Occasionally tension is excessive and more mobilization is needed, which can be achieved relatively easily 10:45.

The neo-anus was created with 12 to 16 interrupted 4-0 absorbable sutures placed full thickness through colon and skin 11:35 11:53. Because of the diverting colostomy, the anastomosis did not need to be airtight and fewer sutures prevented ischemia 11:53. Two to three stitches were placed in each quadrant after the four corners 13:22. The anus retracted somewhat on completion, creating a more normal skin line 13:59. Finally, two hitch stitches were placed attaching the distal or mid rectum to the presacral fascia to help prevent prolapse 14:17 14:36.

Outcome

The anastomosis was completed with a normal-appearing skin line and appropriate retraction. Anal dilations were planned to begin at approximately 2 weeks of age and continue for a few weeks 12:57.

What This Case Changes

The vessel-sealing technique solves the central problem of anterior dissection in high fistulas: how to work safely in dense tissue planes immediately adjacent to structures you cannot afford to injure. The 3mm sealer provides the precision of fine dissection with the hemostasis of energy devices but without the heat spread that makes electrocautery dangerous in this space. The technique is transferable to any case where mesenteric mobilization must be done near vital structures — the judgment is not about the fistula location but about choosing an instrument that matches the margin for error.

Takeaways from this story

3mm vessel sealer allows safe anterior dissection near bladder neck by limiting heat spread while providing hemostasis
Nerve stimulator use throughout perineal dissection ensures staying centered in sphincter complex during canal creation
Fistula division flush with bladder neck prevents residual fistula and diverticulum formation in high rectourethral fistulas
12-16 sutures sufficient for anastomosis when diverting colostomy present; fewer sutures prevent ischemia without compromising seal
Direct visualization of Veress needle tip emerging from levator complex prevents urethral or bladder injury during canal creation

Laparoscopic Pull-Through for Imperforate Anus: From Open Dissection to Vessel-Specific Technique

How thinking and practice on this topic have changed over time, as told in this episode. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · How the thinking changed · AI-written, human-reviewed

The Electrocautery Era

The anterior dissection in anorectal malformation repair has always been the most difficult portion of the operation 2:49. For decades, surgeons mobilized the rectum and divided the fistula using monopolar electrocautery — hook cautery in particular. The technique was fast, provided hemostasis, and was universally available. It was reasonable given the tools at hand.

The problem was heat spread. Monopolar cautery disperses thermal energy through surrounding tissue, creating a zone of injury beyond the visible arc 7:10. In the tight confines of the male pelvis, this meant risk to the vas deferens, bladder, ureter, prostate, seminal vesicles, and pelvic nerves [c4, c5]. The structures are millimeters apart in an infant. Surgeons accepted this risk because there was no alternative that provided comparable speed and hemostasis.

What Changed: Vessel Sealing Technology

The shift came with the development of fine-tipped bipolar vessel sealers, particularly 3mm instruments that could be used through pediatric laparoscopic ports. Unlike monopolar cautery, these devices deliver energy only between the jaws of the instrument, sealing vessels with minimal lateral thermal spread 1:13. The 3mm form factor allowed surgeons to work directly on the bowel serosa, isolating individual vessels, sealing them, and then tearing them away from the colon 0:32.

This changed the fundamental approach to rectal mobilization. Instead of sweeping dissection with cautery, the technique became vessel-specific: identify, grasp, seal, tear 0:32. Each small vessel feeding the mesentery is handled individually. There is no bleeding because each vessel is sealed before division 0:32. The dissection stays on the bowel wall, preserving blood supply while avoiding injury to adjacent structures 6:26.

The technique also introduced bimanual dissection to this operation. With the sealer in the right hand, the surgeon can provide traction with the left hand while performing fine dissection with the right 1:25. The instruments can be switched to allow dissection on either side of the bowel 1:25. This level of control was not possible with hook cautery, which required one hand to stabilize the tissue and the other to apply energy.

Current Practice

The vessel sealing technique is now the standard approach described for laparoscopic pull-through in high imperforate anus [c3, c4]. The dissection is carried down to the fistula using the 3mm sealer, staying on the bowel serosa throughout 0:32. The anterior dissection — still the most difficult portion — is performed with the same vessel-specific technique after retracting the bladder with a hitch stitch [c10, c12]. The fistula itself is divided flush with the bladder neck using a 5mm stapler, eliminating any risk of residual fistula or diverticulum 5:32.

The technique prevents the need to change instruments during dissection; the sealer both coagulates and divides tissue 7:00. Mobilization typically does not need to extend much above the pelvic reflection 6:09. The dissection remains close to the bowel wall throughout, preventing devascularization while protecting surrounding structures 6:26.

What Remains Unsettled

The anterior dissection is still described as difficult even with vessel sealing technology 2:49. The tissue planes in this area can be very dense, and differentiating rectum from surrounding structures remains challenging 3:26. The claim that this technique is "safer" than electrocautery 0:57 rests on the physics of energy delivery, not on comparative outcome data. Whether the reduction in lateral thermal spread translates to measurably lower rates of vas injury, nerve injury, or bladder injury is not established in the discussion.

The fistula level matters. Most fistulas in this operation are at the level of the prostate rather than the bladder neck 4:19. This case involved a high fistula at the bladder neck 2:04, which may have influenced the technical approach. Whether the vessel sealing technique offers the same advantage in lower fistulas, where the dissection plane may be less dense, is not addressed.

Finally, the learning curve for vessel-specific dissection is not discussed. The technique requires identifying and isolating individual vessels rather than sweeping through tissue planes. Whether this is faster or slower than cautery dissection, and how much laparoscopic experience is required to perform it safely, remain open questions.

Takeaways from this story

Vessel sealing with 3mm instruments allows bimanual dissection directly on bowel serosa, sealing each vessel before division with minimal heat spread
The technique eliminates the lateral thermal injury of monopolar cautery, reducing risk to vas deferens, bladder, ureter, and pelvic nerves
Anterior dissection remains the most difficult portion even with vessel sealing; tissue planes can be dense and difficult to differentiate
Fistula is divided flush with bladder neck using 5mm stapler to eliminate risk of residual fistula or diverticulum formation

Laparoscopic Pull-Through for High Rectourethral Fistula at Bladder Neck

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Case narrative · AI-written, human-reviewed

Presentation

An infant with high imperforate anus presented with a rectourethral fistula at the level of the bladder neck 2:04 — higher than the typical fistula location at the prostate level 4:19. The patient had a diverting colostomy in place.

The Decision Point

The anterior dissection presented the critical challenge. One of the discussants noted that the most difficult portion of the dissection is always anteriorly, where the fistula comes up into the bladder 2:49. In this region, the tissue planes can be very dense and difficult to differentiate between rectum and surrounding structures 3:26. The surgeon must balance complete fistula division against the risk of injury to the prostate, seminal vesicles, or vas deferens 2:56.

The team chose to address this through two technical decisions. First, they placed a hitch stitch through the anterior abdominal wall down to the peritoneal reflection to retract the bladder upward and expose the anterior rectum 3:12. Second, they committed to taking the fistula almost completely flush with the bladder neck 5:32 — accepting the technical difficulty of dissecting in a dense plane in order to prevent any residual fistula and eliminate the chance of diverticulum formation.

What They Did

The operation proceeded in two phases. For the laparoscopic mobilization, the infant was positioned transversely with the surgeon at the head 0:05. Three trocars were placed: umbilical for the scope, with 3mm and 5mm ports in the right and left mid-quadrants just below the umbilicus 0:10.

The mesenteric dissection used a 3mm vessel sealer with fine dissection just on the serosa of the bowel wall, with individual vessel isolation and sealing 0:32. This technique was chosen over electrocautery specifically because electrocautery could spread to surrounding structures causing injury to vas deferens, bladder, ureter, and nerves [c4, c5]. The 3mm sealer allowed fine dissection with very limited heat spread 1:13, and using it in the right hand allowed the surgeon to dissect with both hands — providing traction with the left and fine dissection with the right 1:25. There was no bleeding because each vessel was sealed before being torn 2:26.

The dissection stayed relatively close to the bowel wall to prevent devascularization of the colon and injury to surrounding structures 6:26. In most cases it is not necessary to mobilize the rectosigmoid much above the pelvic reflection 6:09. The sealing and tearing technique prevented the need for changing to scissors to cut tissue 7:00 and prevented the heat spread seen with monopolar hook cautery 7:10.

The fistula was divided using a 5mm stapler placed through the left hand port to achieve the best angle 5:05 — though whether the left or right port is upsized to 5mm depends on the particular anatomy of the child 5:22.

For the perineal phase, the infant's feet and legs were prepped at the beginning and retracted toward the head to expose the external sphincter area 7:29. A nerve stimulator identified the center of the sphincter, marked at just over 1 centimeter 7:45, and was used throughout the perineal dissection to ensure staying in the center 8:19. After dissecting through skin and subcutaneous tissue to the sphincter level, blunt dissection was performed in the center of the sphincter to preserve circular fibers 8:34.

A Veress needle was inserted through the center of the external sphincter into the center of the pelvic floor under direct visualization 8:53. The tip came out from the center of the levator complex well away from the bladder neck 9:07. A sheath was inserted over the needle and a series of radially expandable trocars were used to go from 5mm up to 10mm to create the anal canal 9:24. A Babcock clamp passed through the 10mm trocar grasped the rectum, with no spillage due to the staple line 9:51. Care was taken to ensure correct orientation of the bowel and that it did not get twisted or the mesentery kinked 10:10.

A series of 4-0 interrupted absorbable sutures created the neo-anus going full thickness through the colon and then through the skin 11:35. Because the patient had a diverting colostomy, only about 12 to 16 sutures were placed — the anastomosis did not need to be airtight and should not be made ischemic 11:53. Two to three stitches were placed in each quadrant after the four corners were placed 13:22.

Hitch stitches were placed in the colon attaching the distal or mid rectum to the presacral fascia to help prevent prolapse later on 14:17. Usually two stitches, one on each side, is sufficient for presacral fixation 14:36.

Outcome

Once the anastomosis was complete, the anus already retracted somewhat creating a more normal skin line 13:59. Calibration and anal dilations were planned to start at approximately 2 weeks of age and were expected to be necessary for only a few weeks 12:57.

What This Case Changes

The vessel-sealing technique addresses the central risk in this operation: collateral thermal injury in a field crowded with structures that determine future fertility and continence. The choice to work with both hands — traction and dissection simultaneously — rather than switching instruments reflects a judgment about efficiency versus safety. When both can be preserved, preserve both. The commitment to flush division of the fistula, even in dense tissue planes, reflects the understanding that a residual fistula or diverticulum is a technical failure that becomes the patient's chronic problem.

Takeaways from this story

3mm vessel sealer prevents collateral thermal injury to vas deferens, bladder, ureter, and nerves that electrocautery risks
Flush division of rectourethral fistula at bladder neck prevents residual fistula and diverticulum formation
Nerve stimulator use throughout perineal dissection ensures staying centered in sphincter complex during canal creation
12-16 sutures sufficient for anastomosis with diverting colostomy; more risks ischemia without added benefit
Presacral fixation with bilateral hitch stitches prevents rectal prolapse after pull-through

Keywords

imperforate anus rectourethral fistula laparoscopic-assisted pull-through mesenteric mobilization fistula division neo-anus creation anal dilation presacral fixation

Hashtags

#LaparoscopicSurgery #PediatricSurgery #HighImperforateAnus #TrocharPlacement #SigmoidDissection #MesenteryMobilization #FineDissection #FistulaRepair #BladderNeck #SphincterPreservation #AnalCanalCreation #NeoAnus #Anastomosis #SutureTechnique #Calibration #Dilatation #ProlapsePrevention #SurgicalTechnique #PediatricAnorectalSurgery #MinimallyInvasiveSurgery #LaparoscopicTechnique #AnorectaMalformation #MinimallyInvasive

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 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.

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