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.
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What the experts said
The patient is placed transversely on the table with the surgeon standing at the head for laparoscopic pull-through for high imperforate anus.
Three trocars are used: one umbilical for the scope, and 3mm and 5mm trocars in the right and left mid-quadrants just below the umbilicus.
The mesenteric mobilization technique uses fine dissection just on the serosa of the bowel wall, with small vessels individually isolated, grasped with the sealer, sealed, and retracted away from the bowel.
This vessel sealing technique is safer than using electrocautery in the pelvic area, which could spread to surrounding structures causing injury to the vas deferens, bladder, ureter, and other structures.
Electrocautery could also damage surrounding nerves in the pelvic dissection.
The 3mm sealer allows fine dissection completely around the circumference of the bowel with very limited heat spread.
Using 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.
In this case, the rectourethral fistula is a high fistula at the level of the bladder neck.
There is no bleeding during the dissection because each of the vessels is sealed before being divided.
The posterior dissection goes quite quickly 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, requiring careful technique 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 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 in high fistulas.
Most of the rectourethral fistulas dealt with in this procedure are closer to the level of the prostate rather than at the bladder neck.
The fistula is taken using a 5mm stapler, with the best angle achieved by placing the stapler 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 to prevent any residual fistula and eliminate the chance of a diverticulum.
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 vessel sealing and tearing technique prevents the need for changing to scissors to cut tissue and 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 toward the baby's head to expose the area of the external sphincter for the perineal portion.
A nerve stimulator is used to identify the center of the external sphincter, which is marked just over 1 centimeter from a reference point.
A skin incision is made in the center of the sphincter, and needle-tip cautery is used to gently divide the tissues in the midline.
The nerve stimulator is used throughout the perineal dissection to ensure the 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 laparoscopic visualization.
It is important to visualize the tip of the Veress needle coming through the levator complex under laparoscopy, 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 serially expandable trocars are used to go from 5mm up to 10mm to create the anal canal.
A Babcock clamp is passed through the 10mm trocar and used to grasp the rectum; because of the staple line, there is no spillage during this portion of the procedure.
Care should be taken to ensure the orientation of the bowel is correct and that it does not get twisted or the mesentery kinked during pull-through.
Occasionally there is too much tension during pull-through and more mobilization needs to be done, which can be achieved relatively easily laparoscopically.
The staple line is resected from the exteriorized bowel end, and stay sutures are placed to give better exposure.
A 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.
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.
Anal calibration and dilations are started at approximately 2 weeks postoperatively and are often only necessary for a few weeks.
Two to three stitches are placed in each quadrant after the four corner sutures are placed for the anastomosis.
Once the anastomosis is complete, the anus already retracts somewhat, creating a more normal-appearing 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 presacral fixation stitches, one on each side, are sufficient to prevent prolapse.