Laparoscopic approach for imperforate anus

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Laparoscopic approach for imperforate anus

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Media type

Surgical video

Duration

05'30''

Publication

2006-01

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E-publication

WeBSurg.com, Jan 2006;6(01).
URL: http://www.websurg.com/doi-vd01en1895.htm

Laparoscopic approach for imperforate anus

1. Patient positioning (1st case) 00'14''

This is the case of a little boy presenting with an anorectal malformation with a rectourethral fistula. As soon as he was born, a colostomy was created. Four months later, laparoscopic surgery is used.

2. Trocar placement 00'30''

Three operating trocars and one optical trocar are introduced. The surgeon stands to the patient’s right.

3. Start of procedure 00'41''

The monitor is positioned between the patient’s legs. Intraperitoneal insufflation to 8mm Hg is achieved. The pouch of Douglas is opened. No vascular, nor nerve division is carried out. The rectourethral fistula is simply dissected in the subperitoneal space. Progressively the seminal vesicles can be seen, and most of the dissection is performed using blunt dissection in order to avoid any damage to neighbouring tissues. An excellent view of the rectourethral fistula is achieved. A urethrovesical catheter was placed at the beginning of the procedure to support the urethra.

4. Division of fistula 02'30''

The fistula is then divided paying attention not to leave behind too much of the stump. The fistula is then closed being sutured using a figure of eight stitch. This utilizes a 5/0 Vicryl. The knot is an intracorporeal one. Electric stimulation of the muscles can be used to perform the pull-through procedure. The view of the endopelvic cavity is perfect as all the sphincteric anatomical structures can be easily identified. A trocar is introduced into the medial portion of the external sphincteric ring under coelioscopic guidance. A traction forceps held through the perineal trocar makes it possible to achieve a rectal pull-through procedure to the anal verge.

5. Anal anastomosis 04'41''

A few stitches are used to anchor the rectal limb to the anus.

6. Description of 2nd case 04'52''

The second case presentation is a typical case of Currarino syndrome with long perineal rectal fistula anteriorly to a large anterior meningocele.

7. 3D CT reconstruction 05'09''

No meconium had ever passed through the distal part of the fistula and this only contained a whitish mucous deposit uncoloured by bile. Characteristic of Currarino syndrome, sacrococcygeal abnormalities and malformations are often observed. This 3-D reconstruction of the patient helps to mark the presence of the anterior meningocele which is seen in a silvery gray colour. Three operating trocars are used.

8. Trocar placement and start of procedure 05'56''

The pouch of Douglas is the first place where the dissection starts. The dissection is carried out close to the rectum and to the fistula. We do not use monopolar cautery, and once again most of the dissection is using blunt retraction and blunt dissection. Extreme caution must be taken to avoid rupturing the anterior meningocele which can be seen; in this case it is covered with abundant fat. Certain teams prefer to resect this at the same time. However, our neurosurgeons prefer to wait when it is not associated with any neurological defects. Low rectal dissection is continued. The large anterior meningocele may occasionally cause difficulties with posterior rectal dissection. However, in this case, the exploration is continued beyond the anterior meningocele into the pelvis and down to the pelvic floor. The fistula is partially opened in order to guide the passage of a trocar introduced by the perineal route after electrical stimulation has identified the muscle structures. Once the trocar has been perfectly positioned, the perineal fistula is completely divided and the rectal pull-through is performed. In this case, it was found that the perineal fistula was extending into the scrotum. The trocar is now being introduced into the pelvic cavity and it is through this that the pull-through will be performed. The end of the rectal stump is grasped using Johan’s forceps. It is then reduced through the striated sphincter complex where it will then be secured in order to achieve a rectoperineal anastomosis.

9. Anastomosis 10'38''

The final step of the procedure is to control the patency of anastomosis using a Hegar’s dilator. This is done in a sequential fashion in order to ensure that the anus is patent.